Targeted therapy in chronic lymphocytic leukemia

Chronic lymphocytic leukemia (CLL) is characterized by the accumulation of mature B lymphocytes in blood, bone marrow and lymphoid tissues. Historically, patients with TP53 aberration and with refractoriness to chemoimmunotherapy had a dismal prognosis. During the past few years a paradigm shift has taken place in the treatment of CLL as new, targeted agents have been introduced. The aim of this thesis was to explore targeted agents in patients with advanced CLL. In the first study, the safety and efficacy of lenalidomide in combination with alemtuzumab was explored in a phase I-II trial. The rational was that lenalidomide has its major effects in lymph nodes and alemtuzumab in the bone marrow. Furthermore, the capacity of low-dose lenalidomide in maintaining immune functions in advanced-phase CLL patients during alemtuzumab treatment was evaluated. The combination showed an acceptable safety profile as well as clinical efficacy with an overall response rate (ORR) of 58%. Median response duration was 12 months. Lenalidomide had a narrow therapeutic dose range, 2.5 mg/day was not efficient, and the maximum tolerated dose was 5 mg/day. Low-dose lenalidomide increased the frequency of proliferating CD8+ T cells but had no effect on the immune checkpoint marker, programmed cell death 1 (PD-1), on T cells. After combination treatment, granzyme B+ T cells increased. In conclusion, low-dose lenalidomide and alemtuzumab induced major changes in T cells, including increased proliferative activity and cytotoxic potential. In the second study, the safety and efficacy of ibrutinib in combination with alemtuzumab was explored in a phase I trial. The rational was that ibrutinib has its major effects in lymph nodes and alemtuzumab in the bone marrow. Further, the toxicity profiles differ. The treatment combination was efficient: 7 out of 8 patients responded to treatment and 7 achieved minimal residual disease negativity. Within 2 weeks, ibrutinib led to decreased proliferation of CLL cells and T cells. After 4 weeks of ibrutinib therapy, PD-1 expression was unchanged on T cells. Due to a high rate of opportunistic infections, the study was closed in advance and we recommend against the combination of ibrutinib and alemtuzumab. In the third study, the safety and efficacy of ibrutinib, when used in routine health care, was evaluated. Ninety-five consecutive patients, treated in a compassionate use program, were analyzed. At a median follow-up of 10 months, the ORR was 84%, the progression free survival (PFS) rate was 77% and the overall survival (OS) rate was 83%. PFS and OS were significantly inferior in patients with TP53 aberration. Atrial fibrillation occurred in 8% and Richter transformation (RT) occurred in 7% of patients. Half of the patients would not have met the inclusion criteria for the pivotal study of ibrutinib: this demonstrates the real-world representativity of the patients. The observed efficacy and toxicity of ibrutinib in the study were similar to that in pivotal studies. In the fourth study, a long-term follow-up of the patients in the compassionate use program for ibrutinib was carried out. At 30-month follow-up, the ORR rate was unchanged at 84%, the PFS rate was 52% and the OS rate was 63%. Fifty-one percent of patients remained on treatment. In contrast to the early (10-month) report, TP53 aberration had no negative survival impact. In multivariate analyses, OS was significantly associated with baseline comorbidities and PFS was associated with baseline comorbidities and number of prior therapies. Fifty-one percent of the patients had grade 3-4 infections and 13% had grade 3-5 opportunistic infections. Fifteen percent developed atrial fibrillation. RT occurred in 13%. Twenty-six percent of patients had dose reduction or temporary treatment breaks, which had no significant impact on the outcome. Four of 6 patients who had progressive disease while on ibrutinib were tested for mutation of Bruton’s tyrosine kinase. All of them carried the most common mutation leading to ibrutinib resistance. In conclusion, ibrutinib was effective and well tolerated for long-term use. The observed efficacy of ibrutinib was somewhat inferior to that of pivotal studies. The observed frequencies of treatment discontinuation and dose reductions were greater than in clinical studies

Loss of the Lupus Autoantigen Ro52/Trim21 Induces Tissue Inflammation and Systemic Autoimmunity by Disregulating the IL-23–Th17 Pathway

