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Paterno G, Palmieri R, Tesei C, Nunzi A, Ranucci G, Mallegni F, Moretti F, Meddi E, Tiravanti I, Marinoni M, Page C, Fagiolo S, Buzzatti E, Secchi R, Gurnari C, Maurillo L, Buccisano F, Venditti A, Del Principe MI. The ISTH DIC-score predicts early mortality in patients with non-promyelocitic acute myeloid leukemia. Thromb Res 2024; 236:30-36. [PMID: 38387301 DOI: 10.1016/j.thromres.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 02/24/2024]
Abstract
Coagulation disorders frequently complicate the clinical course of acute myeloid leukemia (AML) patients. This study examined the frequency and prognostic significance, with regards of early mortality, of the presence of overt disseminated intravascular coagulation (DIC) at AML diagnosis and its correlation with clinical and biological characteristics. A retrospective analysis of 351 newly diagnosed non-promyelocytic AML patients was conducted, utilizing the 2018 ISTH DIC-Score criteria to evaluate the presence of overt DIC at AML onset. The study cohort had a median age of 65 years with a predominance of male gender (59 %). Overt DIC was present in 21 % of cases and was associated with advanced age, comorbidities, poor performance status, hyperleukocytosis, LDH levels, NPM1 mutations, expression of CD33 and CD4, and lack of expression of CD34. With a median follow-up of 72 months (3-147 months), the 6-year overall survival (OS) was 17.4 %, with patients having overt DIC showing significantly poorer outcomes (7.2 % compared to 20.3 % of those without DIC, p < 0.001). Patients with overt DIC showed markedly high early mortality rates at 30 (42.5 % vs 8 %), 60 (49.3 % vs 16.9 %), and 120 days (64.4 % vs 25.6 %) from disease onset. In multivariate analysis overt DIC retained its independent prognostic value for early mortality. In conclusion, the prevalence and clinical relevance of DIC in non-promyelocytic AML is not negligible, underlining its potential as an unfavorable prognostic marker. In newly diagnosed patients with AML, early recognition and measure to counteract coagulation disturbances might help mitigate the elevated mortality risk associated with DIC.
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Affiliation(s)
| | - Raffaele Palmieri
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Cristiano Tesei
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Andrea Nunzi
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Giorgia Ranucci
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Flavia Mallegni
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Federico Moretti
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Elisa Meddi
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Ilaria Tiravanti
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Massimiliano Marinoni
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Camilla Page
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Solaria Fagiolo
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Elisa Buzzatti
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Roberto Secchi
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Carmelo Gurnari
- Hematology, Fondazione Policlinico Tor Vergata, Rome, Italy; Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy; Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Luca Maurillo
- Hematology, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Francesco Buccisano
- Hematology, Fondazione Policlinico Tor Vergata, Rome, Italy; Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Adriano Venditti
- Hematology, Fondazione Policlinico Tor Vergata, Rome, Italy; Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy.
| | - Maria Ilaria Del Principe
- Hematology, Fondazione Policlinico Tor Vergata, Rome, Italy; Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
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2
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Guarnera L, Santinelli E, Galossi E, Cristiano A, Fabiani E, Falconi G, Voso MT. Microenvironment in acute myeloid leukemia: focus on senescence mechanisms, therapeutic interactions, and future directions. Exp Hematol 2024; 129:104118. [PMID: 37741607 DOI: 10.1016/j.exphem.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/10/2023] [Accepted: 09/12/2023] [Indexed: 09/25/2023]
Abstract
Acute myeloid leukemia (AML) is a disease with a dismal prognosis, mainly affecting the elderly. In recent years, new drugs have improved life expectancy and quality of life, and a better understanding of the genetic-molecular nature of the disease has shed light on previously unknown aspects of leukemogenesis. In parallel, increasing attention has been attracted to the complex interactions between cells and soluble factors in the bone marrow (BM) environment, collectively known as the microenvironment. In this review, we discuss the central role of the microenvironment in physiologic and pathologic hematopoiesis and the mechanisms of senescence, considered a fundamental protective mechanism against the proliferation of damaged and pretumoral cells. The microenvironment also represents a fertile ground for the development of myeloid malignancies, and the leukemic niche significantly interacts with drugs commonly used in AML treatment. Finally, we focus on the role of the microenvironment in the engraftment and complications of allogeneic hematopoietic stem cell transplantation, the only curative option in a conspicuous proportion of patients.
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Affiliation(s)
- Luca Guarnera
- Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy
| | - Enrico Santinelli
- Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Elisa Galossi
- Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy
| | - Antonio Cristiano
- Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy
| | - Emiliano Fabiani
- Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy; Saint Camillus International, University of Health Sciences, Rome, Italy
| | - Giulia Falconi
- Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy; Neuro-Oncohematology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Santa Lucia, Rome, Italy.
