[Comparison of BCR::ABL (P210) mRNA levels detected by dPCR and qPCR methods in patients with chronic myeloid leukemia]

Objective: To compare digital polymerase chain reaction (dPCR) and real-time quantitative PCR (qPCR) measurements of BCR::ABL (P210) mRNA expression in patients with chronic myeloid leukemia (CML) . Methods: In this non-interventional, cross-sectional study, BCR::ABL (P210) mRNA was simultaneously measured by dPCR and qPCR in peripheral blood samples collected from patients with CML who underwent tyrosine kinase inhibitor therapy and who achieved at least a complete cytogenetic response from September 2021 to February 2023 at Peking University People's Hospital. The difference, correlation, and agreement between the two methods were evaluated using the Wilcoxon signed-rank test, Spearman's correlation, and Bland-Altman analysis, respectively. Results: In total, 459 data pairs for BCR::ABL mRNA expression measured by dPCR and qPCR from 356 patients with CML were analyzed. There was a significant difference in BCR::ABL mRNA expression between the two methods (P<0.001). When analyzed by the depth of the molecular response (MR), a significant difference only existed for patients with ≥MR4.5 (P<0.001). No significant difference was observed for those who did not achieve a major MR (no MMR; P=0.922) or for those who achieved a major MR (MMR; P=0.723) or MR4 (P=0.099). There was a moderate correlation between the BCR::ABL mRNA expression between the two methods (r=0.761, P<0.001). However, the correlation gradually weakened or disappeared as the depth of the MR increased (no MMR: r=0.929, P<0.001; MMR: r=0.815, P<0.001; MR4: r=0.408, P<0.001; MR4.5: r=0.176, P=0.176). In addition, the agreement in BCR::ABL mRNA expression between the two methods in those with MR4.5 was weaker than other groups (no MMR: ▉= 0.042, P=0.846; MMR:▉=0.054, P=0.229; MR4:▉=-0.020, P=0.399; MR4.5:▉=-0.219, P<0.001) . Conclusions: dPCR is more accurate than qPCR for measuring BCR::ABL (P210) mRNA expression in patients with CML who achieve a stable deep MR.

[Factors influencing severe cytopenia in chronic phase chronic myeloid leukemia patients receiving initial second generation tyrosine kinase inhibitors and its impact on treatment responses and outcomes]

Objective: To explore the influencing covariates of severe neutrophils and/or thrombocytopenia and their effect on treatment response and outcome in patients with chronic-phase chronic myeloid leukemia (CP-CML) receiving initial second-generation tyrosine kinase inhibitors (2G-TKI) . Methods: Data from consecutive patients aged ≥18 years with newly diagnosed CP-CML who received initial 2G-TKI at Peking University People's Hospital from September 2008 to November 2021 were interrogated. Binary logistic regression models and Fine-Gray and Cox regression models were applied. Results: Data from 267 patients who received initial 2G-TKI, including nilotinib (n=239, 89.5% ) and dasatinib (n=28, 10.5% ) , were interrogated. The median age was 36 (range, 18-73) years, and 156 (58.4% ) patients were male. At a median treatment period of 1.0 (0.1-3.0) month, 43 (16.1% ) patients developed grade ≥3 neutrophils and/or thrombocytopenia and recovered within 1.0 (0.1-24.6) month. Male (OR=2.9, 95% CI 1.2-6.8; P=0.018) , age of ≥36 years (OR=3.2, 95% CI 1.4-7.2, P=0.005) , a spleen below a costal margin of ≥7 cm (OR=2.8, 95% CI 1.2-6.6, P=0.020) , and a hemoglobin (HGB) level of <100 g/L (OR=2.9, 95% CI 1.3-6.8, P=0.012) at diagnosis were significantly associated with grade ≥ 3 neutrophils and/or thrombocytopenia. Based on their regression coefficients, male, age of ≥36 years, a spleen below a costal margin of ≥7 cm, and an HGB level of <100 g/L were given 1 point to form a predictive system. All patients were divided into three risk subgroups, and the incidence of severe cytopenia significantly differed among the three groups (P < 0.001) . Grade ≥3 neutrophils and/or thrombocytopenia for >2 weeks was significantly associated with lower cumulative incidences of complete cytogenetic response (CCyR, HR=0.5, 95% CI 0.3-0.7, P<0.001) and major molecular response (MMR, HR=0.4, 95% CI 0.3-0.8, P=0.004) and was not significantly associated with failure, progression, and survival. Conclusion: Male, advanced age, a large spleen, and a low HGB level were significantly associated with severe cytopenia. The four covariates were used to establish a prediction model, in which the incidence of severe cytopenia among different risk groups was significantly different. Severe cytopenia for >2 weeks was a negative factor for responses but not for outcomes.