Ro52/Trim21 is targeted as an autoantigen in systemic lupus erythematosus and Sjögren's syndrome. Polymorphisms in the Ro52 gene have been linked to these autoimmune conditions, but the molecular mechanism by which Ro52 may promote development of systemic autoimmune diseases has not been explored. To address this issue, we generated Ro52-null mice ($Ro52^{−/−}$), which appear phenotypically normal if left unmanipulated. However, $Ro52^{−/−}$ mice develop severe dermatitis extending from the site of tissue injury induced by ear tags. The affected mice further develop several signs of systemic lupus with hypergammaglobulinemia, autoantibodies to DNA, proteinuria, and kidney pathology. Ro52, which was recently identified as an E3 ligase, mediates ubiquitination of several members of the interferon regulatory factor (IRF) family, and the Ro52-deficient mice have an enhanced production of proinflammatory cytokines that are regulated by the IRF transcription factors, including cytokines involved in the Th17 pathway (interleukin [IL] 6, IL-12/IL-23p40, and IL-17). Loss of IL-23/IL-17 by genetic deletion of IL-23/p19 in the $Ro52^{−/−}$ mice conferred protection from skin disease and systemic autoimmunity. These data reveal that the lupus-associated Ro52 protein is an important negative regulator of proinflammatory cytokine production, and they provide a mechanism by which a defective Ro52 function can lead to tissue inflammation and systemic autoimmunity through the IL-23–Th17 pathway

Effects of ventilation improvement on measured and perceived indoor air quality in a school building with a hybrid ventilation system

Ventilation system design and operation may significantly affect indoor air quality (IAQ). The aims of this case study were to investigate the functionality of a supply air fan-assisted hybrid ventilation system in a newly built school building with reported IAQ problems and to determine the effects of ventilation improvement on measured and perceived IAQ. The ventilation system function was researched simultaneously with IAQ measurements, with an analysis of total volatile organic compounds (TVOC), single volatile organic compounds (VOCs), and indoor mycobiota, and with questionnaires about perceived IAQ. At the baseline, an operational error of the ventilation system was found, which prevented the air from coming into the classrooms, except for short periods of high carbon dioxide (CO2 ) concentrations. After the ventilation operation was improved, a significant change in indoor mycobiota was found; the dominant, opportunistic human pathogenic species Trichoderma citrinoviride found in settled dust in the classroom before the improvement was no longer detected. In addition, the concentrations of CO2, TVOC, and some single VOCs, especially toluene and decamethylcyclopentasiloxane, decreased. The analysis of the questionnaire results indicated that the perceptions of unpleasant odors and stuffy air decreased, although a statistically significant improvement in perceived IAQ was not observed. The results provided evidence that the properly controlled hybrid ventilation system operating in mechanical supply mode provided adequate ventilation and was effective in decreasing the concentrations of some indoor-generated pollutants. With simple ventilation adjustments, microbiological exposure from building structures might be prevented.Peer reviewe

Parameters for characterising indoor space connected to ill health symptoms?

Proceeding volume: 33Suuren toimistokiinteistön työtiloista (11 kpl) mitattiin sisäilman mikrobilaskeumien lajistoa ja resistenssejä homeeenesto kemikaaleille, toksiineja tuottavia mikrobeja pölyissä ja rakenneavausnäytteissä; sisäpölyn toksisuutta ja sisäilmasta tiivistetyn veden toksisuutta, sekä monitoroitiin sisäilman 24/7 hengitettäviä hiukkasia (PM2.5, PM10), ilman painetta, lämpötilaa, suhteellista kosteutta sekä formaldehydiä, hiilidioksidia ja VOC aineita. Tavoitteena oli saada mittaustietoa niistä tekijöistä jotka ovat yhteydessä hyvinvointihaittaan. Tulokset osoittivat, että jokainen tutkittu, ongelmainen huone oli yksilöllinen mikrobiston, toksisuuksien, kemiallisten ja fysikaalisten parametrien suhteen, ja että useat 24/7 mitatut parametrit osoittivat viikkorytmiin, vuorokauden aikaan, tunti- tai jopa minuuttirytmiin kytkettyä syklisyyttä