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3
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Dong X, Peng S, Ling Y, Huang B, Tu W, Sun X, Li Q, Fang Y, Wu J. ATRA treatment slowed P-selectin-mediated rolling of flowing HL60 cells in a mechano-chemical-dependent manner. Front Immunol 2023; 14:1148543. [PMID: 37168856 PMCID: PMC10164934 DOI: 10.3389/fimmu.2023.1148543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/03/2023] [Indexed: 05/13/2023] Open
Abstract
All-trans retinoic acid (ATRA)-induced differentiation of acute promyelocytic leukemia (APL) toward granulocytes may trigger APL differentiation syndrome (DS), but there is less knowledge about the mechano-chemical regulation mechanism of APL DS under the mechano-microenvironment. We found that ATRA-induced changes in proliferation, morphology, and adhesive molecule expression levels were either dose or stimulus time dependent. An optimal ATRA stimulus condition for differentiating HL60 cells toward neutrophils consisted of 1 × 10-6 M dose and 120 h of stimulus time. Under wall shear stresses, catch-slip bond transition governs P-selectin-mediated rolling for neutrophils and untreated or ATRA-treated (1 × 10-6 M, 120 h) HL60 cells. The ATRA stimuli slowed down the rolling of HL60 cells on immobilized P-selectin no matter whether ICAM-1 was engaged. The β2 integrin near the PSGL-1/P-selectin axis would be activated within sub-seconds for each cell group mentioned above, thus contributing to slow rolling. A faster β2 integrin activation rate and the higher expression levels of PSGL-1 and LFA-1 were assigned to induce the over-enhancement of ATRA-treated HL60 adhesion in flow, causing APL DS development. These findings provided an insight into the mechanical-chemical regulation for APL DS development via ATRA treatment of leukemia and a novel therapeutic strategy for APL DS through targeting the relevant adhesion molecules.
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Affiliation(s)
- Xiaoting Dong
- Institute of Mechanics/School of Biology and Biological Engineering, South China University of Technology, Guangzhou, China
| | - Shiping Peng
- Institute of Mechanics/School of Biology and Biological Engineering, South China University of Technology, Guangzhou, China
| | - Yingchen Ling
- Institute of Mechanics/School of Biology and Biological Engineering, South China University of Technology, Guangzhou, China
| | - Bing Huang
- Institute of Mechanics/School of Biology and Biological Engineering, South China University of Technology, Guangzhou, China
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wenjian Tu
- Institute of Mechanics/School of Biology and Biological Engineering, South China University of Technology, Guangzhou, China
| | - Xiaoxi Sun
- Institute of Mechanics/School of Biology and Biological Engineering, South China University of Technology, Guangzhou, China
| | - Quhuan Li
- Institute of Mechanics/School of Biology and Biological Engineering, South China University of Technology, Guangzhou, China
| | - Ying Fang
- Institute of Mechanics/School of Biology and Biological Engineering, South China University of Technology, Guangzhou, China
- *Correspondence: Ying Fang, ; Jianhua Wu,
| | - Jianhua Wu
- Institute of Mechanics/School of Biology and Biological Engineering, South China University of Technology, Guangzhou, China
- *Correspondence: Ying Fang, ; Jianhua Wu,
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How I Manage Transplant Ineligible Patients with Myelodysplastic Neoplasms. Clin Hematol Int 2022; 5:8-20. [PMID: 36574201 PMCID: PMC10063738 DOI: 10.1007/s44228-022-00024-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/14/2022] [Indexed: 12/28/2022] Open
Abstract
AbstractMyelodysplastic neoplasms, formerly known as myelodysplastic syndromes (MDS), represent a group of clonal disorders characterized by a high degree of clinical and molecular heterogeneity, and an invariable tendency to progress to acute myeloid leukemia. MDS typically present in the elderly with cytopenias of different degrees and bone marrow dysplasia, the hallmarks of the disease. Allogeneic hematopoietic stem cell transplant is the sole curative approach to date. Nonetheless, given the disease’s demographics, only a minority of patients can benefit from this procedure. Currently used prognostic schemes such as the Revised International Prognostic Scoring System (R-IPSS), and most recently the molecular IPSS (IPSS-M), guide clinical management by dividing MDS into two big categories: lower- and higher-risk cases, based on a cut-off score of 3.5. The main clinical problem of the lower-risk group is represented by the management of cytopenias, whereas the prevention of secondary leukemia progression is the goal for the latter. Herein, we discuss the non-transplant treatment of MDS, focusing on current practice and available therapeutic options, while also presenting new investigational agents potentially entering the MDS therapeutic arsenal in the near future.
