Outcome of Patients with Chronic Myeloid Leukemia (CML) with Multiple ABL1 Kinase Domain Mutations during Tyrosine Kinase Inhibitor Therapy.

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 2111-2111
Author(s):  
Alfonso Quintas-Cardama ◽  
Hagop M. Kantarjian ◽  
Gautam Borthakur ◽  
Stefan Faderl ◽  
Guillermo Garcia-Manero ◽  
...  
Keyword(s):  
Amino Acid ◽  
Tyrosine Kinase ◽  
Kinase Inhibitor ◽  
Lymphoblastic Leukemia ◽  
Kinase Domain ◽  
Molecular Response ◽  
Cell Transplant ◽  
Term Survival ◽  
2Nd Generation ◽  
Kinase Domain Mutations

Abstract BACKGROUND: BCR-ABL1 kinase domain mutations are the main mechanism of resistance to tyrosine kinase inhibitors (TKIs) by destabilizing the inactive conformation of the enzyme or by causing steric hindrance. Although mutations usually affect one amino acid residue within the ABL1 kinase domain, some patients have been shown to carry multiple ABL1 mutations (MAMs). The outcome of these patients is not well defined. OBJECTIVES: To define the clinical characteristics and outcome of patients harboring MAMs detected by direct sequencing during TKI therapy. RESULTS: MAMs were detected in 24 patients (5%) among a series of 502 patients assayed during TKI therapy: 22 with CML and 2 with BCR-ABL1-positive acute lymphoblastic leukemia (Ph+ALL). Median age was 57 years (range, 27–92). Median time from diagnosis to ABL1 mutation detection was 54 months (range, 8–254) and to detection of MAMs 77 months (range, 8–261). Overall, 21 different mutations affecting 15 amino acid residues were detected. The most frequent mutations were M351T (n=7), T315I (n=6), Y253H (n=6), G250E (n=6), and F317L (n=5). P-loop mutations (residues 244–255) were found in 16 (67%) patients. At the time of detection of MAMs, 13 patients were in CP, 4 in AP, and 7 in BP. Patients had received a median of 5 prior therapies (range, 2–9), including 2 TKIs (range, 1–4). Best response to TKI therapy prior to detection of MAMs (24 imatinib, 10 nilotinib, 15 dasatinib, 6 SKI- 606, 1 INNO-406, 1 MK-0457) was complete hematologic response (CHR) in 16 (67%) and cytogenetic response in 7 (29%; complete [CCyR] in 4, partial [PCyR] in 1, minor [mCyR] in 1). One patient had achieved a complete molecular response (CMR). The median follow-up from the detection of MAMs was 10 months (range, 1–51). Twenty-two patients received a 2nd generation TKI after imatinib failure. Among 13 with MAMs prior to start of 2nd generation TKI, 7 (54%) responded (5 CHR, 1 return to CP, and 1 CCyR) for a median of 6.5 months (range, 2–31). By contrast, all 9 (100%) patients without MAMs prior to 2nd generation TKI responded (4 CHR, 3 CCyR, 1 PCyR, 1 CMR) for a median of 43 months (range, 7–48) (p=0.005). Although most patients with MAMs prior to 2nd generation TKIs start had short-lived responses to those agents, those were sustained for significant periods of time in 3 patients: one in BP harboring simultaneously M244V and M351T achieved a CHR and a mCyR with dasatinib 35mg twice daily, sustained for 8 months. A second patient acquired M351T and F359V while receiving imatinib 800mg/d in CP. Therapy with bosutinib 300mg/d rendered a mCyR that has been sustained for more than 9 months. A third patient in AP receiving imatinib 800mg/d acquired G250E and F317L mutations. Therapy with nilotinib 800mg/d resulted in CCyR for 33 months; although F317L became undetectable, CCyR was lost and later regained and has been ongoing for the last 11 months on bosutinib 500mg/d. Four patients underwent allogeneic stem cell transplant (allo-SCT) and 2 are alive: 1 in CHR 2+ months after allo-SCT and 1 who relapsed 3 months post transplant and is currently in CCyR (BCR-ABL1/ABL1 ratio 0.55%) after 19+ months on dasatinib. Ten (42%) of the 24 patients died. The 2-year survival for patients in CP, AP, or BP at the time of detection of MAMs was 86%, 50%, and 0%, respectively. CONCLUSION: Patients expressing more than 1 ABL1 kinase domain mutation respond poorly to TKI therapy. Responses to 2nd generation TKIs, when they occur, are mostly hematologic and typically last <12 months. The long-term survival of patients with MAMs is highly influenced by CML phase.