FANCM mutation c.5791C > T is a risk factor for triple-negative breast cancer in the Finnish population

The FANCM c.5101C > T nonsense mutation was previously found to associate with breast cancer in the Finnish population, especially among triple-negative cases. Here, we studied the prevalence of three other FANCM variants: c.5791C > T, which has been reported to predispose to familial breast cancer, and the c.4025_4026delCT and c.5293dupA variants recently identified in Finnish cancer patients. We genotyped the FANCM c.5791C > T mutation in 4806 invasive breast cancer patients, including BRCA1/2 mutation negative familial cases and unselected cases, and in 2734 healthy population controls from four different geographical areas of Finland. The association of the mutation with breast cancer risk among patient subgroups was statistically evaluated. We further analyzed the combined risk associated with c.5101C > T and c.5791C > T mutations. We also genotyped 526 unselected ovarian cancer patients for the c.5791C > T mutation and 862 familial breast cancer patients for the c.4025_4026delCT and c.5293dupA variants. The frequency of the FANCM c.5791C > T mutation was higher among breast cancer cases than in controls (OR 1.94, 95% CI 0.87-4.32, P = 0.11), with a statistically significant association with triple-negative breast cancer (OR 5.14, 95% CI 1.65-16.0, P = 0.005). The combined analysis for c.5101C > T and c.5791C > T carriers confirmed a strong association with breast cancer (OR 1.86, 95% CI 1.32-2.49, P = 0.0002), especially among the triple-negative patients (OR 3.08, 95% CI 1.77-5.35, P = 0.00007). For the other variants, only one additional c.4025_4026delCT carrier and no c.5293dupA carriers were observed. These results support the role of FANCM as a breast cancer susceptibility gene, particularly for triple-negative breast cancer.Peer reviewe

Case-control analysis of truncating mutations in DNA damage response genes connects TEX15 and FANCD2 with hereditary breast cancer susceptibility

Several known breast cancer susceptibility genes encode proteins involved in DNA damage response (DDR) and are characterized by rare loss-of-function mutations. However, these explain less than half of the familial cases. To identify novel susceptibility factors, 39 rare truncating mutations, identified in 189 Northern Finnish hereditary breast cancer patients in parallel sequencing of 796 DDR genes, were studied for disease association. Mutation screening was performed for Northern Finnish breast cancer cases (n = 578-1565) and controls (n = 337-1228). Mutations showing potential cancer association were analyzed in additional Finnish cohorts.c.7253dupT in TEX15, encoding a DDR factor important in meiosis, associated with hereditary breast cancer (p = 0.018) and likely represents a Northern Finnish founder mutation. A deleterious c.2715 + 1G > A mutation in the Fanconi anemia gene, FANCD2, was over two times more common in the combined Finnish hereditary cohort compared to controls. A deletion (c.640_644del5) in RNF168, causative for recessive RIDDLE syndrome, had high prevalence in majority of the analyzed cohorts, but did not associate with breast cancer. In conclusion, truncating variants in TEX15 and FANCD2 are potential breast cancer risk factors, warranting further investigations in other populations. Furthermore, high frequency of RNF168 c.640_644del5 indicates the need for its testing in Finnish patients with RIDDLE syndrome symptoms.Peer reviewe

Loss of the lupus autoantigen Ro52/Trim21 induces tissue inflammation and systemic autoimmunity by disregulating the IL-23-Th17 pathway.

Ro52/Trim21 is targeted as an autoantigen in systemic lupus erythematosus and Sjögren\u27s syndrome. Polymorphisms in the Ro52 gene have been linked to these autoimmune conditions, but the molecular mechanism by which Ro52 may promote development of systemic autoimmune diseases has not been explored. To address this issue, we generated Ro52-null mice (Ro52(-/-)), which appear phenotypically normal if left unmanipulated. However, Ro52(-/-) mice develop severe dermatitis extending from the site of tissue injury induced by ear tags. The affected mice further develop several signs of systemic lupus with hypergammaglobulinemia, autoantibodies to DNA, proteinuria, and kidney pathology. Ro52, which was recently identified as an E3 ligase, mediates ubiquitination of several members of the interferon regulatory factor (IRF) family, and the Ro52-deficient mice have an enhanced production of proinflammatory cytokines that are regulated by the IRF transcription factors, including cytokines involved in the Th17 pathway (interleukin [IL] 6, IL-12/IL-23p40, and IL-17). Loss of IL-23/IL-17 by genetic deletion of IL-23/p19 in the Ro52(-/-) mice conferred protection from skin disease and systemic autoimmunity. These data reveal that the lupus-associated Ro52 protein is an important negative regulator of proinflammatory cytokine production, and they provide a mechanism by which a defective Ro52 function can lead to tissue inflammation and systemic autoimmunity through the IL-23-Th17 pathway