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Realgar (As 4S 4), a traditional Chinese medicine, induces acute promyelocytic leukemia cell death via the Bcl-2/Bax/Cyt-C/AIF signaling pathway in vitro. Aging (Albany NY) 2022; 14:7109-7125. [PMID: 36098742 PMCID: PMC9512515 DOI: 10.18632/aging.204281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/01/2022] [Indexed: 11/25/2022]
Abstract
Acute promyelocytic leukemia (APL) is a specific subtype of acute myelogenous leukemia (AML) characterized by the proliferation of abnormal promyelocytes. Realgar, a Chinese medicine containing arsenic, can be taken orally. Traditional Chinese medicine physicians have employed realgar to treat APL for over a thousand years. Therefore, realgar may be a promising candidate for the treatment of APL. Nevertheless, the underlying mechanism behind realgar therapy is largely unclear. The present study aimed to investigate the effect of realgar on cell death in the APL cell line (NB4) in vitro and to elucidate the underlying mechanism. In this study, after APL cells were treated with different concentrations of realgar, the cell survival rate, apoptotic assay, morphological changes, ATP levels and cell cycle arrest were assessed. The expression of Bcl-2, Bax, Cytochrome C (Cyt-C) and apoptosis-inducing factor (AIF) at the mRNA and protein levels were also measured by immunofluorescence, quantitative PCR (qPCR) and Western blotting. We found that realgar could significantly inhibit APL cell proliferation and cell death in a time- and dose-dependent manner. Realgar effectively decreased the ATP levels in APL cells. Realgar also induced APL cell cycle arrest at the S and G2/M phases. Following realgar treatment, the mRNA and protein levels of Bcl-2 were significantly downregulated, whereas the levels of Bax, Cyt-C, and AIF were significantly upregulated. In summary, realgar can induce APL cell death via the Bcl-2/Bax/Cyt-C/AIF signaling pathway, suggesting that realgar may be an effective therapeutic for APL.
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Abu Bakar N, Wan Ibrahim WN, Che Abdullah CA, Ramlan NF, Shaari K, Shohaimi S, Mediani A, Nasruddin NS, Kim CH, Mohd Faudzi SM. Embryonic Arsenic Exposure Triggers Long-Term Behavioral Impairment with Metabolite Alterations in Zebrafish. TOXICS 2022; 10:toxics10090493. [PMID: 36136458 PMCID: PMC9502072 DOI: 10.3390/toxics10090493] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 05/10/2023]
Abstract
Arsenic trioxide (As2O3) is a ubiquitous heavy metal in the environment. Exposure to this toxin at low concentrations is unremarkable in developing organisms. Nevertheless, understanding the underlying mechanism of its long-term adverse effects remains a challenge. In this study, embryos were initially exposed to As2O3 from gastrulation to hatching under semi-static conditions. Results showed dose-dependent increased mortality, with exposure to 30-40 µM As2O3 significantly reducing tail-coiling and heart rate at early larval stages. Surviving larvae after 30 µM As2O3 exposure showed deficits in motor behavior without impairment of anxiety-like responses at 6 dpf and a slight impairment in color preference behavior at 11 dpf, which was later evident in adulthood. As2O3 also altered locomotor function, with a loss of directional and color preference in adult zebrafish, which correlated with changes in transcriptional regulation of adsl, shank3a, and tsc1b genes. During these processes, As2O3 mainly induced metabolic changes in lipids, particularly arachidonic acid, docosahexaenoic acid, prostaglandin, and sphinganine-1-phosphate in the post-hatching period of zebrafish. Overall, this study provides new insight into the potential mechanism of arsenic toxicity leading to long-term learning impairment in zebrafish and may benefit future risk assessments of other environmental toxins of concern.
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Affiliation(s)
- Noraini Abu Bakar
- Department of Biology, Faculty of Science, Universiti Putra Malaysia, Serdang 43400, Malaysia
| | - Wan Norhamidah Wan Ibrahim
- Department of Biology, Faculty of Science, Universiti Putra Malaysia, Serdang 43400, Malaysia
- Natural Medicines and Products Research Laboratory, Institute of Bioscience, Universiti Putra Malaysia, Serdang 43400, Malaysia
| | - Che Azurahanim Che Abdullah
- Department of Physics, Faculty of Science, Universiti Putra Malaysia, Serdang 43400, Malaysia
- The Institute of Advanced Technology (ITMA), Universiti Putra Malaysia, Serdang 43400, Malaysia
| | - Nurul Farhana Ramlan
- Department of Biology, Faculty of Science, Universiti Putra Malaysia, Serdang 43400, Malaysia
| | - Khozirah Shaari
- Natural Medicines and Products Research Laboratory, Institute of Bioscience, Universiti Putra Malaysia, Serdang 43400, Malaysia
| | - Shamarina Shohaimi
- Department of Biology, Faculty of Science, Universiti Putra Malaysia, Serdang 43400, Malaysia
| | - Ahmed Mediani
- Institute of Systems Biology, Universiti Kebangsaan Malaysia (UKM), Bangi 43600, Malaysia
| | - Nurrul Shaqinah Nasruddin
- Centre for Craniofacial Diagnostics, Faculty of Dentistry, Universiti Kebangsaan Malaysia (UKM), Kuala Lumpur 50300, Malaysia
| | - Cheol-Hee Kim
- Department of Biology, Chungnam National University, Daejeon 34134, Korea
- Correspondence: (C.-H.K.); (S.M.M.F.)
