Abundant and equipotent founder cells establish and maintain acute lymphoblastic leukaemia

High frequencies of blasts in primary acute lymphoblastic leukaemia (ALL) samples have the potential to induce leukaemia and to engraft mice. However, it is unclear how individual ALL cells each contribute to drive leukaemic development in a bulk transplant and the extent to which these blasts vary functionally. We used cellular barcoding as a fate mapping tool to track primograft ALL blasts in vivo. Our results show that high numbers of ALL founder cells contribute at similar frequencies to leukaemic propagation over serial transplants, without any clear evidence of clonal succession. These founder cells also exhibit equal capacity to home and engraft to different organs, although stochastic processes may alter the composition in restrictive niches. Our findings enhance the stochastic stem cell model of ALL by demonstrating equal functional abilities of singular ALL blasts and show that successful treatment strategies must eradicate the entire leukaemic cell population

Implementation of paediatric precision oncology into clinical practice: The Individualized Therapies for Children with cancer program 'iTHER'

iTHER is a Dutch prospective national precision oncology program aiming to define tumour molecular profiles in children and adolescents with primary very high-risk, relapsed, or refractory paediatric tumours. Between April 2017 and April 2021, 302 samples from 253 patients were included. Comprehensive molecular profiling including low-coverage whole genome sequencing (lcWGS), whole exome sequencing (WES), RNA sequencing (RNA-seq), Affymetrix, and/or 850k methylation profiling was successfully performed for 226 samples with at least 20% tumour content. Germline pathogenic variants were identified in 16% of patients (35/219), of which 22 variants were judged causative for a cancer predisposition syndrome. At least one somatic alteration was detected in 204 (90.3%), and 185 (81.9%) were considered druggable, with clinical priority very high (6.1%), high (21.3%), moderate (26.0%), intermediate (36.1%), and borderline (10.5%) priority. iTHER led to revision or refinement of diagnosis in 8 patients (3.5%). Temporal heterogeneity was observed in paired samples of 15 patients, indicating the value of sequential analyses. Of 137 patients with follow-up beyond twelve months, 21 molecularly matched treatments were applied in 19 patients (13.9%), with clinical benefit in few. Most relevant barriers to not applying targeted therapies included poor performance status, as well as limited access to drugs within clinical trial. iTHER demonstrates the feasibility of comprehensive molecular profiling across all ages, tumour types and stages in paediatric cancers, informing of diagnostic, prognostic, and targetable alterations as well as reportable germline variants. Therefore, WES and RNA-seq is nowadays standard clinical care at the Princess Máxima Center for all children with cancer, including patients at primary diagnosis. Improved access to innovative treatments within biology-driven combination trials is required to ultimately improve survival. Keywords: Adolescent; Cancer; Child; Hereditary; Molecular biology; Molecular targeted therapy; Next-generation sequencing; Precision medicin

Targeted inhibitors and antibody immunotherapies: Novel therapies for paediatric leukaemia and lymphoma

Despite improved outcomes achieved in the last decades for children with newly diagnosed leukaemia and lymphoma, treatment of patients with refractory/relapsed disease remains a challenge. The cure rate is still unsatisfactory and often achieved at the cost of significant morbidity. Exploring treatment with novel agents should offer less toxic therapeutic options, without compromising efficacy. Bispecific and antibody-drug conjugates targeting CD19 and CD22 (blinatumomab and inotuzumab ozogamicin) play an important role in the treatment of relapsed and refractory B-cell precursor acute lymphoblastic leukaemia (BCP-ALL); antibodies targeting CD123 and CD38 are also under investigation for acute myeloid leukaemia (AML) and T-ALL, respectively. Targeted therapy with small molecules is of primary importance for specific genetic subtypes, such as BCR-ABL-positive ALL, FLT3-ITD AML and anaplastic lymphoma kinase (ALK)-positive anaplastic large cell lymphoma. KMT2A-directed targeted therapy with menin inhibitors holds promise to be of relevance in KMT2A-rearranged leukaemias, known to have dismal prognosis. Target inhibition in cellular pathways such as BCL-2, RAS, MEK, Bruton's tyrosine kinase, JAK-STAT or CDK4/CDK6 inhibition may be suitable for different diseases with common mutated pathways. Nevertheless, development and approval of new agents for paediatric cancers lags behind adult therapeutic options. New regulations were implemented to accelerate drug development for children. Considering the number of oncology medicinal products available for adults and the rarity of paediatric cancers, prioritisation based on scientific evidence and medical need, as well as international collaboration, is critical. Herein, we review the current status of drug development for children with leukaemia and lymphoma, excluding cellular therapy despite its well-known significance