Treatment Selection for Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia in the Era of Tyrosine Kinase Inhibitors

Chemotherapy ◽  
2019 ◽  
Vol 64 (2) ◽  
pp. 81-93 ◽  
Author(s):  
Yingying Ma ◽  
Quanchao Zhang ◽  
Peiyan Kong ◽  
Jingkang Xiong ◽  
Xi Zhang ◽  
...  
Keyword(s):  
Acute Lymphoblastic Leukemia ◽  
Tyrosine Kinase ◽  
Tyrosine Kinase Inhibitors ◽  
Kinase Inhibitors ◽  
Lymphoblastic Leukemia ◽  
Philadelphia Chromosome ◽  
Molecular Response ◽  
Term Survival ◽  
Hematopoietic Stem ◽  
Philadelphia Chromosome Positive

With the advent of tyrosine kinase inhibitors (TKIs), the treatment of Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL) has entered a new era. The efficacy of TKIs compared with other ALL treatment options is emphasized by a rapid increase in the number of TKI clinical trials. Subsequently, the use of traditional approaches, such as combined chemotherapy and even allogeneic hematopoietic stem cell transplantation (allo-HSCT), for the treatment of ALL is being challenged in the clinic. In light of the increased use of TKIs in the clinic, several questions have been raised. First, is it necessary to use intensive chemotherapy during the induction course of therapy to achieve a minimal residual disease (MRD)-negative status? Must a patient reach a complete molecular response/major molecular response before receiving allo-HSCT? Does MRD status affect long-term survival after allo-HSCT? Is auto-HSCT an appropriate alternative for allo-HSCT in those Ph+ ALL patients who lack suitable donors? Here, we review the recent literature in an attempt to summarize the current status of TKI usage in the clinic, including several new therapeutic approaches, provide answers for the above questions, and speculate on the future direction of TKI utilization for the treatment of Ph+ ALL patients.

AML-associated Flt3 kinase domain mutations show signal transduction differences compared with Flt3 ITD mutations

Blood ◽  
2005 ◽  
Vol 106 (1) ◽  
pp. 265-273 ◽  
Author(s):  
Chunaram Choudhary ◽  
Joachim Schwäble ◽  
Christian Brandts ◽  
Lara Tickenbrock ◽  
Bülent Sargin ◽  
...  
Keyword(s):  
Tyrosine Kinase ◽  
Target Genes ◽  
Kinase Inhibitor ◽  
Point Mutations ◽  
Kinase Domain ◽  
Tyrosine Kinase Domain ◽  
Activating Mutations ◽  
Myeloid Progenitor ◽  
Myeloid Progenitor Cells ◽  
Kinase Domain Mutations

Activating mutations of Flt3 are found in approximately one third of patients with acute myeloid leukemia (AML) and are an attractive drug target. Two classes of Flt3 mutations occur: internal tandem duplications (ITDs) in the juxtamembrane and point mutations in the tyrosine kinase domain (TKD). We and others have shown that Flt3-ITD induced aberrant signaling including strong activation of signal transducer and activator of transcription 5 (STAT5) and repression of CCAAT/estradiol-binding protein α (c/EBPα) and Pu.1. Here, we compared the signaling properties of Flt3-ITD versus Flt3-TKD in myeloid progenitor cells. We demonstrate that Flt3-TKD mutations induced autonomous growth of 32D cells in suspension cultures. However, in contrast to Flt3-ITD and similar to wild-type Flt3 (Flt3-WT), Flt3-TKD cannot support colony formation in semisolid media. Also, in contrast to Flt3-ITD, neither Flt3-WT nor Flt3-TKD induced activation or induction of STAT5 target genes. Flt3-TKD also failed to repress c/EBPα and Pu.1. No significant differences were observed in receptor autophosphorylation and the phosphorylation of Erk-1 and -2, Akt, and Shc. Importantly, TKD but not ITD mutations were a log power more sensitive toward the tyrosine kinase inhibitor protein kinase C 412 (PKC412) than Flt3-WT. In conclusion, Flt3-ITD and Flt3-TKD mutations display differences in their signaling properties that could have important implications for their transforming capacity and for the design of mutation-specific therapeutic approaches.