| | - Siti Munirah Mohd Faudzi
- Natural Medicines and Products Research Laboratory, Institute of Bioscience, Universiti Putra Malaysia, Serdang 43400, Malaysia
- Department of Chemistry, Faculty of Science, Universiti Putra Malaysia, Serdang 43400, Malaysia
- Correspondence: (C.-H.K.); (S.M.M.F.)
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7
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Jiang Y, Shen X, Dong C, Zhi F, Gao Y, Shi C, Chao Y, Xu J, Shang D, Xu J, Yang B, Li X, Bai Y. The whole transcriptome analysis and the circRNA-lncRNA network construction in arsenic trioxide-treated mice myocardium. Biomed Pharmacother 2022; 151:113183. [PMID: 35676786 DOI: 10.1016/j.biopha.2022.113183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/18/2022] [Accepted: 05/22/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND/AIMS Arsenic trioxide (ATO) is an effective anti-cancer drug. Nonetheless, it possesses cardiotoxic effects which limit its clinical application. The present study aims to elucidate the molecular basis of ATO-induced cardiotoxicity through using whole transcriptome analysis. METHODS The whole transcriptome in ATO-treated mice myocardium was analyzed using RNA sequencing technique. These results were confirmed by real-time PCR. The lncRNA-mRNA and circRNA-mRNA co-expression networks were constructed. Finally, a circRNA-lncRNA co-regulated competing endogenous RNA (ceRNA) network was constructed. GO and KEGG pathway analyses were performed. The expression levels of Txnip and Spp1 in ATO-treated neonatal mouse cardiomyocytes were validated by real-time PCR. RESULTS A total of 113 mRNAs, 159 lncRNAs, 35 miRNAs, and 94 circRNAs were differentially expressed in ATO-treated mice myocardium. A lncRNA-circRNA co-regulation network was constructed. Function annotation revealed that aberrantly expressed genes may be enriched in the 'Wnt signaling pathway', 'Hippo signaling pathway', 'Notch signaling pathway', etc. Finally, the expression levels of Txnip and Spp1 were validated in ATO-treated cardiomyocytes, which was in accordance with the RNA-sequencing results. CONCLUSION ATO altered coding and noncoding RNA profiles in myocardium of mice. The ATO-related lncRNA-circRNA co-regulation network was constructed. Genes in the co-regulation network are likely to play important roles in the cardiotoxicity of ATO. This study provides new insights into the prevention and treatment of ATO-induced cardiotoxicity.
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Affiliation(s)
- Yanan Jiang
- Department of Pharmacology (State-Province Key Laboratories of Biomedicine, Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China; Translational Medicine Research and Cooperation Center of Northern China, Heilongjiang Academy of Medical Sciences, Harbin, China; College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, China.
| | - Xiuyun Shen
- Department of Pharmacology (State-Province Key Laboratories of Biomedicine, Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China.
| | - Chaorun Dong
- Department of Pharmacology (State-Province Key Laboratories of Biomedicine, Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China.
| | - Fengnan Zhi
- Department of Pharmacology (State-Province Key Laboratories of Biomedicine, Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China.
| | - Yang Gao
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China.
| | - Chunpeng Shi
- Department of Pharmacology (State-Province Key Laboratories of Biomedicine, Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China.
| | - Yuqiu Chao
- Department of Pharmacology (State-Province Key Laboratories of Biomedicine, Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China.
| | - Jincheng Xu
- Department of Pharmacology (State-Province Key Laboratories of Biomedicine, Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China.
| | - Desi Shang
- The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, China.
| | - Juan Xu
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, China.
| | - Baofeng Yang
- Department of Pharmacology (State-Province Key Laboratories of Biomedicine, Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China; Translational Medicine Research and Cooperation Center of Northern China, Heilongjiang Academy of Medical Sciences, Harbin, China.
| | - Xia Li
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, China.
| | - Yunlong Bai
- Department of Pharmacology (State-Province Key Laboratories of Biomedicine, Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China; Translational Medicine Research and Cooperation Center of Northern China, Heilongjiang Academy of Medical Sciences, Harbin, China.
