scholarly journals Targeting Chronic Myeloid Leukemia Stem/Progenitor Cells Using Immunolipsome Loaded Venetoclax

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 39-39
Author(s):  
Mohammad Houshmand ◽  
Paola Circosta ◽  
Francesca Garello ◽  
Valentina Gaidano ◽  
Alessandro Cignetti ◽  
...  
Keyword(s):  
Stem Cells ◽  
Bone Marrow ◽  
Side Effects ◽  
Chronic Myeloid Leukemia ◽  
Myeloid Leukemia ◽  
Research Funding ◽  
Residual Disease ◽  
Molecular Response ◽  
Newly Diagnosed ◽  
Number Of Patients

The introduction of different generations of tyrosine kinase inhibitors (TKIs) significantly improved outcome and survival rate in chronic myeloid leukemia (CML) patients. However, long-term use of TKIs is concomitant with many side effects that affect the quality of life in patients. Approximately half of CML patients achieve deep molecular response (DMR), this makes them suitable candidates to discontinue the TKI therapy in a controlled condition, and about half of them will remain in treatment free remission (TFR) after discontinuation. It has been shown that a small population of leukemia stem cells (LSCs) as the residual disease burden is present at diagnosis, during the treatment, and in patients who are in TFR. While CML LSCs have many features in common with HSCs, they express specific markers such as CD25, CD26, IL1-RAP, etc., which can be used for the diagnosis and targeting. Protection by the bone marrow microenvironment and activity of signaling pathways such as WNT/β catenin, Hedgehog, PI3K, JAK/STAT in CML LSCs in a BCR-ABL dependent and independent manner guarantee their survival and elimination of these cells solely using TKIs seems ineffective. Herein we designed a pegylated liposomal nanocarrier conjugated with a specific antibody against CD26 (Begelomab, ADIENNE, Lugano, Switzerland). Then we loaded this immunoliposome with venetoclax, a BCL2 inhibitor, to eliminate CML LSCs selectively and to spare normal HSCs. First, we measured the expression of CD26 in the bone marrow and peripheral blood samples of newly diagnosed patients. We had a high expression of CD26 in CD34+/CD38- of both PB and BM, and a low expression on CD34+/CD38+ (progenitors) cells. Also, the expression of this marker in resistant patients to TKIs was visible while it was absent in normal stem cells. After the synthesis of the liposome, we conjugated Begelomab to the liposome. Then, we tested the selectivity of the designed system in different positive and negative cells. Our designed immunoliposome showed a strong selectivity toward CD26 positive cells. We also tested the selectivity on CML primary cells; in particular, we sorted newly diagnosed CML samples based on CD34+/CD38-/CD26- for HSCs and CD34+/CD38-/CD26+ for LSCs. Based on the confocal and flow cytometry analysis, our designed immunoliposome selectively targets LSCs and spares HSCs. Then we loaded this immunoliposome with venetoclax, and we treated CD26 positive and negative cells with this system. Based on our preliminary results, this immunoliposome loaded venetoclax specifically induced apoptosis in CD26+ cells, with higher activity compared to free venetoclax at the same dose. However, more analysis will be performed to confirm the selectivity of this system. Based on the obtained results, CD26 in newly diagnosed CML patients is expressed by CML LSCs and is a suitable option for diagnosis and targeting. Our preliminary data strongly suggest that we can selectively target CML LSCs. The main advantage of this system is its precision to hit the target. So we expect that after the drug release, the LSCs will be eliminated without any side effects on normal cells. Liposomes are suitable carriers because of their biocompatibility, self-assembly, large drug payload, and minimal toxicity. This strategy may help us to increase the number of patients attaining and maintaining TFR without relapsing. Disclosures Saglio: Ariad: Research Funding; Pfizer: Research Funding; Incyte: Research Funding; Roche: Research Funding; Bristol-Myers Squibb: Research Funding; Novartis: Research Funding.

Specific Drug Transporter Genotypes Are Significantly Associated with Increased Rates of Major and Complete Molecular Responses In Newly Diagnosed Chronic Myeloid Leukemia Patients Treated with Imatinib – A TOPS Correlative Substudy

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 670-670
Author(s):  
Simona Soverini ◽  
Sabrina Angelini ◽  
Eleonora Turrini ◽  
Matt Burnett ◽  
Gloria Ravegnini ◽  
...  
Keyword(s):  
Chronic Myeloid Leukemia ◽  
Cumulative Incidence ◽  
Myeloid Leukemia ◽  
Research Funding ◽  
Phase Iii ◽  
Molecular Response ◽  
Newly Diagnosed ◽  
First Line ◽  
Favorable Alleles ◽  
Summary Measures

