Co-Crystal Structures of 7-Azaindole Inhibitors of Wild-Type and T315I Imatinib-Resistant Mutant Forms of the BCR-ABL Tyrosine Kinase.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 1018-1018
Author(s):  
Hal A. Lewis ◽  
Fred Zhang ◽  
Richard Romero ◽  
Pierre-Yves Bounaud ◽  
Mark E. Wilson ◽  
...  

Abstract Chronic myelogenous leukemia (CML) arises from uncontrolled cell growth driven by a constitutively active BCR-ABL fusion protein tyrosine kinase, which is the product of the pathognomonic Philadelphia chromosomal translocation. Imatinib mesylate (Gleevec) is a BCR-ABL inhibitor used as a first line treatment of CML. Although imatinib is highly effective in chronic phase CML, in advanced disease patients frequently relapse due to the emergence of drug resistance. Approximately two-thirds of resistance is caused by point mutations in the BCR-ABL kinase domain, which give rise to active mutant forms of the enzyme that are insensitive to Gleevec. The T315I mutation represents one of the most common causes of resistance, is resistant to the second generation BCR-ABL inhibitors dasatinib and nilotinib, and represents an important and challenging target for discovery of next generation targeted CML treatments. We have applied X-ray crystallographic screening of our FAST™ fragment library and structure-guided hit-to-lead optimization to identify potent inhibitors of both wild-type and T315I mutant BCR-ABL. These efforts yielded a 7-azaindole compound series that exhibits binding to and inhibition of both wild-type and T315I BCR-ABL. Methods: Wild-type (with Y393F) and T315I Abl kinase domain protein were expressed in E. coli and purified to homogeneity. These proteins were crystallized in the presence of a reference inhibitor followed by addition of the 7-azaindole series compounds soaked into the preformed crystals to displace the reference compound, giving the desired co-crystal. X-ray diffraction data were recorded at the company’s proprietary synchrotron beamline SGX-CAT at the Advanced Photon Source. Three-dimensional enzyme-inhibitor co-crystal structures were determined by molecular replacement and refined to permit modeling of bound ligand. Results: Both wild-type and T315I Abl structures revealed enzyme in the active conformation with inhibitors bound to the kinase hinge region. The crystal structure of 2-amino-5-[3-(1-ethyl-1H-pyrazol-5-yl)-1H-pyrrolo[2,3-b]pyridin-5-yl]-N,N-dimethylbenzamide in complex with T315I, illustrates the typical binding mode which is independent of the 315 residue, and therefore accounts for the compound inhibiting the T315I mutant form of BCR-ABL (see figure). The inhibitor binds to the hinge region of ABL utilizing hydrogen bonding to backbone carbonyl of Glu316 and NH of Met318, with the pyrazole ring stacking in a lipophilic pocket between Phe382 and Tyr253. In addition, the benzamide carbonyl participates in a hydrogen bond interactioin with the backbone-NH of Glu249 of the p-loop. Conclusions: X-ray crystallographic fragment screening and co-crystal structure studies have been successfully employed in discovery/optimization of 7-azaindole series compounds, yielding potent, selective inhibitors of both wild-type and imatinib-resistant forms of BCR-ABL. Figure Figure

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 5159-5159
Author(s):  
Junichiro Yuda ◽  
Toshihiro Miyamoto ◽  
Yoshikane Kikushige ◽  
Jun Odawara ◽  
Yasuyuki Ohkawa ◽  
...  