Mutation analysis of the ATR gene in breast and ovarian cancer families

INTRODUCTION: Mutations in BRCA1, BRCA2, ATM, TP53, CHK2 and PTEN account for only 20–30% of the familial aggregation of breast cancer, which suggests the involvement of additional susceptibility genes. The ATR (ataxia-telangiectasia- and Rad3-related) kinase is essential for the maintenance of genomic integrity. It functions both in parallel and cooperatively with ATM, but whereas ATM is primarily activated by DNA double-strand breaks induced by ionizing radiation, ATR has been shown to respond to a much broader range of DNA damage. Upon activation, ATR phosphorylates several important tumor suppressors, including p53, BRCA1 and CHK1. Based on its central function in the DNA damage response, ATR is a plausible candidate gene for susceptibility to cancer. METHODS: We screened the entire coding region of the ATR gene for mutations in affected index cases from 126 Finnish families with breast and/or ovarian cancer, 75 of which were classified as high-risk and 51 as moderate-risk families, by using conformation sensitive gel electrophoresis and direct sequencing. RESULTS: A large number of novel sequence variants were identified, four of which – Glu254Gly, Ser1142Gly, IVS24-48G>A and IVS26+15C>T – were absent from the tested control individuals (n = 300). However, the segregation of these mutations with the cancer phenotype could not be confirmed, partly because of the lack of suitable DNA samples. CONCLUSION: The present study does not support a major role for ATR mutations in hereditary susceptibility to breast and ovarian cancer

BRCA2 polymorphic stop codon K3326X and the risk of breast, prostate, and ovarian cancers

Background: The K3326X variant in BRCA2 (BRCA2*c.9976A>T; p.Lys3326*; rs11571833) has been found to be associated with small increased risks of breast cancer. However, it is not clear to what extent linkage disequilibrium with fully pathogenic mutations might account for this association. There is scant information about the effect of K3326X in other hormone-related cancers. Methods: Using weighted logistic regression, we analyzed data from the large iCOGS study including 76 637 cancer case patients and 83 796 control patients to estimate odds ratios (ORw) and 95% confidence intervals (CIs) for K3326X variant carriers in relation to breast, ovarian, and prostate cancer risks, with weights defined as probability of not having a pathogenic BRCA2 variant. Using Cox proportional hazards modeling, we also examined the associations of K3326X with breast and ovarian cancer risks among 7183 BRCA1 variant carriers. All statistical tests were two-sided. Results: The K3326X variant was associated with breast (ORw = 1.28, 95% CI = 1.17 to 1.40, P = 5.9x10- 6) and invasive ovarian cancer (ORw = 1.26, 95% CI = 1.10 to 1.43, P = 3.8x10-3). These associations were stronger for serous ovarian cancer and for estrogen receptor–negative breast cancer (ORw = 1.46, 95% CI = 1.2 to 1.70, P = 3.4x10-5 and ORw = 1.50, 95% CI = 1.28 to 1.76, P = 4.1x10-5, respectively). For BRCA1 mutation carriers, there was a statistically significant inverse association of the K3326X variant with risk of ovarian cancer (HR = 0.43, 95% CI = 0.22 to 0.84, P = .013) but no association with breast cancer. No association with prostate cancer was observed. Conclusions: Our study provides evidence that the K3326X variant is associated with risk of developing breast and ovarian cancers independent of other pathogenic variants in BRCA2. Further studies are needed to determine the biological mechanism of action responsible for these associations