Abstract Abstract 670 The availability of multiple options for chronic myeloid leukemia (CML) treatment is not paralleled by the availability of biological predictors of outcome allowing to identify patients (pts) who are more likely to benefit from dasatinib or nilotinib rather than imatinib (IM). Pharmacogenetics has proven a potential source of biomarkers given the known influence of polymorphisms in key genes encoding drug transporters and metabolizing enzymes on drug delivery – hence effectiveness. In CML, only two studies had so far explored this field, but both were conducted in heterogeneous populations including pts at different stages of disease, not all receiving IM first-line. We thus aimed to investigate a panel of 20 single nucleotide polymorphisms (SNPs) in ABCB1, ABCG2, SLC22A1, OATP1A2, OCTN1, CYP3A4 and CYP3A5 genes that can be hypothesized to influence IM transport and metabolism in 189 newly diagnosed CML pts enrolled in the TOPS phase III trial (Cortes et al, J Clin Oncol 2010). Pts selection was exclusively based on availability of written informed consent and sufficient amount of archived material. Median age was 46 years; male to female ratio was 103 to 86; 156 (83%) pts were Caucasian and 23 (12%) were Asian; low, intermediate and high Sokal risk pts were 84 (44.4%), 65 (34.4%) and 40 (21.2%), respectively. Baseline demographic/clinical features did not differ significantly from those of the overall population. Treatment outcomes (complete cytogenetic response [CCyR]; major molecular response [MMR] and complete molecular response [CMR]) were compared according to i) each candidate genotype ii) summary measures based on combinations of SNPs in the same gene and iii) summary measures based on combinations of SNPs in functionally related genes (uptake; efflux). CC genotype in OCTN1 had a favorable impact on the achievement of MMR at 12 months (MMR@12m; P = 0.03). With respect to the summary measures, combination of SNPs in the SLC22A1 gene was significantly correlated with MMR@12m (P = 0.03). When considering summary measures of uptake and efflux, the former was found to be associated with both MMR@12m and CMR@12m (P = 0.003 and P = 0.01, respectively). A separate analysis limited to Caucasian pts (n=156) yielded similar results (Table 1). In addition, the analysis in the Caucasian subgroup evidenced a significant association between the CC genotype in ABCB1 rs60023214 and MMR@12m (P = 0.005) (Table 1). Cumulative incidence plots based on the Kaplan-Meier method were also analyzed in the overall population and in Caucasians, with comparable results. Representative plots are shown in Figure 1. There was evidence for difference among MMR cumulative incidence curves for 2 single SNPs and 2 score measures. Presence of the major allele in OCTN1 (CC) and of the minor allele in CYP3A4 rs2740574 (GG) were associated with increased MMR rate (P = 0.028 and P = 0.042, respectively, in the overall population and P = 0.027 and P = 0.038, respectively, in Caucasians). Similarly, an increase in the number of favorable alleles in the SLC22A1 gene was associated with increased MMR rate (P = 0.030 and P = 0.043 in the overall population and in Caucasians, respectively). In addition, the combination of favorable alleles in the genes involved in IM uptake was associated with increased rates of both MMR and CMR (P = 0.004 and P = 0.015, respectively, in the overall population and P = 0.005 and P = 0.009, respectively, in Caucasians). Our results suggest that SNP genotyping might be helpful in selecting pts who are more likely to benefit from first-line use of more potent inhibitors. Further assessment of the SNPs here identified in larger series of pts is warranted. Supported by Novartis Oncology, Clinical Development, TOPS Correlative Studies Network Disclosures: Hughes: Novartis: Honoraria, Research Funding, Speakers Bureau; Bristol-Myers Squibb: Honoraria, Research Funding; Ariad: Honoraria. White:Novartis: Honoraria, Research Funding; Bristol-Myers Squibb: Research Funding. Saglio:Novartis: Consultancy, Honoraria; Bristol-Myers Squibb: Consultancy, Honoraria. Rosti:Novartis: Consultancy, Honoraria; BMS: Consultancy, Honoraria. Hatfield:Novartis: Employment. Martinelli:Novartis: Consultancy, Honoraria; BMS: Honoraria; Pfizer: Consultancy.

Rapid Reduction of Chronic Myeloid Leukemia Stem Cells After Treatment with Second-Generation BCR-ABL Kinase Inhibitors, Dasatinib and Nilotinib

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 4457-4457
Author(s):  
Yosuke Minami ◽  
Akihiro Abe ◽  
Yuka Nomura ◽  
Miho Minami ◽  
Yachiyo Kuwatsuka ◽  
...  
Keyword(s):  
Stem Cells ◽  
Chronic Myeloid Leukemia ◽  
Myeloid Leukemia ◽  
Research Funding ◽  
Second Generation ◽  
Kinase Inhibitors ◽  
Newly Diagnosed ◽  
Rapid Reduction ◽  
Population Total ◽  
Significant Difference

Abstract Abstract 4457 Chronic myeloid leukemia (CML) is effectively treated with imatinib (IM), however, several mathematical models and ex vivo-examinations suggested that IM-therapy does not eradicate BCR-ABL-positive hematopoietic stem cells (HSC). We prospectively (0, 3, 6 and 12 months after IM-therapy) investigated 16 newly diagnosed and 22 long-term followed CML-chronic phase (CP) cases using methods previously reported (Jamieson et al., N Engl J Med, 2004. and Abe et al., Int J Hematol, 2008) (Figure 1) with FACSAria™ and quantitative RT-PCR of BCR-ABL among each sorted population; total mononuclear cells, HSC/Thy-1+, HSC/Thy-1–, common myeloid progenitors (CMP), granulocyte macrophage progenitors (GMP) and megakaryocyte erythroid progenitors (MEP). In optimal responders to IM-therapy, BCR-ABL transcripts in the HSC populations (HSC/Thy-1+ and HSC/Thy-1–) tended to be more retentive than other populations while gradual reduction was observed during the first 12 months in all populations. And discrepancy of minimum residual diseases (MRD) between the HSC populations and other populations was larger in patients after longer IM-therapy. In evaluating properties of CML stem cells and other markers, we observed irrelevant distribution of side population (SP) and expressions of ABC transporters (ABCB1 and ABCG2) in comparison with CD34/38 expression. We also prospectively investigated BCR-ABL transcripts in each population of 23 IM-resistant or -intolerant CML-CP cases and one newly diagnosed CML-accelerated phase (AP) case during treatment with second-generation tyrosine kinase inhibitors (2nd TKIs), dasatinib or nilotinib. Treatment with each inhibitor induced more rapid reduction of BCR-ABL transcripts even in the HSC population (CD34+CD38–) during the first 6 months and there was no significant difference of MRD among each population in optimal responders to 2nd TKIs-therapy. In the stromal co-culturing system using primary cells and leukemic NOD/SCID/IL2rgnull (NOG) mice xenotransplanted with Ph+ leukemia cells, retention of quiescent slow-cycling (Hoechst 33342low/Pyronin Ylow) CD34+ population after IM-treatment were observed and cell death mechanisms after treatment with 2nd TKIs are also under investigation. These results imply that therapy with 2nd TKIs could be a promising approach for quick and efficient reduction of the CML stem cells and cure of disease. Figure 1 Figure 1. Disclosures: Naoe: Kyowa-Kirin: Research Funding; Novartis: Research Funding; Bristol-Myers Squibb: Research Funding.