A population pharmacokinetic model of AT9283 in adults and children to predict the maximum tolerated dose in children with leukaemia

Aims AT9283 is used to treat patients with solid tumours and patients with leukaemia. However, the maximum tolerated dose (MTD) for children with leukaemia remains unknown due to early termination of the Phase I trial. The aim of this study was to develop a population model of AT9283 to describe the pharmacokinetics in adults and children and to estimate the MTD in children with leukaemia. Methods Data from Phase I dose‐escalation studies in adults and children were used to build a population pharmacokinetic model (NONMEM v7.3). Potential covariates investigated included body weight, body surface area (BSA), glomerular filtration rate (GFR), age and sex. Model‐derived area under the concentration–time curve was used to investigate the relationship between dose and exposure in adults and children. Results The plasma concentrations of AT9283 (n = 1770) from 92 patients (53 adults, 39 children) were used to build a two‐compartment model with all pharmacokinetic parameters scaled using body weight. Renal function (GFR), but not BSA, was a significant covariate for the clearance of AT9283. In children with leukaemia (median weight 16 kg), a flat dose of 500 mg 72 h–1 provided similar drug exposures at the MTD as the adult population. The estimated MTD for children with leukaemia, therefore, is 30 mg kg−1 72 h–1. Conclusion For adults, GFR was a significant predictor of clearance, whilst body‐weight based dosing was more useful than BSA in determining the drug exposure in children. The MTD was estimated to be 30 mg kg−1 72 h–1 children with leukaemia

MAPK-ERK is a central pathway in T-cell acute lymphoblastic leukemia that drives steroid resistance

(Patho-)physiological activation of the IL7-receptor (IL7R) signaling contributes to steroid resistance in pediatric T-cell acute lymphoblastic leukemia (T-ALL). Here, we show that activating IL7R pathway mutations and physiological IL7R signaling activate MAPK-ERK signaling, which provokes steroid resistance by phosphorylation of BIM. By mass spectrometry, we demonstrate that phosphorylated BIM is impaired in binding to BCL2, BCLXL and MCL1, shifting the apoptotic balance toward survival. Treatment with MEK inhibitors abolishes this inactivating phosphorylation of BIM and restores its interaction with anti-apoptotic BCL2-protein family members. Importantly, the MEK inhibitor selumetinib synergizes with steroids in both IL7-dependent and IL7-independent steroid resistant pediatric T-ALL PDX samples. Despite the anti-MAPK-ERK activity of ruxolitinib in IL7-induced signaling and JAK1 mutant cells, ruxolitinib only synergizes with steroid treatment in IL7-dependent steroid resistant PDX samples but not in IL7-independent steroid resistant PDX samples. Our study highlights the central role for MAPK-ERK signaling in steroid resistance in T-ALL patients, and demonstrates the broader application of MEK inhibitors over ruxolitinib to resensitize steroid-resistant T-ALL cells. These findings strongly support the enrollment of T-ALL patients in the current phase I/II SeluDex trial (NCT03705507) and contributes to the optimization and stratification of newly designed T-ALL treatment regimens

A phase I/II trial of AT9283, a selective inhibitor of aurora kinase in children with relapsed or refractory acute leukemia: challenges to run early phase clinical trials for children with leukemia