Patients With Philadelphia-Positive Leukemia With BCR-ABL Kinase Mutations Prior To Allogeneic Transplantation Predominantly Relapse With The Same Mutation

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 4043-4043
Author(s):  
Daniel N. Egan ◽  
Lan Beppu ◽  
Jerald Radich
Keyword(s):  
Conflicts Of Interest ◽  
Lymphoblastic Leukemia ◽  
Kinase Domain ◽  
Cell Transplant ◽  
Hematopoietic Stem ◽  
Abl Kinase ◽  
Advanced Phase ◽  
Number Of Patients ◽  
Kinase Domain Mutations

Abstract Introduction Tyrosine kinase inhibitors (TKIs) remain the front-line therapy for chronic myeloid leukemia (CML). TKIs also improve remission rates when incorporated into induction and maintenance regimens for Philadelphia-positive acute lymphoblastic leukemia (Ph+ ALL). Unfortunately, resistance to TKIs can occur, and is commonly associated with a point mutation in the ABL kinase domain of BCR-ABL. Allogeneic hematopoietic stem cell transplant (HSCT) is indicated for patients with advanced phase CML or for those who fail TKI therapy, and is also often used in Ph+ ALL patients with suitably matched donors. Sadly, relapse after HSCT is fairly common in both advanced phase CML and Ph+ ALL. Studies have explored the benefit of TKIs given post-HSCT to prevent relapse, but there is limited data as to guide their selection and administration. An important consideration is that the “second generation” TKIs may be associated with more toxicity, particularly cytopenias, in the post-HSCT setting. The question arises whether pre-HSCT mutation status should guide prophylactic TKI selection. Given that resistance can occur with a mix of wild type and mutant clones, which clones “win” in the post-transplant setting? Thus, the purpose of this study is to investigate if specific ABL kinase domain mutations persist or recur in CML and Ph+ ALL patients after HSCT. Methods In this retrospective analysis, subjects were at least 18 years of age, had undergone allogeneic HSCT at our center between 2000 and 2010 for CML or Ph+ ALL, and had a positive p210 or p190 BCR-ABL transcript by polymerase chain reaction (PCR) in both the pre- and post-HSCT settings. Patients without available records for chart review and those without available pre- and post-HSCT RNA were excluded. Bone marrow and peripheral blood samples obtained prior to HSCT were analyzed for mutations in BCR-ABL. Total RNA was extracted using a TRIzol reagent (Invitrogen, CA, USA) method. A nested PCR, including an initial RT-PCR step for p210 and/or p190 transcripts, was used to amplify a 928-bp product spanning exons 4-9 of the ABL kinase domain. Sanger sequencing of the PCR product was performed using an Applied Biosystems (ABI, CA, USA) 3730xl Analyzer. In patients with a mutation identified, post-HSCT samples were then sequenced. Results A total of 95 CML patients and 20 Ph+ ALL patients who underwent HSCT were included in the study. History was notable for pre-HSCT TKI therapy in 64.2% of CML and 90.0% of Ph+ ALL patients, correlating with a mean duration of pre-HSCT TKI exposure of 12.3 and 10.6 months, respectively. At a mean of 2.1 years of follow-up, 30.5% of CML and 70.0% of Ph+ ALL patients had received a TKI post-HSCT either for prophylaxis or relapsed/refractory disease. Sequencing revealed pre-HSCT ABL kinase mutations in 10 (10.5%) of CML and in 4 (20.0%) of Ph+ ALL patients. All 14 harbored at least one mutation known to be associated with resistance to one or more TKIs. Mutations occurred across the kinase domain, including the TKI-binding site, P-loop and A-loop: L248V, G250E, Q252H, Y253H, T315I, F317L, M351T, F359V, R362G, E450K, E459K and F486S. In 9 of the 14 (64.2%), the mutation conferring TKI resistance was also detectable post-HSCT at an average of day +191 (range +25 to +559). Seven of the 14 patients had refractory or relapsed disease by last follow-up and, of these, 5 (71.4%) received a TKI known to be resistant to the pre-HSCT mutation and failed to respond. Discussion We have shown that resistance mutations often continue to be detectable in patients with molecular relapse or persistently positive BCR-ABL transcripts after HSCT, attributable to persistence or relapse of a TKI-resistant leukemic clone. This finding suggests that in these patients at greatest risk for disease relapse, resistance patterns may be greatly influenced by any drug-resistant clone present before transplant. Thus, in choosing a TKI for use in the prophylactic setting, if no other clinical features (such as co-morbidities) force the exclusion of a particular TKI, the selection of the TKI with predicted activity against the mutant clone might “hedge the bet.” Notably, our overall rate of ABL mutations in CML is somewhat lower than expected, though this may be attributable to the number of patients without TKI exposure. To our knowledge, this is the largest analysis of ABL kinase domain mutations in a transplant population. Further analysis of additional samples is also underway. Disclosures: No relevant conflicts of interest to declare.