Chronic Myeloid Leukemia in Pediatrics — First Results From Study CML-PAED II.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 342-342 ◽  
Author(s):  
Meinolf Suttorp ◽  
Christian Thiede ◽  
Josefine T Tauer ◽  
Silja Roettgers ◽  
Petr Sedlacek ◽  
...  
Keyword(s):  
Side Effects ◽  
Chronic Myeloid Leukemia ◽  
Bone Metabolism ◽  
Treatment Response ◽  
Muscle Pain ◽  
Myeloid Leukemia ◽  
Research Funding ◽  
Response Rates ◽  
Longitudinal Growth ◽  
Molecular Response

Abstract Abstract 342 Background: Chronic myeloid leukemia (CML) is a rare malignancy in pediatrics. In this decade -like in adults- imatinib meyslate (IMA) has been established also as first line treatment for children with CML while allogeneic stem cell transplantation (SCT) as treatment option is postponed for those cases becoming intolerant or refractory to tyrosine kinase inhibitor (TKI) treatment. However, results from controlled trials in children are lacking so far. We here report an analysis of pediatric data from patients (pts) with newly diagnosed Philadelphia-chromosome positive (Ph+) CML on up-front treatment with IMA. Pts and Methods: According to protocol CML-PAED II pediatric pts with confirmed diagnosis of Ph+ CML were treated in CP with IMA 300 mg/sqm once daily, while in accelerated phase (AP) or in blastic phase (BC) the dose was increased to 400 mg/sqm and 500 mg/sqm (bis daily), respectively. Initial and long-term clinical and laboratory data, treatment response and side effects were reported to the study center on standardized forms by the treating physician. Specimen from peripheral blood (pB) and bone marrow (BM) were assessed by cytogenetics and by quantitative RT-PCR for BCR-ABL transcript rates in central laboratories for standardized monitoring in three months intervals. Results: From 1. Jan 2004 until 31. Mrch 2009 a total of 51 pts (21 female, 30 male; median age: 10.6 yrs [range:1-20 yrs]) were registered: 10 pts with ongoing IMA treatment were recruited and analyzed retrospectively while 41 pts were enrolled prospectively from centers in Austria (n=1), Czech Rep. (n=6), Germany (n=40), Italy (n=1), Netherlands (n=1), Slovak Rep. (n=2). Stages of disease were: CP n=47; AP n=1; BC n=3 (two myeloid). Those four pts diagnosed in AP and BC underwent early SCT. Observed side effects in the whole group included: nausea (n=9), muscle pain (n=7), edema (n=3), rhabdomyolysis (n=1, short interruption of IMA), reduced blood cell count (n=2, short interruption of IMA in one pt), biochemical alterations in bone metabolism [for details see: N Engl J Med 2006;354:2006] (n = 8), impaired longitudinal growth (n=1, [Haematologica 2009;94:1177]). Two pts experienced intolerance (muscle pain) or toxicity (hepatic), respectively, therefore stopped IMA and were put on dasatinib after 4 and 10 months, respectively. Having achieved complete cytogenetic response (CyR) and 2 log-fold reduction of BCR-ABL transcript rate, one pt opted for SCT from her HLA-identical brother after 15 mo of treatment. Response rates in advanced stages of CML were as follows: in BC (n=3) two pts became hematological responders (HR), one pt exhibited partial HR. The only one pt diagnosed in AC exhibited partial CyR but complete HR. A landmark analysis in pts entering CML-paed II in CP exhibited that 2/42 pts (5%) had no complete HR at month 3; 2/28 (7%) had no complete CyR at month 12, and 2/19 (15%) pts achieved no major molecular response (MMR, defined as >0.1% BCR-ABL [Blood 2006;108:28–37]) at month 18 after start of IMA. Each two of those four patients with incomplete response (one pt with no CyR at month 12, one pt with no MMR at month 18) underwent SCT from a sibling donor and the other two pts stopped IMA and were put on dasatinib. With a median follow-up of 19 months (range: 0-63 months) all 47 pts diagnosed in CP are alive. Of note none of the six pts (median age at diagnosis: 5 yrs; range 1–13 years) treated by imatinib meanwhile for >36 months have opted for SCT. Conclusion: Keeping in mind that the number of pediatric pts is still small, IMA treatment for children and adolescents with CML in CP is associated -like in adults- with high treatment response rates. Refractoriness to IMA is uncommon and side effects seem tolerable, as only 10% of the total cohort stopped imatinib and were put on 2nd generation TKI. However, disturbances of bone metabolism and longitudinal growth impairment may be of special concern in this not yet outgrown cohort [N Engl J Med 2006;354:2006, Blood 2008;111:2538; Haematologica 2008;93:1101; Lancet 2008;372:111; Int J Hematol; 2009;89:251; Haematologica 2009;94:1177]. Only 3/47 pts not diagnosed in advanced phases of CML so far underwent SCT thus underlining that also in pediatrics SCT has been shifted to a second-line strategy for high-risk patients and those who failed therapy with IMA. Disclosures: Suttorp: Novartis : Research Funding. Thiede:Novartis: Research Funding.

A New Computational Method to Predict Long-Term Minimal Residual Disease and Molecular Relapse after TKI-Cessation in CML

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 3099-3099 ◽  
Author(s):  
Ingmar Glauche ◽  
Hendrik Liebscher ◽  
Christoph Baldow ◽  
Matthias Kuhn ◽  
Philipp Schulze ◽  
...  
Keyword(s):  
Chronic Myeloid Leukemia ◽  
Tyrosine Kinase ◽  
Tyrosine Kinase Inhibitor ◽  
Myeloid Leukemia ◽  
Research Funding ◽  
Kinase Inhibitor ◽  
Residual Disease ◽  
Molecular Response ◽  
Tki Treatment