Aurora kinases regulate mitosis and are commonly overexpressed in leukemia. This phase I/IIa study of AT9283, a multikinase inhibitor, was designed to identify maximal tolerated doses, safety, pharmacokinetics, and pharmacodynamic activity in children with relapsed/refractory acute leukemia. The trial suffered from poor recruitment and terminated early, therefore failing to identify its primary endpoints. AT9283 caused tolerable toxicity, but failed to show clinical responses. Future trials should be based on robust preclinical data that provide an indication of which patients may benefit from the experimental agent, and recruitment should be improved through international collaborations and early combination with established treatment strategies

Seasonal drought prediction for semiarid northeast Brazil: what is the added value of a process-based hydrological model?

The semiarid northeast of Brazil is one of the most densely populated dryland regions in the world and recurrently affected by severe droughts. Thus, reliable seasonal forecasts of streamflow and reservoir storage are of high value for water managers. Such forecasts can be generated by applying either hydrological models representing underlying processes or statistical relationships exploiting correlations among meteorological and hydrological variables. This work evaluates and compares the performances of seasonal reservoir storage forecasts derived by a process-based hydrological model and a statistical approach. Driven by observations, both models achieve similar simulation accuracies. In a hindcast experiment, however, the accuracy of estimating regional reservoir storages was considerably lower using the process-based hydrological model, whereas the resolution and reliability of drought event predictions were similar by both approaches. Further investigations regarding the deficiencies of the process-based model revealed a significant influence of antecedent wetness conditions and a higher sensitivity of model prediction performance to rainfall forecast quality. Within the scope of this study, the statistical model proved to be the more straightforward approach for predictions of reservoir level and drought events at regionally and monthly aggregated scales. However, for forecasts at finer scales of space and time or for the investigation of underlying processes, the costly initialisation and application of a process-based model can be worthwhile. Furthermore, the application of innovative data products, such as remote sensing data, and operational model correction methods, like data assimilation, may allow for an enhanced exploitation of the advanced capabilities of process-based hydrological models.</p

Seasonal drought prediction for semiarid northeastern Brazil: verification of six hydro-meteorological forecast products

A set of seasonal drought forecast models was assessed and verified for the Jaguaribe River in semiarid northeastern Brazil. Meteorological seasonal forecasts were provided by the operational forecasting system used at FUNCEME (Ceará's research foundation for meteorology) and by the European Centre for Medium-Range Weather Forecasts (ECMWF). Three downscaling approaches (empirical quantile mapping, extended downscaling and weather pattern classification) were tested and combined with the models in hindcast mode for the period 1981 to 2014. The forecast issue time was January and the forecast period was January to June. Hydrological drought indices were obtained by fitting a multivariate linear regression to observations. In short, it was possible to obtain forecasts for (a) monthly precipitation, (b) meteorological drought indices, and (c) hydrological drought indices.The skill of the forecasting systems was evaluated with regard to root mean square error (RMSE), the Brier skill score (BSS) and the relative operating characteristic skill score (ROCSS). The tested forecasting products showed similar performance in the analyzed metrics. Forecasts of monthly precipitation had little or no skill considering RMSE and mostly no skill with BSS. A similar picture was seen when forecasting meteorological drought indices: low skill regarding RMSE and BSS and significant skill when discriminating hit rate and false alarm rate given by the ROCSS (forecasting drought events of, e.g., SPEI1 showed a ROCSS of around 0.5). Regarding the temporal variation of the forecast skill of the meteorological indices, it was greatest for April, when compared to the remaining months of the rainy season, while the skill of reservoir volume forecasts decreased with lead time.This work showed that a multi-model ensemble can forecast drought events of timescales relevant to water managers in northeastern Brazil with skill. But no or little skill could be found in the forecasts of monthly precipitation or drought indices of lower scales, like SPI1. Both this work and those here revisited showed that major steps forward are needed in forecasting the rainy season in northeastern Brazil.</p