[A scoring system to predict molecular responses in patients with chronic myeloid leukemia in the chronic phase receiving initial imatinib therapy]

Objective: To develop a scoring system to predict molecular responses in patients with chronic myeloid leukemia in the chronic phase (CML-CP) receiving initial imatinib therapy. Methods: Data from consecutive adults with newly diagnosed CML-CP treated by initial imatinib was interrogated and subjects were distributed randomly into training and validation cohort, in a ratio of 2∶1. Fine-gray models were applied in the training cohort to identify co-variates of predictive value for major molecular response (MMR) and MR4. A predictive system was built using significant co-variates. The predictive system was then tested in the validation cohort and the area under the receiver-operator characteristic curve (AUROC) was used to estimate accuracy of the predictive system. Results: 1 364 CML-CP subjects receiving initial imatinib were included in this study. Subjects were distributed randomly into training cohort (n=909) and validation cohort (n=455) . In the training cohort, the male gender, European Treatment and Outcome Study for CML (EUTOS) Long-Term Survival (ELTS) intermediate-risk, ELTS high-risk, high WBC (≥130×10(9)/L or 120×10(9)/L, MMR or MR4) and low HGB (<110 g/L) at diagnosis were significantly related with poor molecular responses and were given points based on their regression coefficients. For MMR, male gender, ELTS intermediate-risk and low HGB (<110 g/L) were given 1 point; ELTS high-risk and high WBC (≥130×10(9)/L) , 2 points. For MR4, male gender was given 1 point; ELTS intermediate-risk and low HGB (<110 g/L) were given 2 points; high WBC (≥120×10(9)/L) , 3 points; ELTS high-risk, 4 points. We divided all subjects into 3 risk subgroups according to the predictive system above. Cumulative incidence of achieving MMR and MR4 in 3 risk subgroups was significantly different in both training and validation cohort (all P values <0.001) . In the training and validation cohorts, the time-dependent AUROC ranges of MMR and MR4 predictive systems were 0.70-0.84 and 0.64-0.81, respectively. Conclusions: A scoring system combining gender, WBC, HGB level and ELTS risk was built to predict MMR and MR4 in CML-CP patients receiving initial imatinib therapy. This system had good discrimination and accuracy, which could help phsicians optimize the selsction of initial TKI-therapy.

[Observational study of chronic myeloid leukemia Chinese patients who discontinued tyrosine kinase inhibitors in the real-world]

Objective: This study aimed to observe whether the treatment-free remission (TFR) of second-generation tyrosine kinase inhibitors (TKI) in chronic myeloid leukemia (CML) is better than imatinib (IM) . Methods: The clinical data of 274 CML patients who discontinued treatment and with complete clinical data were retrospectively studied from June 2013 to March 2021. Using both univariate and multivariate Cox proportional hazards regression models, risk factors influencing TFR outcomes after drug withdrawal in CML patients were assessed. Results: A total of 274 patients were enrolled, 140 patients were women (51.1%) , with a median age of 48 (9-84) years at the time of TKI discontinuation. Prior to TKI discontinuation, 172 (62.8%) patients were treated with IM, and 102 (37.2%) had received second-generation TKI treatment, including 73 patients who had shifted from IM to a second-generation TKI and 29 patients who used second-generation TKI as the first-line treatment. The rationale for converting to a second-generation TKI are as follows: 37 patients aimed deep molecular response (DMR) to achieve TFR, seven patients changed due to IM intolerance, and 29 patients changed because of failure to achieve the optimal treatment response. The use of the last type of TKI included 96 patients (94.1%) with nilotinib, three patients (2.9%) with dasatinib, and two patients (2%) with flumatinib, including one patient who changed to IM due to second-generation TKI intolerance. No statistical differences were found in the median age at diagnosis and TKI discontinuation, sex, Sokal score, IFN treatment before TKI, median time of TKI treatment to achieve DMR, and the reasons for TKI discontinuation between the second TKI and IM (P>0.05) .The median cumulative treatment time of TKI (71.5 months vs 88 months, P<0.001) , the last TKI median treatment time (60 months vs 88 months, P<0.001) , and the median duration of DMR (58 months vs 66 months, P=0.002) were significantly shorter in the second-generation TKI compared with IM. In the median follow-up of 22 (6-118) months after TKI discontinuation, 88 patients (32.1%) had lost their MMR at a median of 6 (1-91) months; of the 53 patients (60.2%) who lost MMR within 6 months, the overall TFR rate was 67.9%, and the cumulative TFR rates at 12 and 24 months were 70.5% and 67.5%, respectively. Withdrawal syndrome occurred in 26 patients (9.5%) . For patients who restarted TKI treatment, 72 patients (83.7%) achieved DMR again at a median treatment of 4 (1 to 18) months. The univariate analysis showed that the TFR rate of patients treated with second-generation TKI was significantly higher than those who were treated with IM (77.5% vs 62.2%, P=0.041) . A further subgroup analysis found that the TFR rate of the second-generation TKI patients was significantly higher than those treated with IM (80.8% vs 62.2%, P=0.026) . No significant difference was found in the second-generation TKI used as the first line treatment compared with those who were treated with IM (69.0% vs 62.2%, P=0.599) . The multivariate analysis results showed that second-generation TKI treatment was an independent prognostic factor affecting TFR in patients who discontinued TKI (RR=1.827, 95%CI 1.015-3.288, P=0.044) . Conclusion: In the clinical setting, more CML patients rapidly achieved TFR using second-generation TKI than IM treatment.