Abstract Predicting minimal residual disease (MRD) levels in tyrosine kinase inhibitor (TKI)-treated chronic myeloid leukemia (CML) patients is of major clinical relevance. The reason is that residual leukemic (stem) cells are the source for both, potential relapses of the leukemicclone but also for its clonal evolution and, therefore, for the occurrence of resistance. The state-of-the art method for monitoring MRD in TKI-treated CML is the quantification of BCR-ABL levels in the peripheral blood (PB) by PCR. However, the question is whether BCR-ABL levels in the PB can be used as a reliable estimate for residual leukemic cells at the level of hematopoietic stem cells in the bone marrow (BM). Moreover, once the BCR-ABL levels have been reduced to undetectable levels, information on treatment kinetics is censored by the PCR detection limit. Clearly, BCR-ABL negativity in the PB suggests very low levels of residual disease also in the BM, but whether the MRD level remains at a constant level or decreases further cannot be read from the BCR-ABL negativity itself. Thus, also the prediction of a suitable time point for treatment cessation based on residual disease levels cannot be obtained from PCR monitoring in the PB and currently remains a heuristic decision. To overcome the current lack of a suitable biomarker for residual disease levels in the BM, we propose the application of a computational approach to quantitatively describe and predict long-term BCR-ABL levels. The underlying mathematical model has previously been validated by the comparison to more than 500 long-term BCR-ABL kinetics in the PB from different clinical trials under continuous TKI-treatment [1,2,3]. Here, we present results that show how this computational approach can be used to estimate MRD levels in the BM based on the measurements in the PB. Our results demonstrate that the mathematical model can quantitatively reproduce the cumulative incidence of the loss of deep and major molecular response in a population of patients, as published by Mahon et al. [4] and Rousselot et al. [5]. Furthermore, to demonstrate how the model can be used to predict the BCR-ABL levels and to estimate the molecular relapse probability of individual patients, we compare simulation results with more than 70 individual BCR-ABL-kinetics. For this analysis we use patient data from different clinical studies (e.g. EURO-SKI: NCT01596114, STIM(s): NCT00478985, NCT01343173) where TKI-treatment had been stopped after prolonged deep molecular response periods. Specifically, we propose to combine statistical (non-linear regression) and mechanistic (agent-based) modelling techniques, which allows us to quantify the reliability of model predictions by confidence regions based on the quality (i.e. number and variance) of the clinical measurements and on the particular kinetic response characteristics of individual patients. The proposed approach has the potential to support clinical decision making because it provides quantitative, patient-specific predictions of the treatment response together with a confidence measure, which allows to judge the amount of information that is provided by the theoretical prediction. References [1] Roeder et al. (2006) Dynamic modeling of imatinib-treated chronic myeloid leukemia: functional insights and clinical implications, Nat Med 12(10):1181-4 [2] Horn et al. (2013) Model-based decision rules reduce the risk of molecular relapse after cessation of tyrosine kinase inhibitor therapy in chronic myeloid leukemia, Blood 121(2):378-84. [3] Glauche et al. (2014) Model-Based Characterization of the Molecular Response Dynamics of Tyrosine Kinase Inhibitor (TKI)-Treated CML Patients a Comparison of Imatinib and Dasatinib First-Line Therapy, Blood 124:4562 [4] Mahon et al. (2010) Discontinuation of imatinib in patients with chronic myeloid leukaemia who have maintained complete molecular remission for at least 2 years: the prospective, multicentre Stop Imatinib (STIM) trial. Lancet Oncol 11(11):1029-35 [5] Rousselot 
et al. (2014) Loss of major molecular response as a trigger for restarting TKI therapy in patients with CP- CML who have stopped Imatinib after durable undetectable disease, JCO 32(5):424-431 Disclosures Glauche: Bristol Meyer Squib: Research Funding. von Bubnoff:Amgen: Honoraria; Novartis: Honoraria, Research Funding; BMS: Honoraria. Saussele:ARIAD: Honoraria; Novartis: Honoraria, Other: Travel grants, Research Funding; Pfizer: Honoraria, Other: Travel grants; BMS: Honoraria, Other: Travel grants, Research Funding. Mustjoki:Bristol-Myers Squibb: Honoraria, Research Funding; Pfizer: Honoraria, Research Funding; Ariad: Research Funding; Novartis: Honoraria, Research Funding. Guilhot:CELEGENE: Consultancy. Mahon:NOVARTIS PHARMA: Honoraria, Research Funding; BMS: Honoraria; PFIZER: Honoraria; ARIAD: Honoraria. Roeder:Bristol-Myers Squibb: Honoraria, Research Funding.

Reduced Expression Level of SHP1 Gives An Additive Survival Advantage to the Ph+ Cells of Chronic Myeloid Leukemia (CML) Patients and Provides a Novel Pretreatment Predictor of Major Molecular Response Achievement in CML Patients.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 2212-2212
Author(s):  
Nicola Esposito ◽  
Concetta Quintarelli ◽  
Irene Colavita ◽  
Barbara Izzo ◽  
Anna Lucia Peluso ◽  
...  
Keyword(s):  
Chronic Myeloid Leukemia ◽  
Myeloid Leukemia ◽  
Research Funding ◽  
Molecular Response ◽  
Imatinib Treatment ◽  
Newly Diagnosed ◽  
Major Molecular Response ◽  
Positive Regulator ◽  
Oncogenic Pathways ◽  
Sokal Score