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8
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Guarnera L, Ottone T, Fabiani E, Divona M, Savi A, Travaglini S, Falconi G, Panetta P, Rapanotti MC, Voso MT. Atypical Rearrangements in APL-Like Acute Myeloid Leukemias: Molecular Characterization and Prognosis. Front Oncol 2022; 12:871590. [PMID: 35494081 PMCID: PMC9039303 DOI: 10.3389/fonc.2022.871590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/25/2022] [Indexed: 02/02/2023] Open
Abstract
Acute promyelocytic leukemia (APL) accounts for 10–15% of newly diagnosed acute myeloid leukemias (AML) and is typically caused by the fusion of promyelocytic leukemia with retinoic acid receptor α (RARA) gene. The prognosis is excellent, thanks to the all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) combination therapy. A small percentage of APLs (around 2%) is caused by atypical transcripts, most of which involve RARA or other members of retinoic acid receptors (RARB or RARG). The diagnosis of these forms is difficult, and clinical management is still a challenge for the physician due to variable response rates to ATRA and ATO. Herein we review variant APL cases reported in literature, including genetic landscape, incidence of coagulopathy and differentiation syndrome, frequent causes of morbidity and mortality in these patients, sensitivity to ATRA, ATO, and chemotherapy, and outcome. We also focus on non-RAR rearrangements, complex rearrangements (involving more than two chromosomes), and NPM1-mutated AML, an entity that can, in some cases, morphologically mimic APL.
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Affiliation(s)
- Luca Guarnera
- Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Tiziana Ottone
- Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy.,Santa Lucia Foundation, Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S.) Neuro-Oncohematology, Rome, Italy
| | - Emiliano Fabiani
- Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy.,Department of Biomedicine and Prevention, UniCamillus-Saint Camillus International University of Health Sciences, Rome, Italy
| | - Mariadomenica Divona
- Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Arianna Savi
- Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Serena Travaglini
- Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Giulia Falconi
- Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Paola Panetta
- Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Maria Cristina Rapanotti
- Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy.,Department of Experimental Medicine, Tor Vergata University of Rome, Rome, Italy
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy.,Santa Lucia Foundation, Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S.) Neuro-Oncohematology, Rome, Italy
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9
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Zoulikha M, He W. Targeted Drug Delivery for Chronic Lymphocytic Leukemia. Pharm Res 2022; 39:441-461. [DOI: 10.1007/s11095-022-03214-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/21/2022] [Indexed: 02/06/2023]
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10
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Zhong X, Di Z, Xu Y, Liang Q, Feng K, Zhang Y, Di L, Wang R. Mineral medicine: from traditional drugs to multifunctional delivery systems. Chin Med 2022; 17:21. [PMID: 35144660 PMCID: PMC8830990 DOI: 10.1186/s13020-022-00577-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 01/28/2022] [Indexed: 11/10/2022] Open
Abstract
Mineral drugs are an important constituent of traditional Chinese medicine (TCM). Taking minerals that contain heavy metals as drugs is a very national characteristic part of TCM. However, the safety and scientific nature of mineral drugs are controversial owing to their heavy metals and strong toxicity. In 2000, the Food and Drug Administration (FDA) authorized arsenic trioxide (ATO) as first-line therapy for acute promyelocytic leukemia. This makes the development and utilization of mineral drugs become a research hotspot. The development of nanomedicine has found a great prospect of mineral drugs in nano-delivery carriers. And that will hold promise to address the numerous biological barriers facing mineral drug formulations. However, the studies on mineral drugs in the delivery system are few at present. There is also a lack of a detailed description of mineral drug delivery systems. In this review, the advanced strategies of mineral drug delivery systems in tumor therapy are summarized. In addition, the therapeutic advantages and research progress of novel mineral drug delivery systems are also discussed. Here, we hope that this will provide a useful reference for the design and application of new mineral drug delivery systems.
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Affiliation(s)
- Xiaoqing Zhong
- College of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, 210023, China.,Jiangsu Provincial TCM Engineering Technology Research Center of High Efficient Drug Delivery System, Nanjing, 210023, China
| | - Zhenning Di
- College of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, 210023, China.,Jiangsu Provincial TCM Engineering Technology Research Center of High Efficient Drug Delivery System, Nanjing, 210023, China
| | - Yuanxin Xu
- College of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, 210023, China.,Jiangsu Provincial TCM Engineering Technology Research Center of High Efficient Drug Delivery System, Nanjing, 210023, China
| | - Qifan Liang
- College of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, 210023, China.,Jiangsu Provincial TCM Engineering Technology Research Center of High Efficient Drug Delivery System, Nanjing, 210023, China
| | - Kuanhan Feng
- College of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, 210023, China.,Jiangsu Provincial TCM Engineering Technology Research Center of High Efficient Drug Delivery System, Nanjing, 210023, China
| | - Yuting Zhang
- College of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, 210023, China.,Jiangsu Provincial TCM Engineering Technology Research Center of High Efficient Drug Delivery System, Nanjing, 210023, China
| | - Liuqing Di
- College of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, 210023, China. .,Jiangsu Provincial TCM Engineering Technology Research Center of High Efficient Drug Delivery System, Nanjing, 210023, China.
| | - Ruoning Wang
- College of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, 210023, China. .,Jiangsu Provincial TCM Engineering Technology Research Center of High Efficient Drug Delivery System, Nanjing, 210023, China.