scholarly journals BCR-ABL1 compound mutations in tyrosine kinase inhibitor–resistant CML: frequency and clonal relationships

Blood ◽  
2013 ◽  
Vol 121 (3) ◽  
pp. 489-498 ◽  
Author(s):  
Jamshid S. Khorashad ◽  
Todd W. Kelley ◽  
Philippe Szankasi ◽  
Clinton C. Mason ◽  
Simona Soverini ◽  
...  
Keyword(s):  
Tyrosine Kinase ◽  
Kinase Inhibitors ◽  
Kinase Inhibitor ◽  
Negative Impact ◽  
Direct Sequencing ◽  
Kinase Domain ◽  
Missense Mutations ◽  
Sequencing Method ◽  
Kinase Domain Mutations ◽  
High Level

Abstract BCR-ABL1 compound mutations can confer high-level resistance to imatinib and other ABL1 tyrosine kinase inhibitors (TKIs). The third-generation ABL1 TKI ponatinib is effective against BCR-ABL1 point mutants individually, but remains vulnerable to certain BCR-ABL1 compound mutants. To determine the frequency of compound mutations among chronic myeloid leukemia patients on ABL1 TKI therapy, in the present study, we examined a collection of patient samples (N = 47) with clear evidence of 2 BCR-ABL1 kinase domain mutations by direct sequencing. Using a cloning and sequencing method, we found that 70% (33/47) of double mutations detected by direct sequencing were compound mutations. Sequential, branching, and parallel routes to compound mutations were common. In addition, our approach revealed individual and compound mutations not detectable by direct sequencing. The frequency of clones harboring compound mutations with more than 2 missense mutations was low (10%), whereas the likelihood of silent mutations increased disproportionately with the total number of mutations per clone, suggesting a limited tolerance for BCR-ABL1 kinase domain missense mutations. We conclude that compound mutations are common in patients with sequencing evidence for 2 BCR-ABL1 mutations and frequently reflect a highly complex clonal network, the evolution of which may be limited by the negative impact of missense mutations on kinase function.

Drug Resistance and Bcr-Abl Kinase Domain Mutations In Philadelphia-Positive Acute Lymphoblastic Leukemia From the Imatinib to the 2nd-Generation Tyrosine Kinase Inhibitor Era: The Main Changes Are In the Type of Mutations, but Not In the Frequency of Mutation Involvement

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 575-575
Author(s):  
Simona Soverini ◽  
Alessandra Gnani ◽  
Caterina De Benedittis ◽  
Ilaria Iacobucci ◽  
Annalisa Lonetti ◽  
...  
Keyword(s):  
Acute Lymphoblastic Leukemia ◽  
Board Of Directors ◽  
Genetic Instability ◽  
Kinase Inhibitor ◽  
Direct Sequencing ◽  
Lymphoblastic Leukemia ◽  
Kinase Domain ◽  
Advisory Committees ◽  
2Nd Generation ◽  
Abl Kinase