Abstract Abstract 2212 Poster Board II-189 Treatment of Chronic Myeloid Leukemia (CML) has shown an outstanding progress while new understanding of the disease has increased significantly. Nevertheless in the era of targeted therapy, Sokal index remains a dominant prognostic determinant of newly diagnosed CML patients. Our study has aimed to identify novel prognostic indicators to improve both an initial assessment and subsequent monitoring of CML patients. Initially, we have found that the protein-tyrosine phosphatase SHP1, that has a tumour suppressor activity, may play an important role in the resistance to imatinib treatment. We applied gene profiling and proteomic bidimensional electrophoresis to compare the differential pattern of gene and protein expression between KCL22s (imatinib-sensitive) and KCL22r (imatinib-resistant) cell lines. We found SHP1 to be one of the most differentially expressed genes. By ESI-TRAP MS technique, we found that one of the main interactors of SHP1 is SHP2, a protein phosphatase well known as positive regulator of oncogenic pathways, including the Ras/MAPK pathway. Gain-of-function mutations in SHP2 gene, have been described in various haematopoietic neoplasias and myeloproliferative disorders including Juvenile Chronic Myelomonocytic Leukemia. This protein is regulated throw phosphorylation on 542- and 580-Tyr, and unlike SHP1, acts as a positive regulator of the same oncogenic pathways. We found that KCL22r cell line, that has low SHP1 levels, showed complete phosphorylation of both SHP2 tyrosine residues, while these residues are not phosphorylated in the KCL22s line, which could explain an important mechanism for imatinib sensitivity. Consistently with this hypothesis, knock-down of SHP2 phosphatase in KCL22r by a specific shRNA resulted in 60% inhibition of KCL22r proliferation. Furthermore, the KCL22rSHP2- cells showed significant reduction in STAT3 (60%) and ERK1/2 (70%) phosphorylation. Our initial results from CML patients (Esposito et al , ASH 2008 Abs 1106) have suggested a differential expression of SHP1 in patients with different response to imatinib treatment. To further explore the role of SHP1 as a determinant of imatinib sensitivity we evaluated the expression of SHP1 in 93 newly-diagnosed CML patients enrolled into the TOPS trial investigating 400mg versus 800mg imatinib (Cortes et al, EHA 2008). The results of this study indicate that the mRNA levels of SHP1, as assessed by QPCR in peripheral blood of patients at the time of enrolment, are significantly different between patients who do or don't achieve Major Molecular Response (MMR) by 12 months (7.9±4.0 vs. 5.9±3.4; p=0.01). Logistic regression was used to estimate regression coefficients and corresponding odds ratio using MMR by 12 months as outcome variable in our model. Since the 25th and 75th percentiles of SHP1 were 4.3 and 8.4, respectively (resulting in an interquartile range of 4.1), statistical analysis shown that a value of 4.1 or more in SHP1 is associated with almost 2-fold odds of achieving MMR by 12 months (OR=1.92; 95% CI=1.12, 3.29; p=0.018). Moreover, in a contingency table, chi-square analysis has been shown a high risk of not achieving MMR by 12 month in those patients with either low SHP1 expression and high Sokal score, when compared with patients with high-intermediate SHP1 expression and low-intermediate Sokal score (p=0.0068). In conclusion, these results suggest that, measuring expression levels of SHP1 could be of value in assessing newly diagnosed CP-CML patients and estimating treatment response, which could help optimizing Gleevec treatment, or recommending patients to more potent TKIs. Supported by Novartis Oncology, Clinical Development, TOPS Clinical Correlative Studies Network Disclosures: Saglio: Novartis: Honoraria; Celgene: Honoraria. Pane:Novartis: Research Funding; Ministero dell'Università/PRIN: Research Funding; Regione Campania: Research Funding; Ministero della Salute/Progetto integrato Oncologia: Research Funding.

scholarly journals Druggable Biochemical Pathways and Potential Therapeutic Alternatives to Target Leukemic Stem Cells and Eliminate the Residual Disease in Chronic Myeloid Leukemia

2019 ◽  
Vol 20 (22) ◽  
pp. 5616 ◽  
Author(s):  
Fabien Muselli ◽  
Jean-François Peyron ◽  
Didier Mary
Keyword(s):  
Stem Cells ◽  
Bone Marrow ◽  
Chronic Myeloid Leukemia ◽  
Tyrosine Kinase ◽  
Myeloid Leukemia ◽  
Molecular Mechanisms ◽  
Kinase Inhibitors ◽  
Residual Disease ◽  
Leukemic Cells ◽  
Hematopoietic Stem

Chronic Myeloid Leukemia (CML) is a disease arising in stem cells expressing the BCR-ABL oncogenic tyrosine kinase that transforms one Hematopoietic stem/progenitor Cell into a Leukemic Stem Cell (LSC) at the origin of differentiated and proliferating leukemic cells in the bone marrow (BM). CML-LSCs are recognized as being responsible for resistances and relapses that occur despite the advent of BCR-ABL-targeting therapies with Tyrosine Kinase Inhibitors (TKIs). LSCs share a lot of functional properties with Hematopoietic Stem Cells (HSCs) although some phenotypical and functional differences have been described during the last two decades. Subverted mechanisms affecting epigenetic processes, apoptosis, autophagy and more recently metabolism and immunology in the bone marrow microenvironment (BMM) have been reported. The aim of this review is to bring together the modifications and molecular mechanisms that are known to account for TKI resistance in primary CML-LSCs and to focus on the potential solutions that can circumvent these resistances, in particular those that have been, or will be tested in clinical trials.

scholarly journals Study of Treatment-Free Remission Evaluation in Real-World Chronic Myeloid Leukemia; Cost-Effectiveness Analysis

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 4261-4261
Author(s):  
Bora Nam ◽  
Soktae Kim ◽  
Jae Hoon Lee ◽  
Kwai Han Yoo ◽  
Jeong-Yeal Ahn ◽  
...  
Keyword(s):  
Chronic Myeloid Leukemia ◽  
Markov Model ◽  
Myeloid Leukemia ◽  
Age Groups ◽  
Phase Iii ◽  
Low Grade ◽  
Molecular Response ◽  
Newly Diagnosed ◽  
Number Of Patients ◽  
Treatment Free Remission