Abstract Background Chronic myeloid leukemia (CML) is effectively treated with tyrosine kinase inhibitors (TKIs), but reactivation of BCR-ABL frequently occurs through acquisition of kinase domain point mutations. The mechanism of resistance in patients without BCR-ABL kinase domain point mutation is still elusive. Previous studies have revealed the abnormal splicing of BCR-ABL kinase domain, including Exon8/9 junction 35bp insertion and exon-skipping of Exon 7 (T O'Hare et al, Blood 2011. Gaillard JB, et al. Mol Cancer Ther 2010). The insertion of 35 intronic nucleotides at the exon 8/9 splice junction introduces a stop codon after 10 intron-encoded residues and inactive tyrosine kinase activity. The effect of these splicing abnormalities on susceptibility of cells against TKIs is still controversial. Furthermore, the conventional direct sequence techniques could not evaluate splicing abnormalities in major molecular response (MMR)- complete molecular response (CMR) CML patients, who achieved clinically leukemia-free state with a small number residual CML stem cells. Aims The aim of this study is to evaluate the frequency and the patterns of splicing abnormalities of BCR-ABL in CML patients, especially who achieved MMR-CMR by TKI treatment. Methods We analyzed peripheral blood samples from healthy individuals and CML chronic phase patients. We extracted total RNA from these samples and synthesized cDNA, and then performed PCR-amplification of BCR-ABL kinase domain in CML patients and ABL kinase domain in healthy individuals, respectively. PCR products were subjected to the amplicon sequence: We deeply sequenced BCR-ABL fusion gene transcripts, and evaluated splicing forms of BCR-ABL by using HiSeq 2000 (illumina). Results We successfully established a novel analysis method, which can detect the pattern of splicing abnormalities even in MMR-CMR patients. Using the amplicon sequence technique, we detected abnormal splicing patterns of BCR-ABL in 5 out of 15 CML patients. We also found that the splicing abnormalities were not restricted to 35bp insertion at the exon8/9 junction, thus intronic retention of intron 8 and intron 9 could be frequently detected with or without the 35bp insertion in CML patients (Table 1). Of note, these abnormal splicing patterns always co-existed with wild type BCR-ABL transcripts in all 5 cases analyzed. In addition to the novel splicing abnormalities in CML, we unexpectedly found in healthy individuals that splicing abnormalities such as 35bp insertion at the exon8/9 junction and intronic retention could be detected in ABL1 transcripts (Table 1). This result suggests that this sort of splicing abnormalities could occur at a certain frequency in steady state human hematpoiesis, and is not specific to BCR-ABL. Summary / Conclusion We have newly established an analysis system to efficiently detect splicing abnormalities of BCR-ABL even in MMR-CMR CML patients. Using this highly efficient amplicon sequence technique, we identified novel splicing abnormalities both in healthy individuals and CML patients, and found that the wild type BCR-ABL transcripts always co-exist with abnormally spliced BCR-ABL transcripts. These results collectively suggest that splicing abnormalities within the ABL1 kinase domain are not specific to CML patients treated with TKIs, and that the detection of such kinase domain splicing abnormalities do not reflect insusceptibility of the remaining cells during TKI treatment. Disclosures: No relevant conflicts of interest to declare.


Blood ◽  
2009 ◽  
Vol 114 (10) ◽  
pp. 2168-2171 ◽  
Author(s):  
Simona Soverini ◽  
Alessandra Gnani ◽  
Sabrina Colarossi ◽  
Fausto Castagnetti ◽  
Elisabetta Abruzzese ◽  
...  

Abstract Dasatinib and nilotinib are tyrosine kinase inhibitors (TKIs) developed to overcome imatinib resistance in Philadelphia-positive leukemias. To assess how Bcr-Abl kinase domain mutation status evolves during sequential therapy with these TKIs and which mutations may further develop and impair their efficacy, we monitored the mutation status of 95 imatinib-resistant patients before and during treatment with dasatinib and/or nilotinib as second or third TKI. We found that 83% of cases of relapse after an initial response are associated with emergence of newly acquired mutations. However, the spectra of mutants conferring resistance to dasatinib or nilotinib are small and nonoverlapping, except for T315I. Patients already harboring mutations had higher likelihood of relapse associated with development of further mutations compared with patients who did not harbor mutations (23 of 51 vs 8 of 44, respectively, for patients who relapsed on second TKI; 13 of 20 vs 1 of 6, respectively, for patients who relapsed on third TKI).


Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 3717-3717
Author(s):  
Michael Marit ◽  
Manprit Chohan ◽  
Natasha Matthew ◽  
Kai Huang ◽  
Dwayne Barber

