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Wu X, Manske MK, Ruan GJ, Witter TL, Nowakowski KE, Abeykoon JP, Tang X, Yu Y, Gwin KA, Wu A, Taupin V, Bhardwaj V, Paludo J, Dasari S, Dong H, Ansell SM, Badley AD, Schellenberg MJ, Witzig TE. Secreted ORF8 induces monocytic pro-inflammatory cytokines through NLRP3 pathways in patients with severe COVID-19. iScience 2023; 26:106929. [PMID: 37260746 PMCID: PMC10193824 DOI: 10.1016/j.isci.2023.106929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 04/06/2023] [Accepted: 05/16/2023] [Indexed: 06/02/2023] Open
Abstract
Despite extensive research, the specific factor associated with SARS-CoV-2 infection that mediates the life-threatening inflammatory cytokine response in patients with severe COVID-19 remains unidentified. Herein we demonstrate that the virus-encoded Open Reading Frame 8 (ORF8) protein is abundantly secreted as a glycoprotein in vitro and in symptomatic patients with COVID-19. ORF8 specifically binds to the NOD-like receptor family pyrin domain-containing 3 (NLRP3) in CD14+ monocytes to induce inflammasomal cytokine/chemokine responses including IL1β, IL8, and CCL2. Levels of ORF8 protein in the blood correlate with severity and disease-specific mortality in patients with acute SARS-CoV-2 infection. Furthermore, the ORF8-induced inflammasome response was readily inhibited by the NLRP3 inhibitor MCC950 in vitro. Our study identifies a dominant cause of pathogenesis, its underlying mechanism, and a potential new treatment strategy for severe COVID-19.
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Affiliation(s)
- Xiaosheng Wu
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Michelle K Manske
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Gordon J Ruan
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Taylor L Witter
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN 55905, USA
| | - Kevin E Nowakowski
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Jithma P Abeykoon
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Xinyi Tang
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Yue Yu
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN 55905, USA
| | - Kimberly A Gwin
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Annie Wu
- Department of Immunology, Mayo Clinic, Rochester, MN 55905, USA
| | - Vanessa Taupin
- Electron Microscopy Core, University of California San Diego, La Jolla, CA, USA
| | - Vaishali Bhardwaj
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Jonas Paludo
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Surendra Dasari
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN 55905, USA
| | - Haidong Dong
- Department of Immunology, Mayo Clinic, Rochester, MN 55905, USA
| | - Stephen M Ansell
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Andrew D Badley
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Thomas E Witzig
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Ruan GJ, Wu X, Manske MK, Nowakowski KE, Abeykoon JP, Tang X, Yu Y, Witter TL, Taupin V, Paludo J, Ansell SM, Badley AD, Schellenberg MJ, Witzig TE. The SARS-CoV-2 encoded ORF8 protein Stimulates Human Monocytes to Produce Pro-Inflammatory Cytokines. The Journal of Immunology 2022. [DOI: 10.4049/jimmunol.208.supp.125.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Abstract
Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can result in a cytokine storm that is associated with poor outcomes in patients. The activation of a NOD-like receptor pyrin domain containing 3 (NLRP3) inflammasome following SARS-CoV-2 infection has been shown to play a major role in inflammatory immune responses. In this study, we show that open reading frame 8 (ORF8) protein is abundantly secreted as a glycoprotein in vitro. The glycosylated ORF8 stimulates human CD14+/CD16+ monocytes to cause upregulation of proinflammatory cytokine production and cell surface marker expression within 24 hours. The data suggests that stimulation of human monocytes by ORF8 is not receptor mediated. Rather, ORF8 is likely phagocytosed by human monocytes. ORF8 then stimulates the monocytes by independently binding to the NACHT and LRR domains of the NLRP3 protein. Pharmacologic inhibition of NLRP3 significantly diminished the production of pro-inflammatory cytokines from ORF8-stimulated human monocytes. Finally, this study shows that the ORF8 protein is also secreted in patients with newly diagnosed coronavirus disease 2019 (COVID-19). Levels of ORF8 in the blood of patients diagnosed with COVID-19 correlated with disease mortality and trajectory of disease. ORF8 stimulation of monocytes causes pro-inflammatory cytokine production that leads to the development of severe COVID-19.