[Combination of socio-demographic and clinical co-variates for predicting treatment responses and outcomes in patients with chronic myeloid leukemia in the chronic phase]

Objective: To explore the impacts of socio-demographic and clinical co-variates on treatment responses and outcomes in patients with chronic myeloid leukemia in the chronic phase (CML-CP) receiving tyrosine kinase inhibitor (TKI) and identified the predictive models for them. Methods: Data of newly diagnosed adult patients with CML-CP receiving first-line TKI and having complete socio-demographic data and clinical information were reviewed. Cox model was used to identify the independent variables associated with complete cytogenetic response (CCyR) , major molecular response (MMR) , molecular response 4 (MR(4)) and molecular response 4.5 (MR(4.5)) , as well as failure-free survival (FFS) , progression-free survival (PFS) , overall survival (OS) and CML-related OS. Results: A total of 1414 CML-CP patients treated with first-line imatinib (n=1176) , nilotinib (n=170) or dasatinib (n=68) were reviewed. Median age was 40 (18-83) years and 873 patients (61.7% ) were males. Result of the multivariate analysis showed that lower educational level (P<0.001-0.070) and EUTOS long-term survival intermediate or high-risk (P<0.001-0.009) were significantly associated with lower cumulative incidences of CCyR, MMR, MR(4) and MR(4.5), as well as the inferior FFS, PFS, OS and CML-related OS. In addition, those who were males, from rural households, had white blood cells (WBC) ≥120×10(9)/L, hemoglobin (HGB) <115 g/L and treated with first-line imatinib had significantly lower cumulative incidences of cytogenetic and/or molecular responses. Being single, divorced or widowed, having, rural household registration, WBC≥120×10(9)/L, HGB<15 g/L, and comorbidity (ies) was significantly associated with inferior FFS, PFS, OS, and/or CML-related OS. Thereafter, the patients were classified into several subgroups using the socio-demographic characteristics and clinical variables by cytogenetic and molecular responses, treatment failure and disease progression, as well as overall survival and CML-related OS, respectively. There were significant differences in treatment responses and outcomes among the subgroups (P<0.001) . Conclusion: Except for clinical co-variates, socio-demographic co-variates significantly correlated with TKI treatment responses and outcomes in CML-CP patients. Models established by the combination of independent socio-demographic and clinical co-variates could effectively predict the responses and outcome.

[Treatment status of tyrosine kinase inhibitors in Chinese patients with chronic myeloid leukemia in 2020]

目的

调查中国慢性髓性白血病（CML）患者的治疗现状。

方法

横断面研究，2020年4月末至5月中旬，以填写调研问卷的形式在全国范围内调研CML患者，分析酪氨酸激酶抑制剂（TKI）一线选择、目前用药、药物转换和获得主要分子学反应（MMR）的比例及其影响因素。

结果

2933份来自全国31个省市自治区CML受访者的问卷可供分析，男性1683例（57.4％），中位年龄38（16～87）岁。一线选择：伊马替尼2481例（84.6％），原创性新药（原研药）1803例（61.5％）。填写问卷时用药：伊马替尼1765例（60.2％），原研药1791例（61.1％）。共1185例（40.4％）受访者曾经历TKI药物转换。1944例初发慢性期受访者TKI中位治疗45（3～227）个月，1417例（72.9％）获得≥MMR的疗效。多因素分析显示，城镇户籍（OR＝0.6，95％CI 0.5～0.8，P<0.001）、≥大学学历（OR＝0.5，95％CI 0.4～0.7，P<0.001）和进展期（OR＝0.5，95％CI 0.3～0.8，P＝0.001）受访者更少首选仿制TKI，而来自中部地区受访者比东部地区更多首选国产仿制TKI（OR＝1.7，95％CI 1.4～2.0，P<0.001）。进展期受访者更多首选二代TKI（OR＝5.4，95％CI 3.6～8.2，P<0.001），≥60岁受访者更少首选二代TKI（OR＝0.4，95％CI 0.2～0.7，P＝0.002）。诊断时处于进展期（OR＝2.2，95％CI 1.6～3.2，P<0.001）、首选伊马替尼（OR＝2.0，95％CI 1.6～2.6，P<0.001）、首选国产仿制药（OR＝1.3，95％CI 1.1～1.6，P＝0.002）、诊断距开始TKI治疗的时间更长（OR＝1.2，95％CI 1.1～1.2，P<0.001）和服用TKI的时间更长（OR＝1.1，95％CI 1.0～1.1，P<0.001）与药物转换比例增高显著相关。城镇户籍（OR＝0.7，95％CI 0.6～0.8，P<0.001）、获≥MMR（OR＝0.6，95％CI 0.5～0.8，P<0.001）和疗效未知（OR＝0.7，95％CI 0.6～0.9，P＝0.003）与药物转换比例低显著相关。女性（OR＝1.4，95％CI 1.1～1.7，P＝0.003）、城镇户籍（OR＝1.6，95％CI 1.3～2.0，P<0.001）、初始服用伊马替尼（OR＝1.4，95％CI 1.1～1.9，P＝0.016）和TKI治疗时间更长（OR＝1.2，95％CI 1.2～1.3，P<0.001）与获得≥MMR显著相关，而年龄≥60岁（OR＝0.7，95％CI 0.4～1.0，P＝0.047）和药物转换（OR＝0.6，95％CI 0.5～0.7，P<0.001）与未获得MMR显著相关。