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11
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Gurnari C, Divona M, Voso MT. What are the considerations for the pharmacotherapeutic management of acute promyelocytic leukemia in children? Expert Opin Pharmacother 2021; 23:289-294. [PMID: 34842028 DOI: 10.1080/14656566.2021.2006182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Carmelo Gurnari
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.,Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, OH, USA
| | - Mariadomenica Divona
- Laboratory of Advanced Diagnostics in Oncohematology, Hematology Department, Tor Vergata Hospital, Rome, Italy
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.,Department of Neuro-Oncohematology, Rome, Italy
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12
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Rosati S, Gurnari C, Breccia M, Carmosino I, Scalzulli E, Montefusco E, Perrone S, Annibali O, Martini V, Trapè G, Colafigli G, Trawinska M, Minotti C, Cimino G, Tafuri A, Avvisati G, Martelli M, Voso MT, Latagliata R. Acute promyelocytic leukemia (APL) in very old patients: real-life behind protocols. Acta Oncol 2021; 60:1520-1526. [PMID: 34461798 DOI: 10.1080/0284186x.2021.1971291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Acute promyelocytic leukemia (APL) is uncommon among subjects aged ≥ 70 years and the better therapeutic strategy represents an unmet clinical need. MATERIALS AND METHODS This prompted us to explore our real-life data on a retrospective cohort of 45 older APL patients (≥ 70 years) consecutively diagnosed at eight different hematologic institutions in Latium, Italy, from July 1991 to May 2019. RESULTS Two patients (4.4%) died from early hemorrhagic complications before treatment could begin. Twenty-two patients (51.1%) (Group A) were enrolled or treated according to standard clinical protocols, while 21 (48.8%) (Group B) received an ATRA-based personalized approach due to poor performance status. Morphologic complete remission (CR) after induction therapy was achieved in 33 patients (76.7%) with 100% of patients in Group A and 52.3% in Group B (p < 0.001). Molecular CR was documented in 30 patients (69.7%) [20/22 (90.9%) in Group A and 10/21 (47.6%) in Group B (p = 0.002)]. Ten patients (23.2%) died during induction therapy, all in Group B. Five-year overall survival (OS) of the entire cohort was 46.1% (95% CI 28.2-64.0), with 72.6% (95% CI 42.9-100) in Group A vs. 27.2% (95% CI 7.5-46.9) in the Group B (p = 0.001). CONCLUSIONS The present analysis highlights that almost half of the patients received sub-optimal induction treatments and registered dismal outcomes demonstrating the importance of adopting standard therapies instead of modified or reduced personalized approaches also in the setting of frail older patients.
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Affiliation(s)
- Serena Rosati
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Carmelo Gurnari
- Department of Biomedicine and Prevention, PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, Rome, Italy
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, USA
| | - Massimo Breccia
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Ida Carmosino
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Emilia Scalzulli
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | | | - Salvatore Perrone
- Hematology, Polo Universitario Pontino, "Sapienza", Via A. Canova S.M. Goretti Hospital, Latina, Italy
| | - Ombretta Annibali
- Unit of Hematology and Stem Cell Transplantation, Campus Bio-Medico University, Rome, Italy
| | | | | | - Gioia Colafigli
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | | | - Clara Minotti
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Giuseppe Cimino
- Hematology, Polo Universitario Pontino, "Sapienza", Via A. Canova S.M. Goretti Hospital, Latina, Italy
| | - Agostino Tafuri
- Hematology Institute, La Sapienza University of Rome, S. Andrea Hospital, Rome, Italy
| | - Giuseppe Avvisati
- Unit of Hematology and Stem Cell Transplantation, Campus Bio-Medico University, Rome, Italy
| | - Maurizio Martelli
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Maria Teresa Voso
- Laboratorio di Neuro-Oncoematologia, Fondazione Santa Lucia, Rome, Italy
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Roberto Latagliata
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
- Hematology, Belcolle Hospital, Viterbo, Italy
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Pratama DE, Yang CL, Chen YY, Lin CC, Hu Y, Lee T. Quick-fix agarose beads impregnated with hydrous ferric oxide for As(III) species removal from pharmaceutical wastewater. SEP SCI TECHNOL 2021. [DOI: 10.1080/01496395.2021.1962350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Dhanang Edy Pratama
- Department of Chemical and Materials Engineering, National Central University, Taoyuan City, Taiwan ROC
| | - Chia-Ling Yang