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Affiliation(s)
| | | | | | | | | | | | - Yue Yu
- 2Quantitative Health Sciences, Mayo Clinic Rochester
| | | | - Vanessa Taupin
- 4Electron Microscopy Core, University of California San Diego
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3
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Abeykoon JP, Lasho TL, Dasari S, Rech KL, Ranatunga WK, Manske MK, Tisher A, Ravindran A, Young JR, Tobin WO, Flanagan EP, Nowakowski KE, Ruan GJ, Shah MV, Bennani NN, Vassallo R, Ryu JH, Koster MJ, Davidge-Pitts CJ, Patnaik MM, Wu X, Witzig TE, Goyal G, Go RS. Sustained, complete response to pexidartinib in a patient with CSF1R-mutated Erdheim-Chester disease. Am J Hematol 2022; 97:293-302. [PMID: 34978715 PMCID: PMC9536810 DOI: 10.1002/ajh.26441] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 12/15/2021] [Indexed: 12/19/2022]
Abstract
Erdheim-Chester disease (ECD) is a histiocytic neoplasm that predominantly harbors mitogen-activated protein kinase (MAPK) pathway variants. MAPK inhibitors typically are effective treatments, but mutations outside the MAPK pathway, such as CSF1R variants, may cause refractory ECD. We describe a patient with a novel somatic mutation in CSF1R (CSF1RR549_E554delinsQ ) that resulted in refractory ECD affecting the central nervous system. Cell model studies, RNA sequencing analysis, and in silico protein modeling suggested that she had a gain-of-function mutation occurring in a region critical for autoinhibition. The patient was treated with pexidartinib, a CSF1R inhibitor, and has had a complete clinical and metabolic response lasting more than 1.5 years to date. To our knowledge, this is the first report to describe successful treatment of a patient with ECD by using an agent that specifically targets CSF1R. This case also highlights the critical role of individualized molecular profiling to identify novel therapeutic targets in ECD.
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Affiliation(s)
| | | | - Surendra Dasari
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Karen L. Rech
- Division of Hematopathology, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | | | | | | | | | | | - Robert Vassallo
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jay H. Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Xiaosheng Wu
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Gaurav Goyal
- Division of Hematology-Oncology, University of Alabama at Birmingham, Birmingham, AL;,Research Collaborator (limited-tenure), Division of Hematology, Mayo Clinic, Rochester, MN
| | - Ronald S. Go
- Division of Hematology, Mayo Clinic, Rochester, MN
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4
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Abeykoon JP, Hampel PJ, King RL, Wood AJ, Larson MC, Nowakowski KE, Zanwar SS, Dasari S, Ruan GJ, Ravindran A, Wellik LE, Paludo J, Link BK, Cerhan JR, Ansell SM, Nowakowski GS, Thompson CA, Maurer MJ, Wenzl K, Novak AJ, Wu X, Habermann TM, Witzig TE. The significance of gradient expression of chromosome region maintenance protein 1 (exportin1) in large cell lymphoma. Haematologica 2021; 106:2261-2264. [PMID: 33657788 PMCID: PMC8327726 DOI: 10.3324/haematol.2020.278277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Indexed: 12/02/2022] Open
Affiliation(s)
| | - Paul J Hampel
- Division of Hematology, Department of Internal Medicine
| | - Rebecca L King
- Division of Hematopathology, Department of Laboratory Medicine and Pathology
| | - Adam J Wood
- Division of Hematopathology, Department of Laboratory Medicine and Pathology
| | - Melissa C Larson
- Department of Health Sciences Research,Mayo Clinic, 200 First Street SW, Rochester, MN, 55905
| | | | | | - Surendra Dasari
- Department of Health Sciences Research,Mayo Clinic, 200 First Street SW, Rochester, MN, 55905
| | - Gordon J Ruan
- Division of Hematology, Department of Internal Medicine
| | - Aishwarya Ravindran
- Division of Hematopathology, Department of Laboratory Medicine and Pathology
| | | | - Jonas Paludo
- Division of Hematology, Department of Internal Medicine
| | - Brian K Link
- Division of Hematology, University of Iowa, Iowa City, IA
| | - James R Cerhan
- Department of Health Sciences Research,Mayo Clinic, 200 First Street SW, Rochester, MN, 55905
| | | | | | | | - Matthew J Maurer