结论

截至2020年，中国CML患者中大多数首选并持续服用伊马替尼，半数以上服用原研药。社会人口学特征和疾病分期影响了患者的TKI选择、药物转换和治疗反应。

[Clinical characteristics, treatment pattern, and outcomes in newly diagnosed patients with chronic myeloid leukemia in the chronic phase by age]

目的

探讨初发慢性髓性白血病慢性期（CML-CP）不同年龄患者的临床特征、治疗和结局。

方法

回顾性分析2006年1月至2019年12月在北京大学人民医院确诊的≥14岁初诊酪氨酸激酶抑制剂（TKI）一线治疗的CML-CP连续病例。

结果

共收集957例患者，男性597例（62.4％），中位年龄40（14～83）岁。按年龄分为<40岁组（470例，49.1％）、40～59岁组（371例，38.8％）和≥60岁组（116例，12.1％）。随年龄增长，初诊时脾大（P<0.001）、WBC≥100×10⁹/L（P<0.001）、贫血（P<0.001）、PLT<450×10⁹/L（P＝0.022）、外周血原始细胞比例高（P＝0.010）和具有Ph染色体附加异常（P＝0.006）的患者比例降低，有合并症（P<0.001）、Sokal积分中/高危（P<0.001）和初始选择伊马替尼（P<0.001）的患者比例增高。而性别、ELTS危险度分布在各年龄组间差异无统计学意义（P值均>0.05）。多因素分析显示，≥60岁仅是影响患者总生存（OS）的不利因素（OR＝3.7, 95％ CI 1.5～9.2, P＝0.005），年龄与治疗反应和其他结局无显著相关性。TKI治疗中，随年龄增长，非血液学不良反应发生率显著增加（P<0.001），而血液学不良反应发生率相似。随访末期，随年龄增长，仍服用伊马替尼（P＝0.026）和服用减量TKI（P<0.001）的患者比例显著增加。

结论

初发CML-CP不同年龄组患者的临床特征、TKI用药选择和剂量、治疗反应、OS期和非血液学不良反应发生率存在差异。

[Effect of imatinib on the height of children with chronic myeloid leukemia in the chronic phase]

目的

评估伊马替尼对慢性髓性白血病慢性期（CML-CP）儿童身高的影响。

方法

2018年7月至2019年7月，在全国范围内对诊断时年龄<18周岁、接受伊马替尼治疗至少3个月的CML儿童或其家长发放问卷，调查受访者伊马替尼治疗前后身高的变化。主要评价指标为身高标准差积分值（HtSDS）以及标准差积分的差值（ΔHtSDS），并分析其相关影响因素。

结果

共有238例受访者符合标准并被纳入研究，男性138例（58.0％），初诊时中位年龄11.0（1.4～17.9）岁，青春期前93例（39.0％），至填写答卷时，中位年龄15.0（2.0～34.0）岁，中位伊马替尼服药时间28（3～213）个月。受访者填写答卷时HtSDS（−0.063±1.361）较治疗前HtSDS（0.391±1.244）显著下降（P<0.001），71.0％的患儿出现身高增长减慢。青春期前服药者治疗后HtSDS下降显著（P<0.05），而青春期开始后服药者HtSDS变化不明显（P>0.05）。多因素分析显示，服药初始年龄较小（偏回归系数为0.122，B＝0.572，t＝10.733，P<0.001）和服药时间较长（偏回归系数为−0.006，B＝−0.211，t＝−4.062，P<0.001）是伊马替尼抑制身高增长的独立影响因素。

结论

伊马替尼引起CML-CP儿童身高增长障碍，服药初始年龄越小、服药时间越长，伊马替尼对身高的影响越明显。

[Efficacy of nilotinib in the first-line treatment of chronic myeloid leukemia and the analysis of factors affecting molecular responses]

Objectives: This study aimed to investigate the efficacy and safety of nilotinib as the first-line treatment for patients with chronic myelogenous leukemia (CML) and analyze the factors affecting the realization of the major molecular response. Methods: A retrospective study was conducted on 86 newly diagnosed CML patients from the Affiliated Cancer Hospital of Zhengzhou University from January 2014 to June 2017, who were using nilotinib 300 mg, twice a day, as the first-line treatment. There were 49 males and 37 females. Results: At 12 months, the MMR, MR4, and MR4.5 rates were 59.3%, 22.1%, and 15.1%, respectively. At 24 months, the MMR, MR4, and MR4.5 rates were 76.2%, 44.0%, and 27.4%, respectively.The median follow-up time was 42 months (range, 21-66 months) . The median progression-free survival time (PFS) was 42 months (range, 9-66 months) at a PFS rate of 93%. The time required for BCR-ABL transcript to decrease by half compared with the diagnosis was defined as the halving time (HT) . HT was the influencing factor of the 12-month MMR (OR=0.896, P<0.001) and MR4.5 (OR=0.377, P=0.003) . The most common non-hematologic adverse reactions were rash (37.2%) and headache (32.6%) , and most were grade 1/2. The most common hematologic adverse reactions were mainly neutropenia (27.9%) and thrombocytopenia (32.4%) . Conclusion: Nilotinib was an effective and safe first-line treatment for CML patients. HT ≤ 13.68 days is protective factor for long-term progression-free survival.