Abstract Mutation and activation of JAK2 is a common event in Myeloproliferative Disease as JAK2 V617F and related deletion mutations are observed in Polycythemia Vera, Essential Thrombocythemia and Primary Myelofibrosis. In addition, the TEL-JAK2 chromosomal translocation is a rare event in Acute Myeloid Leukemia and Chronic Myelomonocytic Leukemia. We reasoned that activated alleles of JAK2 would develop resistance to JAK inhibitors in a clinical setting, similar to the development of Imatinib resistance in BCR-ABL-mediated Chronic Myeloid Leukemia. The objective of this study was to develop a random mutagenesis screen to isolate mutations of JAK2 resistant to tyrosine kinase inhibitors. We selected JAK Inhibitor-1 for this study, since the crystal structure of this inhibitor bound to the JAK2 JH1 kinase domain has been reported and would allow for mapping of confirmed mutations. TEL-JAK2(5–12) and JAK2 V617F were subcloned into retroviral expression vectors and random libraries of mutations were generated by transformation into XL-1 Red strain of E. coli, a strain defective in pathways of DNA repair. High titer retroviral supernatants were generated and used to transduce Ba/F3 (for TEL-JAK2) or Ba/F3-EPO-R (for JAK2 V617F). Control experiments were performed with “wild type” versions of each JAK2 allele. Inhibitor-resistant clones were identified and DNA sequencing was performed to identify JAK2 JH1 kinase domain mutations that confer resistance to inhibitor. We have restricted the analysis of JAK inhibitor-resistant mutants to those that map within the kinase domain of JAK2 for purposes of this study. We have confirmed that E864K, V881A, N909K, G935R, R975G confer resistance to JAK inhibitor-1 in growth assays. In addition, M929I (analogous to BCR-ABL T315I) mediates resistance to JAK inhibitor-1, relative to wild-type activated JAK2 alleles. All mutations result in increased phosphorylation of STAT5, Akt and Erk in the presence of inhibitor. We are currently testing the catalytic activity of each mutant to determine whether JAK2 kinase domain mutations have similar enzymatic activity or whether mutation also affects catalysis. We have mapped each mutation within the JAK2 JH1 crystal structure and models for how each mutant affects inhibitor binding will be presented. Importantly, many of these residues are highly conserved in other JAK tyrosine kinases and within BCR-ABL. We are extending these observations by testing clinically relevant inhibitors in our screen. At the conclusion of this study we will be able to identify common residues critical for resistance by JAK2 inhibitors and unique residues that are inhibitor-specific. Random mutagenesis screening offers an excellent strategy to identify JAK2 residues that may be relevant in the clinic and also serve in enhancing our knowledge regarding JAK kinase activation and regulation.


Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 3365-3365 ◽  
Author(s):  
Paul W. Manley ◽  
Sandra W. Cowan-Jacob ◽  
Gabriele Fendrich ◽  
Jürgen Mestan

Abstract AMN107 (Novartis Pharma AG), is a new, highly potent and selective inhibitor of the Abl tyrosine kinase activity of the Bcr-Abl oncoprotein, which causes chronic myelogenous leukemia (CML). In addition to inhibiting wild-type Bcr-Abl, AMN107 inhibits the activity of 32/33 mutant forms of this protein which occur in imatinib-resistant patients. Following promising results from Phase I clinical studies in imatinib-resistant CML patients, AMN107 has now entered Phase II clinical trials. In order to better understand the molecular basis for the activity of this compound we have examined the x-ray crystallographic structures of complexes between AMN107 and the Abl kinase domain of wild-type and mutant Bcr-Abl. For these studies, recombinant proteins (residues 229–500) corresponding to the wild type and M351T mutant of the human Abl kinase domain were expressed in baculovirus infected insect cells and purified in the presence of AMN107. In each case the crystals obtained contained four independent copies of the complex in the unit cell and they diffracted to a resolution of 2.2 and 2.7 Å, respectively. As has been reported for the prototype Bcr-Abl inhibitor, imatinib (Nagar et al., Cancer Research2002;62:4236), AMN107 binds to an inactive conformation of Abl, in which the glycine-rich, P-loop folds over the ATP binding site and the activation-loop adopts a conformation in which it occludes the substrate binding site and disrupts the ATP-phosphate binding site to block the catalytic activity of the enzyme. In order to induce the inactive conformation of the protein, AMN107 participates in hydrogen-bond interactions between (i) the pyridine-N and the backbone-C=O of Met318, (ii) the anilino-NH and the side-chain hydroxyl of Thr315, (iii) the carboxamido-C=O and the backbone-NH of Asp381, and (iv) the carboxamido-NH and the side-chain carboxylate of Glu286. These hydrogen-bond interactions are complemented by a large number of lipophilic interactions, surrounding the pyridine and 4-methylimidazole moieties in particular. Furthermore, careful analysis has revealed the presence of interactions between the protein and the trifluoromethyl group of AMN107, in which a fluorine atom is in close contact with the backbone-C=O of Asp381, with a mean F-C distance of 3.02 Å (4 mols/unit cell: 2.95, 2.97, 3.08 and 3.09). This compares with a value of 3.30 Å for the sum of the van der Waals radii of fluorine and carbon. Similar F-C=O interactions (mean F-C distance 3.02 Å) are observed in a complex between AMN107 and M351TAbl. Such interactions have been reported in the literature (Olsen et al., ChemBioChem2004;5:666) and are the result of dipolar interactions between the electronegative fluorine and the positively polarised carbon of the carbonyl group. In order to evaluate the contribution of the fluorine interactions to the binding of AMN107 to Abl we compared the effects of AMN107 on Bcr-Abl autophosphorylation in Ba/F3 cells to those of the corresponding analogue of AMN107, possessing a methyl group in place of trifluoromethyl. Whereas AMN107 displayed a mean IC50 value of 17 ± 0.5 nM, the methyl analogue had a mean IC50 of 83 ± 13 nM, which translates into a difference in binding energy in the region of 0.7 kcal/mole. Although Asp381 is therefore important for the binding of AMN107 to Abl through a hydrogen bond and through F-C interactions, resistance-mutations of this residue are unlikely the arise, since it plays a key role in the catalytic activity of the enzyme by interacting with a Mg ion which coordinates the phosphate groups of ATP.


Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 836-836 ◽  
Author(s):  
Simona Soverini ◽  
Giovanni Martinelli ◽  
Sabrina Colarossi ◽  
Alessandra Gnani ◽  
Fausto Castagnetti ◽  
...  

Abstract Dasatinib (BMS-354825) is a second-generation BCR-ABL inhibitor active against several imatinib-insensitive BCR-ABL mutant forms. We have treated in the phase II program with dasatinib a total of forty-five Ph+ pts who were resistant to or intolerant of imatinib. At the time of writing, twenty pts have failed to respond to or relapsed on dasatinib therapy. In order to assess which pre-existent or emerging ABL kinase domain (KD) mutations are challenging for dasatinib clinical efficacy, we retrospectively analyzed ABL KD sequences before the start of treatment and every month thereafter, until dasatinib discontinuation. Mutation monitoring was done by D-HPLC, followed by sequencing in D-HPLC-positive cases. Eight pts had primary resistance to dasatinib (Table 1). In all cases, a T315I or a F317L mutation was already detectable before the onset of treatment or became detectable after one month. The mutations persisted up to the time of disease progression, which occurred at a median of 1.5 months (range, 1–4) from dasatinib start. Twelve pts had acquired resistance to dasatinib (Table 1). Relapse occurred after a median of 7.5 months (range, 3–15) from dasatinib start. Mutation analysis performed before the onset of treatment showed that five of these pts had a wild-type ABL sequence, while the remaining seven pts had evidence of various imatinib-resistant KD mutations (G250E, Y253H, E255K, D276G, M351T). At the time of relapse, however, most of the original mutant clones had disappeared, whereas mutations at residues 315 (T315I or T315A) and/or 317 (F317L or F317I) had invariably emerged in all but one pt. This pt was found to have developed a novel K356R mutation which is now under characterization. Our results indicate that residues 315 and 317 are mutation hotspots in dasatinib-resistant pts, according to the experimental observation that they are both involved in inhibitor binding. They also provide a proof of principle that novel, inhibitor-specific mutant variants (i.e., T315A, F317I, K356R) may be selected, and raise some concerns about the limitations of single-agent treatment in the long term disease control of advanced phase-CML or Ph+ ALL pts. Supported by European LeukemiaNet, AIL, AIRC, FIRB and PRIN projects. Table 1 Pt Disease Mutation(s) before dasatinib start Best HR Best CgR Months on dasatinib Mutation(s) at relapse NE, not evaluated Primary resistance 1 CML/AP WT NR none 4 T315I 2 CML/AP T315I NR NE 1 T315I 3 CML/myBC T315I NR NE 1 T315I 4 CML/myBC F317L NR none 3 F317L 5 CML/lyBC T315I NR NE 1 T315I 6 Ph+ ALL T315I, M351T, L387M NR NE 2 T315I, M351T, L387M 7 Ph+ ALL T315I NR NE 1 T315I 8 Ph+ ALL F359V NR NE 2 T315I Acquired resistance 9 CP WT CHR minor 15 T315I 10 CML/myBC G250E NEL none 8 F317L 11 CML/lyBC Y253H CHR complete 9 CHR T315I 12 CML/lyBC WT CHR complete 4 T315I 13 CML/lyBC E255K CHR none 3 E255K, T315I 14 CML/lyBC D276G CHR complete 7 T315I 15 CML/lyBC WT CHR partial 9 F317L 16 Ph+ ALL E255K CHR NE 4 T315I 17 Ph+ ALL Y253H CHR complete 13 T315A, F317L, D276G 18 Ph+ ALL M351T CHR complete 13 M351T, F317L 19 Ph+ ALL WT CHR complete 6 F317I 20 Ph+ ALL WT CHR complete 4 K356R


Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 1104-1104 ◽  
Author(s):  
Ruriko Tanaka ◽  
Matthew S Squires ◽  
Shinya Kimura ◽  
Asumi Yokota ◽  
Kirsty Mallett ◽  
...  

Abstract CML is caused by a consistent genetic abnormality, termed the Philadelphia chromosome, that results from a reciprocal (9;22) translocation leading to the expression of the BCR-ABL fusion protein. Although treatment has been revolutionized by the introduction of tyrosine kinase inhibitors which target Abl activity, reactivation of Abl signaling via several different point mutations remains problematic. In particular the mutation of Threonine 315 to Isoleucine (T315I) confers resistance to all existing therapies with tyrosine kinase inhibitors in the clinical settings. We describe the in vitro and in vivo effects of AT9283, a potent inhibitor of several protein kinases, including Abl kinase (wild type BCR-ABL and several of the drug resistant mutant variants that have arisen in clinical practice e.g. T315I), JAK2, JAK3 and Aurora kinases A and B, on imatinib-resistant CML cells including those harboring BCR-ABL (T315I). AT9283 has potent anti-proliferative activity in a panel of BaF3 and human cell lines expressing the BCR-ABL or its mutant forms. In BaF3 BCR-ABL wild-type and T315I mutant cells and K562 CML cells we observed inhibition of substrates of both BCR-ABL (STAT5) and Aurora B (Histone H3) at concentrations >300nM and <100nM, respectively, suggesting that AT9283 is capable of inhibiting Aurora and BCR-ABL simultaneously in these cell lines. The in vivo effects of AT9283 were examined in several mouse models engrafted either subcutaneously or intravenously with BaF3, human CML cell lines or primary CML patient samples expressing the BCR-ABL or its mutant forms. Specifically AT9283 prolonged the survival of mice engrafted intravenously with either BaF3 BCR-ABL T315I, or E255K cells when administered intraperitoneally twice daily at doses of either 6.25 or 10mg/kg or once daily at 15mg/kg when administered 5 days in every week repeated twice. Maximal survival advantage was conferred at either 10mg/kg twice daily or 15mg/kg once a day. Similar data were obtained in an intravenous model using primary CML cells taken from a patient harbouring the BCR-ABL E255K mutation. We also present data from ongoing studies showing increased survival rates in these in vivo model systems following multiple cycles of AT9283 administered on the 15mg/kg once daily schedule. These data together support further clinical investigation of AT9283 in patients with treatment resistant CML.


Hematology ◽  
2005 ◽  
Vol 2005 (1) ◽  
pp. 183-187 ◽  
Author(s):  
Neil P. Shah

AbstractThe treatment of chronic myeloid leukemia (CML) has been revolutionized by the small molecule BCR-ABL-selective kinase inhibitor imatinib. Although imatinib is highly effective initially and generally well-tolerated, relapse is increasingly encountered clinically. Until recently, for the majority of CML patients with disease no longer responsive to imatinib, as well as for patients with imatinib intolerance, few effective therapeutic options existed. Our understanding of the major mechanisms of imatinib resistance has led to the clinical development of two novel BCR-ABL inhibitors that harbor significant therapeutic promise in early clinical trial experience. These agents, dasatinib (BMS-354825) and AMN107, are more potent inhibitors of BCR-ABL than imatinib, and moreover, harbor activity against nearly all imatinib-resistant BCR-ABL kinase domain mutant forms tested in vitro. Notably, neither of these compounds is effective against the imatinib-resistant BCR-ABL/T315I mutation. The potential availability of highly effective medications for the treatment of imatinib-resistant and intolerant cases of CML is expected to further complicate the timing of other effective therapies, such as allogeneic stem cell transplantation. Additionally, periodic genotyping of the BCR-ABL kinase domain to screen for drug-resistant mutations may play an increasingly important role in the future management of CML cases.


Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 2118-2118 ◽  
Author(s):  
Simona Soverini ◽  
Alessandra Gnani ◽  
Sabrina Colarossi ◽  
Fausto Castagnetti ◽  
Francesca Palandri ◽  
...  

Abstract Resistance to imatinib in Philadelphia-positive (Ph+) leukemia patients is often associated with selection of point mutations in the Bcr-Abl kinase domain (KD). Dasatinib and nilotinib are second-generation tyrosine kinase inhibitors (TKIs) with different binding modes with respect to imatinib, that have been shown to confer in vitro and in vivo activity against many Bcr-Abl mutated forms. However, both dasatinib and nilotinib have been shown to retain some ‘Achilles heels’, and they include both imatinib-resistant mutations (e.g., T315I) and some novel, inhibitor-specific ones. Selection of either type of KD mutations has frequently been observed in patients (pts) who relapse after an initial response to dasatinib or nilotinib and represents one of the major hurdles on the road to successful treatment of imatinib-resistant pts. We have monitored Abl KD mutation status in a total of 121 pts who received dasatinib (n= 78) or nilotinib (n=43) as 2nd TKI after imatinib failure since February 2005. Fifty-eight (48%) pts had chronic phase (CP) chronic myelogenous leukemia (CML), 63 pts (52%) had accelerated phase (AP) or blast crisis (BC) CML or Ph+ acute lymphoblastic leukemia (ALL). Median age was 55 years (range, 18–76); median time from diagnosis was 49 months (range, 4–181); median time on imatinib was 32 months (range, 4–66). Median follow-up of all pts who received a 2nd TKI is 7 months (range, 1–38). Median follow-up of pts who are still on 2nd TKI treatment is 32 months (range, 28–38). Relapses after an initial response have so far been observed in 46/121 pts. Thirty-eight out of these 46 pts had AP/BC CML or Ph+ ALL at the time 2nd TKI was started. Forty-one out of 121 (34%) pts have experienced relapse after an initial response during the first 12 months of 2nd TKI treatment (median time to relapse, 6,5 months; range 4–12 months), while only five of the 45 (11%) pts who were still on 2nd TKI treatment after >12 months have relapsed (at 13, 15, 18, 20 and 33 months, respectively). Interestingly, none of these 5 pts had never achieved more than a minor cytogenetic response (CgR), and 4/5 pts were receiving a reduced TKI dose because of toxicity. In 36/46 (78%) cases, relapse was associated with newly acquired Abl KD mutations. In particular 26/30 (87%) pts who relapsed on dasatinib and 10/16 (63%) pts who relapsed on nilotinib had evidence of a newly acquired KD mutation presumably responsible for treatment failure. Newly acquired mutations in pts who relapsed on dasatinib as 2nd TKI were T315I (n= 12 pts) F317L (n= 8 pts) T315A (n=3 pts); V299L (n=3 pts); F317I (n=2 pts); 2 pts had multiple mutations. Newly acquired mutations in pts who relapsed on nilotinib as 2nd TKI were E255K (n=3); E255V (n=2); Y253H (n=2); T315I (n=1); F359V (n=1); F359C (n=1). Sixteen pts (but none of those harboring the T315I) switched to dasatinib or nilotinib or high-dose imatinib as 3rd TKI and this rescued hematologic or even cytogenetic responses in a proportion of cases. Our observations suggest that: newly acquired mutations leading to relapse in Ph+ leukemia pts receiving dasatinib or nilotinib as 2nd TKI usually arise rapidly; the likelihood of mutation selection consistently decreases over time, and seems mainly confined to advanced phase pts and to pts with no or minor CgR; almost all (87%) cases who developed resistance to dasatinib had newly acquired KD mutations - suggesting that the higher potency with respect to imatinib can overcome Bcr-Abl gene amplification and that Src kinase inhibition may turn off Bcr- Abl-independent resistance mechanisms; a lower incidence (63%) of newly acquired KD mutations was observed in pts who developed resistance to nilotinib; with the exception of T315I, there is little if no overlap between dasatinib and nilotinib-resistant mutants, which may allow to regain responses by switching TKIs.


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