Abstract Abstract 575 Incorporation of the tyrosine kinase inhibitor (TKI) imatinib in the frontline treatment of Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL) patients (pts) has significantly improved the anti-leukemic efficacy of induction therapy. In contrast to chronic myeloid leukemia (CML), however, responses are short-lived and relapse is frequently associated with the selection of Bcr-Abl kinase domain (KD) mutations, fostered by the high genetic instability of Ph+ ALL cells. The advent of the 2nd-generation TKIs dasatinib and nilotinib has brought additional treatment options both for newly diagnosed and for imatinib-resistant pts. To analyze the changes they have brought in mutation frequency and type, we have reviewed the database recording the results of BCR-ABL KD mutation analyses done in our laboratory from January 2004 to June 2011. Overall, 781 tests on 258 Ph+ ALL pts (number of tests per pt, range: 1–15) were performed by denaturing high-performance liquid chromatography (D-HPLC) followed by direct sequencing of D-HPLC-positive cases. One hundred and fourty-three pts were analyzed because of imatinib resistance. One hundred and one out of 143 (71%) pts scored positive for one or more KD mutations. Similarly to what is know to occur in CML, hematologic and cytogenetic resistance were by far more frequently associated with mutations than molecular resistance (Bcr-Abl transcript increase as assessed by RT-Q-PCR). Overall, mutations at thirteen residues were detected. In contrast to what can be observed in CML, three mutations were by far the most frequent, accounting for almost 75% of the mutated cases: T315I (n=38 pts, 37%), E255K/V (n=19 pts, 18%) and Y253H (n=19 pts, 18%). The other mutations were, in order of frequency: F359V/I, M244V, M351T, F317L, G250E, Q252H, L387M, D276G, L248R, E279K. Nine out of 103 (9%) pts had two mutations, in the same (2 pts) or in different (7 pts) subclones. In 84 pts who were analyzed because they were reported to have developed resistance to dasatinib (n=72) or nilotinib (n=12) as 2nd- or 3rd-line TKIs, 65 (77%) had newly acquired mutations (57/72 dasatinib-resistant pts and 8/12 nilotinib-resistant pts). The most frequent newly acquired mutation in this setting was the T315I, detected in 35/57 (61%) cases acquiring mutations on dasatinib and in 2/8 cases acquiring mutations on nilotinib. Other recurrent newly acquired mutations were F317L, V299L, T315A in dasatinib-resistant pts and Y253H and E255K in nilotinib-resistant pts. Thirty out of 65 pts (46%) were positive for multiple mutations (2 to 4 mutations, in the same or in different subclones or both) that emerged under the same TKI in 11 cases (37%) and accumulated as a consequence of multiple lines of TKI therapy in the remaining 19 (63%) cases. Mutation analysis was also performed in 15 resistant pts enrolled in a clinical trial of dasatinib as first-line treatment for Ph+ ALL. Twelve pts were positive for mutations; 11/12 had a T315I. Sixty-one pts were analyzed at the time of diagnosis in order to assess whether TKI-resistant mutations could already be detectable. Only two pts (3%) were positive for mutations: one patient had an F311L that disappeared after one month of nilotinib treatment; an additional patient was positive only by D-HPLC, but not by the less sensitive direct sequencing – most likely for the T315I mutation that shortly after the start of dasatinib treatment outgrew and led to resistance. Taking advantage of the recent availability of a next-generation sequencing platform (Roche 454), allowing high sensitivity (0.01%) mutation scanning of the KD, samples collected at the time of diagnosis and during follow-up from selected Ph+ ALL cases who developed mutations and resistance to TKI therapy were retrospectively analyzed – but the mutations were not always already detectable at diagnosis. In conclusion: a) although 2nd generation TKIs may ensure a more rapid debulking of the neoplastic clone and have much fewer insensitive mutations, long-term disease control remains a problem and the T315I becomes an even tougher enemy; b) the clinical usefulness of mutation screening of Ph+ ALL pts at diagnosis before TKI start, even with highly sensitive approaches is low – not all mutations pre-exist since genetic instability remains high and fosters mutational events anytime during treatment. Supported by PRIN, FIRB, AIL and AIRC. Disclosures: Soverini: ARIAD: Consultancy; Novartis: Consultancy; Bristol-Myers Squibb: Consultancy. Luppi:CELGENE CORPORATION: Research Funding. Foà:Bristol-Myers Squibb: Consultancy, Membership on an entity's Board of Directors or advisory committees. Baccarani:Bristol-Meyers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees. Martinelli:Novartis: Consultancy, Honoraria; BMS: Consultancy, Honoraria; Pfizer: Consultancy.

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