[Variables associated with BCR-ABL kinase domain mutation in TKI-resistant patients with chronic myeloid leukemia]

Objectives: To explore BCR-ABL kinase domain mutation profiles and clinical variables associated with them in tyrosine kinase inhibitor (TKI) -resistant patients with chronic myeloid leukemia (CML) . Methods: Imatinib-, nilotinib-, and/or dasatinib-resistant patients with CML who screened BCR-ABL mutation (s) in Peking University People's Hospital between June 2001 and September 2019 were retrospectively reviewed. BCR-ABL mutation was analyzed by Sanger sequencing. Binary logistic regression model was built to identify independent clinical variables associated with developing BCR-ABL mutation (s) . Results: Data of 1 093 TKI-resistant cases in 804 patients who experienced resistance to imatinib (n=576, 52.7%) , nilotinib (n=238, 21.8%) , and dasatinib (n=279, 25.5%) were analyzed. In total, 291 (50.5%) imatinib-, 152 (63.9%) nilotinib-, and 160 (57.3%) dasatinib-resistant cases developed BCR-ABL mutation (s) . T315I mutation was the most frequent mutation detected in imatinib-, nilotinib-, and dasatinib-resistant cases, accounting for 12.3%, 27.3%, and 34.1%, respectively. Y253F/H (7.5%) and F359V/C/I (5.6%) were the mutation detected in ≥5% imatinib-resistant cases; F359V/C/I (12.2%) , Y253F/H (11.8%) , and E255K/V (10.5%) in nilotinib-resistant cases; and F317L/V/I/C (11.5%) and E255K/V (5.4%) in dasatinib-resistant cases. In multivariate analyses, no TKI dose reduction or discontinuation of TKI therapy was the common variable associated with developing BCR-ABL mutation (s) . Other variables associated with developing BCR-ABL mutation (s) in imatinib-, nilotinib-, or dasatinib-resistant cases included male gender, younger age, no comorbidity, advanced phase before starting current TKI therapy, longer interval from diagnosis to starting current TKI therapy, acquired resistance, and TKI resistance due to progression to advanced phase or hematologic failure. In addition, interval from TKI failure to BCR-ABL mutation detection, starting initial TKI therapy to TKI failure, and starting current TKI therapy to TKI failure were associated with the frequency of developing BCR-ABL mutation. Dasatinib and nilotinib use and acquired resistance were identified to be associated with the development of T315I mutation in multivariate analyses. Conclusions: More than half of TKI-resistant CML patients developed BCR-ABL mutation (s) by Sanger sequencing. T315I mutation was the most frequently detected. Clinical variables significantly associated with developing BCR-ABL mutation (s) should be used not only as basis for the choice of subsequent TKIs but also the understanding of TKI-resistant mechanisms.

[Effect of nilotinib on pregnancy outcome in female patients with chronic myeloid leukemia]

目的

观察尼洛替尼（NIL）治疗期间女性慢性髓性白血病（CML）患者的妊娠结果。

方法

回顾性收集2015年3月至2019年1月接受NIL治疗期间妊娠的CML患者的治疗情况和生育相关信息。

结果

11例患者，妊娠时中位年龄28（25～40）岁。妊娠前NIL中位治疗34（3～48）个月。11例患者共妊娠12例次，计划妊娠2例次，意外妊娠10例次（83.3％）。10例次意外妊娠患者，妊娠早期NIL暴露剂量600 mg/d者9例（90.0％），NIL中位暴露4（4～7）周，NIL暴露4周者8例次（80.0％）。已知生育结果8例次，其中5例次生产正常婴儿，2例次自然流产，1例次生产并指畸形男婴，其母亲妊娠早期NIL 600 mg/d暴露7周。11例女性患者共生产7例婴儿，男4例，女3例，出生时中位身高50（41～54）cm，中位体重3.2（3.0～4.6）kg。目前，7例患者所生子女生长发育均正常，中位年龄19（4～41）个月。12例次患者妊娠时疾病状态：完全分子学反应3例次、分子学反应4.0（MR^4.0）2例次、主要分子学反应（MMR）3例次、未达MMR 4例次，妊娠期间中位停药35（15～36）周，无患者失去完全血液学反应。

结论

妊娠早期NIL 600 mg/d暴露4周的女性CML患者可生产正常婴儿，但仍有自然流产和生产先天畸形儿的可能。

[Analysis of correlation between plasma trough level and response of generic imatinib in the treatment of Chinese patients with chronic myeloid leukemia]

Objective: To analyze the correlation between plasma trough level of generic imatinib and its metabolism and clinical outcomes in Chinese patients with chronic myeloid leukemia in chronic phase (CML-CP) . Methods: The 21 patients with CML-CP who enrolled in a clinical trial YMTN 1.0 from Oct 11(th), 2012 to May 8(th), 2013 and received generic imatinib were as study subjects. The correlation between steady plasma trough levels of imatinib and its metabolism with clinical response, age, weight and body surface area (BSA) were evaluated. Results: ①The mean steady plasma trough level of generic imatinib and its metabolism was (1 185.07±417.91) μg/L and (251.53±76.50) μg/L, respectively. ②Age, weight and BSA has no significant effects on plasma trough level of generic imatinib and its metabolism (P>0.05) . ③Patients with steady plasma trough level of generic imatinib more than 1 000 μg/L are possible to have higher major molecular response (MMR) /complete molecular response (CMR) rate than those below 1 000 μg/L (42% vs 0, P<0.05) . Conclusion: Plasma trough levels of generic imatinib varied in CML patients. The steady plasma trough levels of generic imatinib is maybe related to molecular response in CML patients.