- Department of Health Sciences Research,Mayo Clinic, 200 First Street SW, Rochester, MN, 55905
| | - Kerstin Wenzl
- Division of Hematology, Department of Internal Medicine
| | - Anne J Novak
- Division of Hematology, Department of Internal Medicine
| | - Xiaosheng Wu
- Division of Hematology, Department of Internal Medicine
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5
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Wu X, Nowakowski KE, Abeykoon JP, Manske M, Stenson MJ, Timm MM, Hanson CA, Van Dyke DL, Dasari S, Witzig TE. MCIR1: A patient-derived mantle cell lymphoma line for discovering new treatments for ibrutinib resistance. Eur J Haematol 2021; 107:458-465. [PMID: 34214199 DOI: 10.1111/ejh.13682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/17/2021] [Accepted: 06/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite the unprecedented success of ibrutinib in lymphoma therapy, the development of ibrutinib resistance due to acquired BTK or PLCγ2 mutations has become a new clinical problem. However, not all resistance is mediated by these mutations and these mechanisms are poorly understood due to a lack of study tools that truly recapitulate this clinical scenario. METHODS We established a novel patient-derived ibrutinib-resistant mantle cell lymphoma (MCL) line named MCIR1. Using immunological, molecular, and cytogenetic approaches, we comprehensively characterized MCIR1 and further demonstrated its utility in the study of resistance mechanisms and treatments to overcome this resistance. RESULTS We show that MCIR1 is a bona fide ibrutinib-resistant MCL cell line with normal BTK-/PLCγ2 but ibrutinib-resistant ERK1/2 and AKT1 signaling. RNA-Seq analysis revealed a robust non-canonical NF-kB signaling that drives the ibrutinib resistance. We also demonstrate the potential utility of a MCIR1-based cell and mouse model for the discovery of new treatments to overcome BTK inhibitor resistance. CONCLUSIONS We have established the first patient-derived ibrutinib-resistant MCL cell line MCIR1 that lacks BTK or PLCγ2 mutations but exhibits a hyperactive non-canonical NF-kB pathway. We further demonstrate its utility in the discovery and validation of new drugs to overcome this resistance.
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Affiliation(s)
- Xiaosheng Wu
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kevin E Nowakowski
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jithma P Abeykoon
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michelle Manske
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mary J Stenson
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael M Timm
- Department of Pathology and Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Curtis A Hanson
- Department of Pathology and Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Daniel L Van Dyke
- Department of Pathology and Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Surendra Dasari
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Thomas E Witzig
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Abeykoon JP, Wu X, Nowakowski KE, Dasari S, Paludo J, Weroha SJ, Hu C, Hou X, Sarkaria JN, Mladek AC, Phillips JL, Feldman AL, Ravindran A, King RL, Boysen J, Stenson MJ, Carr RM, Manske MK, Molina JR, Kapoor P, Parikh SA, Kumar S, Robinson SI, Yu J, Boughey JC, Wang L, Goetz MP, Couch FJ, Patnaik MM, Witzig TE. Salicylates enhance CRM1 inhibitor antitumor activity by induction of S-phase arrest and impairment of DNA-damage repair. Blood 2021; 137:513-523. [PMID: 33507295 PMCID: PMC7845010 DOI: 10.1182/blood.2020009013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 09/30/2020] [Indexed: 01/10/2023] Open
Abstract