- Department of Chemical and Materials Engineering, National Central University, Taoyuan City, Taiwan ROC
| | - Yu-Ying Chen
- TTY Biopharm Co. Ltd., Pharmaceutical Development Center, Taipei City, Taiwan ROC
| | - Chun-Chou Lin
- TTY Biopharm Co. Ltd., Pharmaceutical Development Center, Taipei City, Taiwan ROC
| | - Yufang Hu
- TTY Biopharm Co. Ltd., Pharmaceutical Development Center, Taipei City, Taiwan ROC
| | - Tu Lee
- Department of Chemical and Materials Engineering, National Central University, Taoyuan City, Taiwan ROC
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14
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Ferrara F, Molica M, Bernardi M. Drug treatment options for acute promyelocytic leukemia. Expert Opin Pharmacother 2021; 23:117-127. [PMID: 34348549 DOI: 10.1080/14656566.2021.1961744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Until the late 1980s, acute promyelocytic leukemia (APL) was the most rapidly fatal leukemia; however, nowadays, it is a curable disease with survival rates exceeding 90-95%. The improvement of APL outcome is mainly due to two agents, which target the typical translocation t(15;17) and its fusion transcript PML-RARα responsible for initiating and maintaining the disease: all-trans retinoic acid (ATRA) and arsenic trioxide (ATO). The story of APL represents a pioneering model for the development of precision medicine and curative chemotherapy-free approaches for acute leukemia. AREA COVERED The authors examine the major advances in the treatment of patients with APL focusing on three different eras: 1) the pre-ATRA era; 2) the ATRA era; 3) the ATO era. EXPERT OPINION The combination of ATRA and ATO is effective and curative for the majority of APL patients. It has been approved for low/intermediate risk cases while an experimental trial with a minimal addition of chemotherapy for high-risk ones is ongoing. Disease relapse is infrequent and can be cured with ATRA-ATO rechallenging, with or without subsequent transplantation depending on the interval between complete remission and relapse. New therapeutic landscapes contemplate the use of an oral chemo-free ATRA-ATO combination, implementing treatment as outpatient care, thus increasing quality of life and decreasing medical costs.
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Affiliation(s)
| | | | - Massimo Bernardi
- Haematology and BMT Unit IRCCS San Raffaele Scientific Institute via Olgettina 60, Milan
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Strike a Balance: Between Metals and Non-Metals, Metalloids as a Source of Anti-Infective Agents. INORGANICS 2021. [DOI: 10.3390/inorganics9060046] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Most of the commercially available anti-infective agents are organic molecules. In fact, though, during the pioneering times of modern medicine, at the beginning of the 20th century, several inorganic compounds of transition metals were used for medicinal application, to date, only a small number of inorganic drugs are used in clinical practice. Beyond the transition metals, metalloids—or semimetals—offer a rich chemistry in between that of metallic and non-metallic elements, and accordingly, peculiar features for their exploitation in medicinal chemistry. A few important examples of metalloid-based drugs currently used for the treatment of various diseases do exist. However, the use of this group of elements could be further expanded on the basis of their current applications and the clinical trials they entered. Considering that metalloids offer the opportunity to expand the “chemical-space” for developing novel anti-infective drugs and protocols, in this paper, we briefly recapitulate and discuss the current applications of B-, Si-, As-, Sb- and Te-based anti-infective drugs.
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Gurnari C, Voso MT, Girardi K, Mastronuzzi A, Strocchio L. Acute Promyelocytic Leukemia in Children: A Model of Precision Medicine and Chemotherapy-Free Therapy. Int J Mol Sci 2021; 22:ijms22020642. [PMID: 33440683 PMCID: PMC7826974 DOI: 10.3390/ijms22020642] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 12/12/2022] Open
Abstract
Acute promyelocytic leukemia (APL) represents a paradigm of precision medicine. Indeed, in the last decades, the introduction of all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) completely revolutionized the therapeutic approach to this previously highly fatal disorder. This entirely chemotherapy-free treatment, which provided excellent survival rates, has been initially validated in adults and, recently, translated in the pediatric setting. This review summarizes currently available data on the use of ATRA and ATO combination in pediatric APL, providing a particular focus on peculiar issues and challenges, such as the occurrence of pseudotumor cerebri and death during induction (early death), as well as the advantage offered by the ATO/ATRA combination in sparing long-term sequelae.