Abstract Chronic myeloid leukemia (CML) needs taking life-long tyrosine kinase inhibitor (TKI) which arises serious toxicities such as peripheral occlusive disease and pulmonary hypertension as well as low-grade toxicities. Treatment-free remission (TFR) can make almost half CML patients achieving deep molecular response (DMR) free from TKIs. We investigated total costs of each TKI considering TFR in Korea. Total numbers of annual newly-diagnosed CML patients were adopted from national cancer registration database. TFR was defined as achieving MR4.5 and lasting for 3 years. The proportion of MR4.5 was adopted from phase III studies of imatinib (IM), nilotinib (NIL) and dasatinib (DAS). TKI management followed life-long Markov model (Fig 1). Willingness to pay (WTP)was calculated for beneficial effects of patients who have achieved TFR and taking no TKIs as 2 times of gross domestic product per capita. Cost of progression was calculated based on the study by Jabbour et al. Patients older than 79y was not included in this study because TFR benefit is not considered in this age group. Duration of treatment and TFR was calculated separately according to age groups. We assumed that taking KTI lasted life-long until median life expectancy in Korea (80.87 years). Newly diagnosed annual CML patients were 443; 9 in age 0-14, 96 in age 15-34, 125 in age 35-49, 124 in age 50-64 and 89 in age 65-79. The theoretical number of patients who have sustainable TFR was 73 in IM, 93 in DAS and 119 in NIL. TFR as person-year in IM, DAS and NIL were 1940, 2521 and 3247, respectively. TFR (person-year) was very different according to age groups because of different incidence rates; 99.9 in age 0-14, 788.7 in age 15-34, 666.1 in age 35-49, 353.8 in age 50-64 and 33.7 in age 65-79 when IM was applied. TFR (person-year) were 128.2 in age 0-14, 1014.5 in age 15-34, 861.6 in age 35-49, 464.1 in age 50-64 and 52.8 in age 65-79 when DAS was applied. TFR (person-year) were 164.9 in age 0-14, 1305.6 in age 15-34, 1109.4 in age 35-49, 598.3 in age 50-64 and 69.0 in age 65-79 when NIL was applied. WTP according to TFR was 121.3 in IM, 157.5 in DAS and 202.8 billion KW in NIL. Costs by progression were 32.8 in IM, 26.8 in DAS and 22.3 billion KW in NIL. Life-long maintenance costs for patients who did not achieved sustainable TFR without progression were 128.7 in IM, 294.2 in DAS and 327.1 billion KW in NIL. Net costs considering TFR and progression were 40.2 in IM, 163.5 in DAS and 146.6 billion KW in NIL. Nilotinib was superior to other TKIs in terms of TFR benefit and progression cost according to our life-time Markov model. However, the net cost was lowest in IM. This analysis is limited by our assumption that MR4.5 is achieved by first 5 year and there is no further additional achievement of MR4.5 because of limitation of MR4.5 rates in each TKI trial. Figure. Figure. Disclosures No relevant conflicts of interest to declare.

scholarly journals CD93 Is a Novel Biomarker of Leukemia Stem Cells in Chronic Myeloid Leukemia

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 49-49 ◽  
Author(s):  
Ross Kinstrie ◽  
Gillian A. Horne ◽  
Heather Morrison ◽  
Hothri A. Moka ◽  
Jennifer Cassels ◽  
...  
Keyword(s):  
Stem Cells ◽  
Bone Marrow ◽  
Chronic Myeloid Leukemia ◽  
Board Of Directors ◽  
Myeloid Leukemia ◽  
Research Funding ◽  
Fold Increase ◽  
Leukemia Stem Cells ◽  
Advisory Committees

Abstract The introduction of BCR-ABL tyrosine kinase inhibitors (TKIs) has revolutionized the treatment of chronic myeloid leukemia (CML). However, although the majority of patients with chronic phase (CP)-CML obtain durable complete cytogenetic and major molecular responses, there is low level disease persistence postulated to be due to a population of TKI-insensitive leukemia stem cells (LSC). The aims of this study were (1) to fully characterize differences in gene expression between normal hematopoietic stem cells (HSC) and CP-CML LSC and (2) identify potential novel therapeutic targets specific to CML LSC. Lin-CD34+CD38- CD45RA-CD90+ normal HSC (n=3) and CP-CML LSC (n=6 patients at diagnosis), populations were isolated using a FACSAria and applied to Affymetrix HuGene 1.0ST arrays. The raw data (.CEL files) was imported into Partek Genomics Suite and Ingenuity Pathway Analysis software and principal component analysis and gene ontology ANOVA performed. A total of 1217 genes were significantly deregulated between normal HSC and CP-CML LSC. The most significantly deregulated genes and pathways were involved with the molecular and cellular functions of cell cycle, cell assembly and organisation, cellular movement, cell death and DNA replication, recombination and repair. These results suggested that CML LSC were less quiescent than normal HSC. Importantly, complimentary functional studies indicated that CML LSC have significantly increased proliferation (14 fold expansion; P<0.001) compared to normal HSC (no expansion) after 5 days in vitro culture. In addition, equivalent numbers of CML LSC produce ~4-fold more colonies in colony forming cell (CFC) assays than normal HSC (329±56 versus 86±17 per 2,000 cells, respectively; P<0.05). Fluorescence in situ hybridisation (FISH) demonstrated that >90% of lin- CD34+ CD38- CD45RA- CD90+ CML LSC from all patient samples were BCR-ABL positive (+). In addition to these deregulated intracellular pathways, we sought to assess if there were differences in expression of cell surface molecules that may be amenable to therapeutic manipulation. Of particular interest, our microarray studies demonstrated that CD93 was highly upregulated in CP-CML LSC (6 fold, p = 2.5x10-6). Increased CD93 expression was validated by Fluidigm digital PCR (6 fold increase, p = 0.02; n=6). Furthermore, using flow cytometry, we demonstrated significant upregulation of CD93 protein expression on lin-CD34+ CD38- CD45RA- CD90+ CML LSC from peripheral blood and bone marrow of CP-CML patients (n= 17; mean = 63.8% CD93+) compared to normal HSC from healthy peripheral blood stem cell donors (n=7; mean = 0.8% CD93+) and bone marrow donors (n=4; mean = 0.2% CD93+; p < 0.0001). FISH confirmed that 100% of lin-CD34+ CD38- CD90+ CD93+ CML cells were BCR-ABL+ in all samples assessed. CD93 (also known as C1qRp) is a C-type lectin-like domain (CTLD)-containing glycoprotein which regulates phagocytosis, with roles in cell adhesion and leukocyte migration. It is normally expressed on endothelial cells, hematopoietic precursors and mature cells including neutrophils, monocytes and platelets. Previous studies have shown CD93 to be upregulated in a proportion of AML patients (Saito et al, Sci Transl Med, 2010. 2(17): p. 17ra9). Short term (24h) in vitro exposure of lin-CD34+CD38- CD45RA- CD90+ CML LSC to TKIs (Imatinib or Dasatinib; n=3) reduced, but did not fully eliminate CD93 expression (Imatinib, 48.5% to 22.9%; Dasatinib, 47.7% to 9.2%). Importantly, following long-term TKI treatment of patients, lin-CD34+CD38-CD45RA-CD90+ cells from CP-CML patient bone marrow samples (n=2) taken in major molecular response demonstrated a small, but persistent population of CD93+ LSC which were BCR-ABL+ by FISH. Furthermore, in xenograft transplantation experiments (n = 5), after 16 weeks, CD34+CD93+ CML LSC engrafted lethally irradiated NOD/SCID/IL-2Rg-/- (NSG) mice with BCR-ABL+ cells, whereas CD34+CD93- cells from the same patient samples failed to engraft to significant levels (3.5-30 fold increase in engraftment with CD34+CD93- cells; p < 0.03). FISH confirmed that engrafted human cells were BCR-ABL+. Taken together, our results identify CD93 as a potential novel biomarker of CML LSC, which may also be helpful in assessing minimal residual disease at the LSC level. Further studies are ongoing to assess the therapeutic potential of inhibiting CD93 in CML LSC. Disclosures Copland: Ariad: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees; BMS: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.