[Comparison of the efficacy and safety of Chinese generic imatinib and branded imatinib in patients with chronic myeloid leukemia in consideration of demographic characteristics]

目的

比较国产和原研伊马替尼一线治疗慢性髓性白血病慢性期（CML-CP）患者的有效性和安全性；探索服用原研伊马替尼获得完全细胞遗传学反应（CCyR）后转换为国产伊马替尼的患者疾病的稳定性和不良反应的变化。

方法

①一线治疗组：回顾性收集和分析2013年10月至2018年8月期间，接受国产仿制伊马替尼（商品名昕维®）或进口原研伊马替尼（商品名格列卫®）作为一线治疗并定期随访、监测的CML-CP连续病例。②转换组：回顾性收集和分析2006年12月至2016年9月期间，接受原研伊马替尼至少获得CCyR后转换为国产仿制伊马替尼治疗的CML-CP连续病例。

结果

①一线治疗组：共409例（国产伊马替尼201例，原研伊马替尼208例）患者入组，中位年龄42（18~83）岁。国产和原研组患者人口学特征差异具有统计学意义：国产伊马替尼组患者中受教育水平更低（P<0.001）、离异或丧偶者比例更高（P=0.004）、农村户籍者比例更高（P<0.001）。两组年龄、性别、Sokal危险度评分、WBC和HGB水平的差异无统计学意义。中位随访25（3~62）个月，国产伊马替尼组和原研伊马替尼组的3年CCyR、主要分子学反应（MMR）、分子学反应4.0（MR4.0）和分子学反应4.5（MR4.5）的累积获得率差异均无统计学意义（97.5%对94.5%，P=0.592；84.3%对93.1%，P=0.208；42.7%对41.7%，P=0.277；25.4%对33.0%，P=0.306），3年无失败生存（FFS）率、无进展生存（PFS）率和总生存（OS）率差异亦无统计学意义（76.7%对81.0%，P=0.448；91.8%对96.3%，P=0.325；95.8%对98.5%，P=0.167）。多因素分析显示，TKI类型不影响患者的治疗反应（CCyR、MMR、MR4.0和MR4.5累积获得率）及结局（FFS、PFS和OS）。两组不良反应发生率也相似。②转换组：共39例患者入组，中位年龄42（23~80）岁，于原研伊马替尼中位治疗38（8~114）个月后换为国产伊马替尼，换药后中位随访39（6~63）个月，23例（58.9%）患者分子学反应维持原来水平，12例（30.8%）分子学反应改善。新发药物不良反应均可耐受。

结论

人口学特征影响CML-CP患者的用药选择。在规范的监测和管理下，国产与原研伊马替尼一线治疗CML-CP患者的有效性和安全性相当。对于接受原研伊马替尼后获得稳定治疗反应的患者，可有效、安全地转换为国产伊马替尼。

[The influence of additive clonal chromosome abnormalities in Ph negative cells on the efficacy of chronic myeloid leukemia]

Objective: To investigate the influence of additional clonal chromosome abnormalities in Ph negative cells (CCA/Ph(-)) on the efficacy of chronic myeloid leukemia (CML) after tyrosine kinase inhibitors (TKI) treatment. Methods: The clinical data of 28 CML patients with CCA/Ph(-) treated in Henan Cancer Hospital from July 2014 to December 2017 were analyzed retrospectively. The univariate analysis was carried out by Kaplan-Meier method. Multivariate analysis was done by Cox proportional risk model. Results: A total of 28 CCA/Ph(-)patients were recruited including 17 males and 11 females with median age of 42.5 years old. The most common CCA/Ph(-)were trisomy 8 (60.7%), monosomy 7 (14.3%). 64.3% CCA/Ph(-)were transient and 35.7% recurrent (more than 2 times). Cytopenia in two or three lineages of peripheral blood was seen in 42.9% patients. As to the efficacy, 89.3% patients achieved major cytogenetic response (MCyR), 25% with major molecular response (MMR). The median follow-up time was 26.5 months. Treatment failure (TF) of TKI occurred in 32.1% patients with median duration of response 8 (1-41) months. Univariate analysis showed that TF rate was significantly correlated with the frequency of CCA/Ph(-)and cytopenia (all P<0.05). The MMR rate was also significantly correlated with cytopenia (P<0.05). Cytopenia of two lineages or pancytopenia was an independent risk factor related to MMR rate (RR=3.868, 95%CI 1.216-12.298, P=0.022) . Conclusions: Cytopenia in CCA/Ph(-)appears to be an independent risk factor of MMR in CML patients with TKI treatment. The recurrent CCA/Ph(-)may link to higher treatment failure rate. Drug withdrawal or alternative strategy should be considered according to response and the ABL kinase mutations.