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Affiliation(s)
- Carmelo Gurnari
- Department of Pediatric Hemato-Oncology and Cell and Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (C.G.); (K.G.); (A.M.)
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy;
- Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy;
- Laboratorio di Neuro-Oncoematologia, Fondazione Santa Lucia, 00179 Rome, Italy
| | - Katia Girardi
- Department of Pediatric Hemato-Oncology and Cell and Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (C.G.); (K.G.); (A.M.)
| | - Angela Mastronuzzi
- Department of Pediatric Hemato-Oncology and Cell and Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (C.G.); (K.G.); (A.M.)
| | - Luisa Strocchio
- Department of Pediatric Hemato-Oncology and Cell and Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (C.G.); (K.G.); (A.M.)
- Correspondence:
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Transcriptional and Metabolic Dissection of ATRA-Induced Granulocytic Differentiation in NB4 Acute Promyelocytic Leukemia Cells. Cells 2020; 9:cells9112423. [PMID: 33167477 PMCID: PMC7716236 DOI: 10.3390/cells9112423] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/31/2020] [Accepted: 11/02/2020] [Indexed: 02/06/2023] Open
Abstract
Acute promyelocytic leukemia (APL) is a hematological disease characterized by a balanced reciprocal translocation that leads to the synthesis of the oncogenic fusion protein PML-RARα. APL is mainly managed by a differentiation therapy based on the administration of all-trans retinoic acid (ATRA) and arsenic trioxide (ATO). However, therapy resistance, differentiation syndrome, and relapses require the development of new low-toxicity therapies based on the induction of blasts differentiation. In keeping with this, we reasoned that a better understanding of the molecular mechanisms pivotal for ATRA-driven differentiation could definitely bolster the identification of new therapeutic strategies in APL patients. We thus performed an in-depth high-throughput transcriptional profile analysis and metabolic characterization of a well-established APL experimental model based on NB4 cells that represent an unevaluable tool to dissect the complex mechanism associated with ATRA-induced granulocytic differentiation. Pathway-reconstruction analysis using genome-wide transcriptional data has allowed us to identify the activation/inhibition of several cancer signaling pathways (e.g., inflammation, immune cell response, DNA repair, and cell proliferation) and master regulators (e.g., transcription factors, epigenetic regulators, and ligand-dependent nuclear receptors). Furthermore, we provide evidence of the regulation of a considerable set of metabolic genes involved in cancer metabolic reprogramming. Consistently, we found that ATRA treatment of NB4 cells drives the activation of aerobic glycolysis pathway and the reduction of OXPHOS-dependent ATP production. Overall, this study represents an important resource in understanding the molecular “portfolio” pivotal for APL differentiation, which can be explored for developing new therapeutic strategies.
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Arsenic Methyltransferase and Methylation of Inorganic Arsenic. Biomolecules 2020; 10:biom10091351. [PMID: 32971865 PMCID: PMC7563989 DOI: 10.3390/biom10091351] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 09/11/2020] [Accepted: 09/18/2020] [Indexed: 12/17/2022] Open
Abstract
Arsenic occurs naturally in the environment, and exists predominantly as inorganic arsenite (As (III) and arsenate As (V)). Arsenic contamination of drinking water has long been recognized as a major global health concern. Arsenic exposure causes changes in skin color and lesions, and more severe health conditions such as black foot disease as well as various cancers originating in the lungs, skin, and bladder. In order to efficiently metabolize and excrete arsenic, it is methylated to monomethylarsonic and dimethylarsinic acid. One single enzyme, arsenic methyltransferase (AS3MT) is responsible for generating both metabolites. AS3MT has been purified from several mammalian and nonmammalian species, and its mRNA sequences were determined from amino acid sequences. With the advent of genome technology, mRNA sequences of AS3MT have been predicted from many species throughout the animal kingdom. Horizontal gene transfer had been postulated for this gene through phylogenetic studies, which suggests the importance of this gene in appropriately handling arsenic exposures in various organisms. An altered ability to methylate arsenic is dependent on specific single nucleotide polymorphisms (SNPs) in AS3MT. Reduced AS3MT activity resulting in poor metabolism of iAs has been shown to reduce expression of the tumor suppressor gene, p16, which is a potential pathway in arsenic carcinogenesis. Arsenic is also known to induce oxidative stress in cells. However, the presence of antioxidant response elements (AREs) in the promoter sequences of AS3MT in several species does not correlate with the ability to methylate arsenic. ARE elements are known to bind NRF2 and induce antioxidant enzymes to combat oxidative stress. NRF2 may be partly responsible for the biotransformation of iAs and the generation of methylated arsenic species via AS3MT. In this article, arsenic metabolism, excretion, and toxicity, a discussion of the AS3MT gene and its evolutionary history, and DNA methylation resulting from arsenic exposure have been reviewed.
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