scholarly journals Correlation of Lymphocyte Count with Treatment Response to Tyrosine Kinase Inhibitors in Newly Diagnosed Chronic Myeloid Leukemia in Chronic Phase

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 4538-4538
Author(s):  
Koji Sasaki ◽  
Ildefonso Ismael Rodriguez-Rivera ◽  
Hagop M. Kantarjian ◽  
Susan O'Brien ◽  
Elias Jabbour ◽  
...  
Keyword(s):  
Overall Survival ◽  
Chronic Myeloid Leukemia ◽  
Lymphocyte Count ◽  
Myeloid Leukemia ◽  
Research Funding ◽  
Chronic Phase ◽  
Patient Characteristics ◽  
Molecular Response ◽  
Newly Diagnosed ◽  
Free Survival

Abstract Background: Total lymphocyte count (TLC) has been shown to correlate with outcomes in patients (pts) with acute leukemia. The clinical correlation to TLC in pts with chronic myeloid leukemia in chronic phase (CML-CP) who were treated with a tyrosine-kinase inhibitor (TKI) is unclear. Methods: Lymphocyte data in pts with newly diagnosed CML-CP who were enrolled in consecutive or parallel clinical trials with front-line imatinib (IM), nilotinib (Nilo), or dasatinib (Dasa) were collected at the time of diagnosis, and 3 and 6 months (M) after the start of TKI. Relative lymphocytrosis (RLC) was defined as lymphocyte >150% at 3 or 6M compared with baseline at diagnosis. Absolute lymphocytosis (ALC) was defined as lymphocyte > 4,000 /µL at 3 or 6M after the start of TKI. Pts were assessed for response, overall survival (OS), event-free survival (EFS), transformation-free survival (TFS), and failure-free survival (FFS) based on ALC and RLC. The Kaplan-Meier method was used to calculate OS, EFS, TFS, and FFS. A log-rank test and Cox regression were used for univariate (UVA) and multivariate analysis (MVA), respectively. Results: A total of 483 pts were enrolled in this study: 271 in IM, 105 in Nilo, and 107 in Dasa. Patient characteristics and outcomes are summarized in Table 1. Median age at diagnosis was 48 years, and median follow-up was 85M and ongoing (5-154+). Time from diagnosis to start of TKI, Sokal risk score, and ALC at baseline between groups did not differ clinically. Of 481 pts, 93 (19%) developed RLC at 3 or 6M; IM, 38 (14%); Nilo, 23 (22%); Dasa, 32 (30%) (p= .001). ALC at 3 or 6M was observed in 15 (3%); IM, 3 (1%); Nilo, 1 (1%); Dasa, 11 (10%) (p<.001). Overall, cumulative incidence of complete cytogenetic response (CCyR) at 6M, major molecular response (MMR) at 12M, molecular response with 4.5 log reduction by IS (MR4.5) at 24M did not differ significantly between RLC and non-RLC (3 or 6M), or between ALC and non-ALC (3 or 6M). 5-y TFS, EFS and OS in ALC group were significantly worse than those in non-ALC group (p= .002, p=.016, p=.008, respectively). By UVA and MVA related to OS, age [p <.001; Hazard ratio (HR), 1.062; 95% confidence interval (95%CI), 1.036-1.089], presence of ALC at 3 or 6M [p = .028; HR, 10.948; 95%CI, 1.297-92.415], absence of MMR at 24M [p=.016; HR, 2.263; 95%CI, 1.165-4.393] were identified as adverse prognostic factors for OS. Conclusion: The presence of ALC ≥4,000/µL at 3 or 6M of TKI therapies is rare but is adversely associated with overall survival. Table 1. Patient Characteristics and Outcomes (N=483)a Overall [n= 481] IM [n= 271] Nilo [n= 105] Dasa [n= 107] Age, (year) 48 (15-85) 48 (15-85) 49 (17-82) 48 (16-83) Sokal Risk, No. (%) Low 334 (69) 175 (65) 79 (75) 80 (75) Intermediate 114 (24) 74 (27) 18 (17) 22 (21) High 32 (7) 20 (7) 8 (8) 4 (4) Time from diagnosis to start of TKI, (M) 0.9 (0-12.6) 1.0 (0-12.6) 0.5 (0-5.6) 0.7 (0.1-7.8) ALC at baseline, (/109L) 2.5 (0-86.6) 2.4 (0-16.7) 2.6 (0.4-9.2) 2.7 (0.3-86.6) Incidence of Relative Lymphocytosis, No. (%) At 3M 65 (14) 25 (9) 16 (15) 24 (22) At 6M 76 (16) 32 (12) 20 (19) 24 (22) Overall 93 (19) 38 (14) 23 (22) 32 (30) Incidence of Absolute Lymphocytosis, No. (%) At 3M 8 (2) 1 (0) 0 7 (7) At 6M 11 (2) 3 (1) 1 (1) 7 (7) Overall 15 (3) 3 (1) 1 (1) 11 (10) Outcomes of RLC and ALC at any time in each group, +/- (%/%) (p) <10% BCR-ABL/ABL at 3M RLC 36/40 (.596) 22/44 (.213) 50/37 (.280) 31/38 (.537) ALC 38/39 (.952) 0/42 (.394) 100/39 (.214) 36/35 (.952) Cumulative CCyR at 6M RLC 75/75 (.288) 50/66 (.063) 96/90 (.413) 90/87 (.628) ALC 67/75 (.711) 33/64 (.276) 0/92 (.001) 82/89 (.599) Cumulative MMR at 12M RLC 67/74 (.406) 53/70 (.030) 83/82 (.921) 72/74 (.903) ALC 60/73 (.488) 33/68 (.197) 0/83 (.033) 73/74 (.745) Cumulative MR4.5 at 24M RLC 46/52 (.564) 37/50 (.139) 57/55 (.889) 50/57 (.729) ALC 33/52 (.332) 33/48 (.610) 0/56 (.264) 36/57 (.252) 5-y FFS RLC 61/71 (.133) 56/69 (.167) 62/70 (.710) 61/74 (.285) ALC 50/69 (.076) 0/68 (<.001) 0/70 (<.001) 71/70 (.974) 5-y TFS RLC 90/93 (.369) 88/93 (.597) 91/88 (.115) 91/99 (.213) ALC 72/93 (.002) 67/93 (.014) 0/90 (<.001) 80/97 (.121) 5-y EFS RLC 80/86 (.213) 71/83 (.154) 84/87 (.450) 86/93 (.486) ALC 64/85 (.016) 33/82 (<.001) 0/87 (<.001) 80/92 (.574) 5-y OS RLC 89/93 (.068) 81/94 (.007) 100/84 (.126) 96/99 (.207) ALC 82/93 (.008) 67/93 (.001) 100/88 (.847) 83/99 (.040) a Two in IM and 1 in Dasa were not evaluable due to lack of differential data at 3 and 6M. Figure 1. OS in Pts with ALC Figure 1. OS in Pts with ALC Disclosures O'Brien: Amgen, Celgene, GSK: Consultancy; CLL Global Research Foundation: Membership on an entity's Board of Directors or advisory committees; Emergent, Genentech, Gilead, Infinity, Pharmacyclics, Spectrum: Consultancy, Research Funding; MorphoSys, Acerta, TG Therapeutics: Research Funding.