[Efficacy and safety of domestic dasatinib as second-line treatment for chronic myeloid leukemia patients in the chronic phase]

目的

探讨国产酪氨酸激酶抑制剂（TKI）达沙替尼（商品名：依尼舒）二线治疗慢性髓性白血病慢性期（CML-CP）患者的疗效及安全性。

方法

回顾性分析2016年3月至2018年7月湖北省CML协作组成员医院收治的二线服用国产达沙替尼的CML-CP患者的病例资料，统计患者治疗3、6和12个月时最佳反应率、累积完全细胞遗传学反应（CCyR）率、累积主要分子学反应（MMR）率、无进展生存（PFS）、无事件生存（EFS）情况及不良反应情况。

结果

共纳入83例CML-CP患者，中位随访时间为23（4~45）个月，达沙替尼治疗3、6、12个月最佳反应率分别为77.5%（54/71）、72.6%（61/75）、60.7%（51/69）。至随访截止，累积CCyR率、MMR率分别为65.5%（55/80）、57.1%（48/73），达CCyR和MMR的中位时间均为3个月。随访时间内，PFS率为94.0%（79/83），EFS率为77.4%（65/83）。国产达沙替尼最常见非血液学不良反应为水肿（32.5%），其次为皮疹瘙痒（18.1%）、乏力（13.3%），血液学不良反应主要有血小板减少（31.3%）、白细胞减少（19.3%）和贫血（6.0%）。

结论

国产达沙替尼二线治疗CML-CP患者具有较好的疗效及安全性，可作为CML-CP患者的治疗选择。

[Tyrosine kinase inhibitors discontinuation for chronic myeloid leukemia: a multicenter retrospective analysis in China]

目的

回顾性分析中国慢性髓性白血病（CML）酪氨酸激酶抑制剂（TKI）自动停药患者的临床特征及转归情况。

方法

回顾性分析2005年6月1日至2018年3月1日国内7家单位109例自动停用TKI的慢性期CML患者临床资料，将其中具有明确停药结局及相对完整临床资料的91例患者进行统计分析，观察患者自动停药后获得无治疗缓解（TFR）情况及其影响因素。

结果

91例患者累积服用TKI中位时间为65（7~138）个月，其中21例患者有减停药史；患者达到主要分子学缓解（MMR）中位时间为开始服用TKI后6（3~57）个月；全部患者停药前达MR^4.0。停药后中位随访9（1~72）个月，53例（58.2%）患者继续维持MMR，获得TFR；38例（41.8%）失去MMR。12个月和25个月的TFR率分别为61.4%和52.6%。31例停药后复发的患者再启动药物治疗，用药后再获得MMR的中位时间为3（1~12）个月。对比分析发现，Sokal评分（P=0.294）、累积服用TKI时间（P=0.827）、获得MMR所需时间（P=0.553），是否减停TKI（P=0.125）等因素对复发无明显影响。而停药前MMR维持时间越长（≥24个月）患者后期复发率越低（P=0.027）。

结论

达停药标准的中国CML患者能够安全停用TKI，停药后TFR率与国外报道相当。停药前MMR时间维持越长，停药后复发率越低。

[Mechanisms of recombinant adenovirus-mediated SD-HA fusion protein proliferation inhibition and induced apoptosis of K562 cells]

Objective: To investigate whether fusion protein SD-HA could regulate its downstream signaling molecule activity by competing with the phospho-BCR-ABL Y177 site, and its mechanisms to inhibit proliferation and induce apoptosis of K562 cells. Methods: Co-immunoprecipitation interaction technology analysis of fusion protein SD-HA functioned by potently binding to the phospho-BCR-ABL Y177 site, Ras, MAPK and Akt activities were observed in the Ad5F35-SD-HA-treated cells. Western blot analyses of SD-HA fusion protein on cell membrane receptor pathway to death cascade caspase-8, caspase-3 and PRAP were performed. Results: Exploration into the underlying mechanisms revealed that Ad5F35-SD-HA infection functioned by binding to the phospho-BCR-ABL Y177 site, which lead to a complex with Grb2. competitively disrupted the Grb2 SH2-phospho-BCR-ABL Y177 formation. The fusion protein SD-HA could reduce the activation of Ras and phosphorylation of MAPK (p-MAPK) and the expression level of p-ELK, inhibition of Ras-MAPK signaling pathway; SD-HA fusion protein could reduce p-Akt and Akt substrate p-GSK with inhibition of PI3K-Akt signaling pathway, thereby inhibiting the proliferation of K562 cells. Caspases-8-induced apoptosis signal could be activated by DED protein binding to DED domain of precursor caspases-8. Conclusions: The strategy of fusion protein SD-HA inhibiting-Y177 BCR-ABL and Grb2 binding could be used as a novel entry point for the treatment of chronic myeloid leukemia.