Chromosome region maintenance protein 1 (CRM1) mediates protein export from the nucleus and is a new target for anticancer therapeutics. Broader application of KPT-330 (selinexor), a first-in-class CRM1 inhibitor recently approved for relapsed multiple myeloma and diffuse large B-cell lymphoma, have been limited by substantial toxicity. We discovered that salicylates markedly enhance the antitumor activity of CRM1 inhibitors by extending the mechanisms of action beyond CRM1 inhibition. Using salicylates in combination enables targeting of a range of blood cancers with a much lower dose of selinexor, thereby potentially mitigating prohibitive clinical adverse effects. Choline salicylate (CS) with low-dose KPT-330 (K+CS) had potent, broad activity across high-risk hematological malignancies and solid-organ cancers ex vivo and in vivo. The K+CS combination was not toxic to nonmalignant cells as compared with malignant cells and was safe without inducing toxicity to normal organs in mice. Mechanistically, compared with KPT-330 alone, K+CS suppresses the expression of CRM1, Rad51, and thymidylate synthase proteins, leading to more efficient inhibition of CRM1-mediated nuclear export, impairment of DNA-damage repair, reduced pyrimidine synthesis, cell-cycle arrest in S-phase, and cell apoptosis. Moreover, the addition of poly (ADP-ribose) polymerase inhibitors further potentiates the K+CS antitumor effect. K+CS represents a new class of therapy for multiple types of blood cancers and will stimulate future investigations to exploit DNA-damage repair and nucleocytoplasmic transport for cancer therapy in general.
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MESH Headings
- Animals
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cell Cycle Checkpoints/drug effects
- Choline/administration & dosage
- Choline/adverse effects
- Choline/analogs & derivatives
- Choline/pharmacology
- DNA Repair/drug effects
- DNA Replication/drug effects
- DNA, Neoplasm/drug effects
- Drug Combinations
- Drug Synergism
- Gene Expression Regulation, Neoplastic/drug effects
- Humans
- Hydrazines/administration & dosage
- Hydrazines/adverse effects
- Hydrazines/pharmacology
- Karyopherins/antagonists & inhibitors
- Lymphoma, Mantle-Cell/drug therapy
- Lymphoma, Mantle-Cell/pathology
- Lymphoma, Non-Hodgkin/drug therapy
- Lymphoma, Non-Hodgkin/genetics
- Lymphoma, Non-Hodgkin/pathology
- Male
- Mice
- Mice, Inbred NOD
- Mice, SCID
- Neoplasm Proteins/antagonists & inhibitors
- Neoplasm Proteins/biosynthesis
- Neoplasm Proteins/genetics
- Phthalazines/administration & dosage
- Phthalazines/pharmacology
- Piperazines/administration & dosage
- Piperazines/pharmacology
- Random Allocation
- Receptors, Cytoplasmic and Nuclear/antagonists & inhibitors
- S Phase Cell Cycle Checkpoints/drug effects
- Salicylates/administration & dosage
- Salicylates/adverse effects
- Salicylates/pharmacology
- Triazoles/administration & dosage
- Triazoles/adverse effects
- Triazoles/pharmacology
- Tumor Cells, Cultured
- Xenograft Model Antitumor Assays
- Exportin 1 Protein
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Affiliation(s)
| | - Xiaosheng Wu
- Division of Hematology, Department of Internal Medicine
| | | | | | - Jonas Paludo
- Division of Hematology, Department of Internal Medicine
| | | | - Chunling Hu
- Department of Laboratory Medicine and Pathology
| | | | | | | | | | | | - Aishwarya Ravindran
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, and
| | - Rebecca L King
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, and
| | - Justin Boysen
- Division of Hematology, Department of Internal Medicine
| | | | | | | | | | | | | | - Shaji Kumar
- Division of Hematology, Department of Internal Medicine
| | | | | | | | | | | | - Fergus J Couch
- Department of Health Sciences Research
- Department of Laboratory Medicine and Pathology
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Nowakowski KE, Abeykoon JP, Stenson MJ, Timm MM, Hanson CA, Van Dyke DL, Novak AJ, Wu X, Witzig TE. Abstract 650: MCIR1: A patient-derived ibrutinib-resistant mantle cell lymphoma line for the study of ibrutinib resistance and drug discovery. Cancer Res 2020. [DOI: 10.1158/1538-7445.am2020-650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Constitutive activation of B-cell receptor (BCR) signaling is a major driving mechanism for the proliferation and survival of various B-cell lineage non-Hodgkin lymphomas (NHL). Blocking BCR signaling using the first-in-class Bruton's tyrosine kinase (BTK) inhibitor, ibrutinib, has proved effective and is currently FDA approved for the treatment of several B-cell lymphomas. Unfortunately, significant subsets of patients possess either primary or acquired resistance to ibrutinib, often resulting in worse prognosis and poorer responses to subsequent therapies. Therefore, overcoming ibrutinib resistance is an urgent clinical need requiring new tools to both delineate the molecular mechanisms of resistance and develop viable therapeutics.