Phenotypic and Functional Alterations of Bone Marrow Mesenchymal Stem and Progenitor Cells in Chronic Myeloid Leukemia

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 2398-2398
Author(s):  
Monika Dolinska ◽  
Johannis Klang ◽  
Pingnan Xiao ◽  
Andranik Durgaryan ◽  
Lakshmi Sandhow ◽  
...  
Keyword(s):  
Stem Cells ◽  
Bone Marrow ◽  
Chronic Myeloid Leukemia ◽  
Stromal Cells ◽  
Myeloid Leukemia ◽  
Research Funding ◽  
Stromal Cell ◽  
Molecular Mechanisms ◽  
Fusion Gene ◽  
Differentiation Potential

Abstract Chronic myeloid leukemia (CML) is a myeloproliferative stem cell neoplasm characterized by the presence of the BCR-ABL1 fusion gene. Although current treatment with tyrosine kinase inhibitors (TKI) has dramatically improved the prognosis of CML, these inhibitors do not eradicate leukemic stem cells (LSC) in most patients with the risk of recurrence of leukemia if TKI are stopped. In vitro studies have suggested that this might be attributable to protection of bone marrow (BM) stromal cells, such as osteoblasts, adipocytes, endothelial and mesenchymal stem cells (MSCs). However, how different BM stromal cells contribute to the persistence of LSC remains largely unknown. To investigate this issue we have compared freshly isolated BM stromal cell subsets including MSCs from newly diagnosed CML patients (n=10) with that from age-matched healthy donors (n=12). Distinct from the previous studies on culture-selected BM stromal cells, the naive stromal cells isolated by multi-color fluorescence activated cell sorting (FACS) were phenotypically, molecularly and functionally characterized in the present study. We observed: 1) Similar to the immunophenotype of normal MSCs (CD45-CD235a-CD31-CD44-, most of which were CD271+CD146+CD106+) (Qian et al., JBC, 2012), the CML MSCs, estimated by colony forming unit-fibroblast (CFU-F), were also enriched in the CD45-CD235a-CD31-CD44- cell fraction. 2) The frequency of CFU-Fs was significantly increased in CML BM compared to that in the age-matched healthy controls (p=0.005). 3) A decreased osteogenic, but enhanced adipogenic differentiation potential of CML MSC was revealed in multilineage differentiation assay. This suggests a skewed differentiation potential of the CML MSCs towards adipocytes, possibly related to an altered stromal cell composition in the patients; 4) An increased proportion of CD31+ endothelial cells was seen in CML BM stroma compared to controls (p=0.023) by FACS. 5) An upregulation of the adhesion receptor integrin α4/CD49D was seen in the CD44- MSCs from CML patients (p=0.0087). Conversely, a downregulation of transcripts of Angiopoietin 1, CXCL12, KIT ligand and LAMA4 in the patient MSCs was detected by Quantitative-PCR, indicating an altered hematopoiesis-supportive function of CML MSCs. 6) Importantly, no BCR-ABL fusion were found in the freshly sorted MSCs and mature stromal cells using Fluorescence In Situ Hybridization analysis, suggesting that these MSCs were not part of the leukemic clone. Taken together, our data provide evidence for phenotypic and functional alterations of BM mesenchymal cells in CML patients. The functional relationship between the stromal cell alterations and the growth of LSC as well as the underlying molecular mechanisms are currently under investigation. Disclosures Mustjoki: Finnish Cancer Institute: Research Funding; Sigrid Juselius Foundation: Research Funding; Academy of Finland: Research Funding; the Finnish Cancer Societies: Research Funding; Pfizer: Honoraria, Research Funding; Bristol-Myers Squibb: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Signe and Ane Gyllenberg Foundation: Research Funding.

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