[The molecular-cytogenetic characterization and tyrosine kinase inhibitors efficacy in newly diagnosed chronic phase CML patients with variant Philadelphia chromosomes]

Objective: To investigate the molecular-cytogenetic characterization and impact on tyrosine kinase inhibitors (TKIs) therapy in chronic phase of chronic myeloid leukemia (CML-CP) patients with variant Ph chromosome (vPh). Methods: The clinical data of 32 patients with vPh chromosomes were collected and compared with 703 patients with typical Ph chromosome in newly diagnosed CML-CP who were on first-line imatinib (IM) and with BCR-ABL transcript of P210. Results: There was no significant difference in demographic and hematological characteristics between vPh and classic Ph patients. 3(9.4%) of the 32 vPh cases were simple variant translocations. Among the remaining 29 cases with complex variant translocations, 28 cases (87.5%) involved 3 chromosomes, and only 1 (3.1%) involved 4 chromosomes. Except for 8, 15, 18, X, and Y chromosomes, the other chromosomes were involved. The frequency of chromosome 12q(15.5%) and 1p (12.1%) were higher involved. The most common FISH signal pattern was 2G2R1Y (74.1%), followed by 1G1R2F (14.8%), 2G1R1Y (3.7%), 1G2R1Y (3.7%), 1G1R1Y (3.7%). The comparison of complete cytogenetic response (CCyR) (P=0.269), major molecular response (MMR) (P=0.391) were carried out between simple and complex mechanisms, without difference. Compared with the classic Ph, the patients with vPh had higher IM primary resistance rate (χ2=3.978, P=0.046), especially primary hematological resistance (χ2=7.870, P=0.005), but the difference of CCyR (χ2=0.192, P=0.661), MMR (χ2=0.822, P=0.365), EFS (χ2=0.509, P=0.476), OS (χ2=3.485, P=0.062) were not statistically significant, and multivariate analysis showed that the presence of vPh did not affect OS (RR=0.692, 95%CI 0.393-1.765, P=0.658)、EFS (RR=0.893, 95%CI 0.347-2.132, P=0.126) and PFS (RR=1.176, 95%CI 0.643-2.682, P=0.703). Conclusion: CML-CP patients with vPh and classic Ph had similar demographic and hematological characteristics. Except for 22q11, 9q34, the frequency of chromosome 12q and 1p were higher involved. The most common FISH signal pattern was 2G2R1Y, and different mechanisms had no impact on TKIs therapy. Compared with cases with classic Ph chromosomes, the patients with vPh chromosomes had higher risk of IM primary resistance, especially primary hematological resistance, which can obtain deeper molecular response quickly after changing to second-generation TKIs and didn't affect long-term outcomes and OS.

[Comparison of generic and original imatinib in the treatment of newly diagnosed patients with chronic myelogenous leukemia in chronic phase: a multicenter retrospective clinical study]

Objective: To evaluate the efficacy and safety of generic imatinib (Genike, Chiatai Tianqing Pharmaceutical Group Co., Ltd.) and imatinib (Glevic, Novartis, Switzerland) in newly diagnosed patients with chronic myeloid leukemia in chronic phase (CML-CP) . Methods: A retrospective study of 323 CML-CP patients (205 in Glivec treatment group and 118 in Genike group) who were ≥ 18 years old receiving imatinib monotherapy over the period of June 2013 to March 2016 was done to compare the differences of cytogenetics, molecular curative effect, survival, and adverse reactions between the two groups. The beginning dosage of imatinib was 400mg per day. There was no statistically difference between the two groups of patients on baseline. Results: ①The median duration of imatinib treatment was 13 (0.5-36) months in Glevic group and 11 (1-31) months in Genike group. ②The rate of complete hematological remission (CHR) had no statistically difference between Glivec and Genike treatment groups[98% (201/205) vs 97.5% (115/118) , χ(2)=0.123, P=0.725]. ③Cumulative rates of major cytogenetic responses (MCyR) at 3, 6 and 12 months after imatinib treatment in Gleevec and Genike groups were (59.7±3.5) % vs (79.8±3.1) %, (89.2±2.6) % vs (59.1±4.7) %, (80.3±4.1) % vs (87.1±4.3) %, respectively, the difference was not statistically significant (χ(2)=0.084, P=0.772) . Cumulative rates of complete cytogenetic response (CCyR) at 3, 6 and 12 months after imatinib treatment in Gleevec and Genike groups were (32.9±3.4) % vs (58.3±3.7) %, (87.4±3.0) % vs (35.2±4.5) %, (64.8±4.8) % vs (87.3±4.7) %, respectively, the difference was not statistically significant (χ(2)=0.660, P=0.417) . ④Cumulative rates of major molecular responses at 6, 12 months after imatinib treatment in Glevic and Genike groups were (24.9±3.3) % vs (57.0±4.1) %, (16.3±4.0) % vs (55.3±7.7) %, respectively, there was no statistical significance (χ(2)=1.617, P=0.204) . Cumulative rates of molecular response 4.5 (MR4.5) at 12 months after imatinib treatment in Glevic and Genike groups were (14.9±3.2) % vs (8.1±2.1) % (χ(2)=3.628, P=0.057) , respectively. ⑤At a median follow-up of 12 months, the difference of progression-free survival (PFS) in Glevic and Genike groups had no statistical significance[ (96.6±1.4) % vs (93.3±2.5) %, χ(2)=2.293, P=0.130]. The difference of event-free survival (EFS) had no statistical significance, either[ (95.6±1.5) % vs (93.3±2.4) %, χ(2)=2.124, P=0.145]. ⑥Genike was well tolerated in patients with CML-CP and had no statistically significant difference in adverse events compared with Glevic group. Conclusion: There were no statistically significant differences in efficacy and safety between Glevic and Genike treatment in newly diagnosed patients with CML-CP.