To that end, we developed a mantle cell lymphoma (MCL) cell line, MCIR1, from a patient with clinically acquired ibrutinib resistance. MCIR1 is a bona fide MCL cell line featuring CD19+/CD5+/CD10-/CD23-/t(11;14)+/TP53+/-; and lacking the previously described mutations in BTK (C481S) and phospholipase C-gamma-2 (R665W, L845F). Importantly, MCIR1 cells possess hallmarks of ibrutinib resistance, including the insensitivity of ERK1/2 phosphorylation to ibrutinib in vitro, and the irresponsiveness of MCIR1 xenograft tumors to ibrutinib treatment in mice as compared with ibrutinib-sensitive Jeko-1 tumors. To delineate the molecular mechanism(s) of ibrutinib resistance, we identified by RNA-Seq analysis that MCIR1 cells possess robust activity of the non-canonical NFkB pathway and elevated expression of NFkB target genes, suggesting that this pathway likely drives their resistance to ibrutinib. Finally, we demonstrated the utility of MCIR1 as a tool for testing new drugs to combat ibrutinib resistance in vitro by showing its sensitivity to the anti-apoptotic B-cell lymphoma-2 (Bcl-2) protein inhibitor, venetoclax.
To our knowledge, MCIR1 is the first patient-derived ibrutinib-resistant cell line to be established. Hence, MCIR1 is especially useful because uniquely possesses the relevant clinical and biological features of patients with ibrutinib-resistant MCL. We propose MCIR1 as a tool to further the understanding of molecular mechanisms conferring ibrutinib resistance by providing a clinically relevant system with the capacity for molecular and genetic manipulations. Further, these features make MCIR1 an ideal model to screen drugs for combating ibrutinib resistance through both in vivo and in vitro approaches.
Citation Format: Kevin E. Nowakowski, Jithma P. Abeykoon, Mary J. Stenson, Michael M. Timm, Curtis A. Hanson, Daniel L. Van Dyke, Anne J. Novak, Xiaosheng Wu, Thomas E. Witzig. MCIR1: A patient-derived ibrutinib-resistant mantle cell lymphoma line for the study of ibrutinib resistance and drug discovery [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 650.
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8
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Abeykoon JP, Paludo J, Nowakowski KE, Stenson MJ, King RL, Wellik LE, Wu X, Witzig TE. The effect of CRM1 inhibition on human non-Hodgkin lymphoma cells. Blood Cancer J 2019; 9:24. [PMID: 30808874 PMCID: PMC6391437 DOI: 10.1038/s41408-019-0188-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 02/02/2019] [Accepted: 02/07/2019] [Indexed: 11/09/2022] Open
Affiliation(s)
- Jithma P Abeykoon
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Jonas Paludo
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Kevin E Nowakowski
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Mary J Stenson
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Rebecca L King
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Linda E Wellik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Xiaosheng Wu
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Thomas E Witzig
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States.
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