Estudio farmacogenético de los polimorfismos de transporte y metabolismo relacionados con el tratamiento de la leucemia mieloblástica aguda

En la leucemia mieloide aguda (LMA) ha sido tratada durante décadas con combinaciones de citarabina y antraciclinas, con tasas de remisión completa (RC) del 60-80%. Desgraciadamente, un 70% de los pacientes recae, y además, parte de ellos muere por toxicidad grave o presenta resistencia inicial al tratamiento. La variabilidad individual en LMA que conduce a distinta efectividad y toxicidad en pacientes con el mismo esquema de inducción no se deben sólo a alteraciones citogenéticas y moleculares, sino que puede estar influida por la variabilidad genética. En este estudio se han analizado 49 polimorfismos de nucleótido único (SNPs) en 33 genes implicados en las vías metabólicas de citarabina y antraciclinas en 225 pacientes adultos con LMA, y su correlación con la efectividad y toxicidad del tratamiento de inducción. Los SNPs en genes ABC, que codifican bombas de eflujo de fármacos, no influyeron en la eficacia de las antraciclinas. Sin embargo, el alelo variante de ABCB1 se correlacionó con mayor muerte en inducción y toxicidad inducida por antraciclinas, asociaciones previamente descritas en la literatura. Además, se describieron por primera vez asociaciones entre los SNPs de ABCG2 y las toxicidades cardíacas y pulmonares, y de los SNPs de ABCC1 y la toxicidad hepática grave, relaciones que son factibles, ya que los tejidos afectados expresan dichos genes. Los polimorfismos relacionados con el metabolismo de antraciclinas afectan principalmente a la toxicidad, destacando las asociaciones entre NQO2 con menor RC y mayor toxicidad gastrointestinal, de NQO1 con mucositis, toxicidad gastrointestinal y trombocitopenia, de CBR3 con toxicidad hepática, y de NOS3 con toxicidad renal, hepática y trombocitopenia. Las variantes de las subunidades de la NADPH oxidasa (CYBA, NCF4, RAC2), responsables de la generación de especies reactivas de oxígeno, influyeron tanto en la tasa de RC y la supervivencia global (SG), como en las toxicidades inducidas por las antraciclinas, destacando la toxicidad cardíaca. Respecto a los SNPs de la vía metabólica de la citarabina, se observó influencia en la eficacia del tratamiento, destacando las asociaciones de SNPs de CDA con la RC y la supervivencia, de DCK con la RC y de RRM1 con la supervivencia. Además, los SNPs de DCK, CDA y NT5C2 se asociaron con toxicidades inducidas por citarabina, destacando la toxicidad cutánea con CDA y la mucositis con DCK. SNPs relacionados con la citotoxicidad de citarabina, de reciente descubrimiento en una cohorte LMA pediátrica, reprodujo su influencia en la supervivencia y descubrió nuevas asociaciones con las toxicidades de citarabina en nuestra cohorte. La farmacogenética ha demostrado ser una herramienta útil en la individualización del tratamiento en pacientes adultos con LMA tratados con citarabina e idarubicina, y permite seleccionar el esquema más adecuado para cada paciente en función de sus variantes genéticas, aumentado su efectividad y reduciendo la potencial toxicidad.Acute myeloid leukemia (AML) it has been treated for decades with combinations of cytarabine and anthracyclines, with complete remission (CR) rates of 60-80%. Unfortunately, 70% of patients who reach CR finally relapsed, and part of them showed induction death from severe toxicity or initial resistance to treatment. The individual variability in AML that leads to different effectiveness and toxicity in patients with the same induction scheme is not only due to cytogenetic and molecular alterations, but can also be influenced by genetic variability. In this study, 49 single nucleotide polymorphisms (SNPs) have been analyzed in 33 genes involved in the metabolic pathways of cytarabine and anthracyclines in 225 adult patients with AML, and their correlation with the effectiveness and toxicity of induction treatment. SNPs in ABC genes, which encode drug efflux pumps, did not influence the efficacy of anthracyclines. However, the variant allele of ABCB1 was correlated with higher induction death and anthracycline-induced toxicity, associations previously described in the literature. Furthermore, associations between ABCG2 SNPs and cardiac and pulmonary toxicities, and ABCC1 SNPs with severe liver toxicity were described for the first time, relationships that are feasible, since the affected tissues express these genes. Polymorphisms related to anthracycline metabolism were mainly correlated with toxicity, highlighting the associations between NQO2 with lower CR and greater gastrointestinal toxicity, NQO1 with mucositis, gastrointestinal toxicity and thrombocytopenia, CBR3 with liver toxicity, and NOS3 with thrombocytopenia, kidney and liver toxicities. Variant alleles of the NADPH oxidase subunits (CYBA, NCF4, RAC2), responsible for the generation of reactive oxygen species, influenced CR rate and overall survival (OS), as well as the toxicities induced by anthracyclines, highlighting cardiac toxicity. Regarding the SNPs of the cytarabine metabolic pathway, influence on the efficacy was observed, highlighting the associations of SNPs of CDA with CR and survival, of DCK with CR and of RRM1 with survival. Furthermore, SNPs of DCK, CDA, and NT5C2 were associated with cytarabine-induced toxicities, highlighting skin toxicity with CDA and mucositis with DCK. SNPs related to cytarabine cytotoxicity, recently discovered in a pediatric AML cohort, reproduced their influence on survival and discovered novel associations with cytarabine toxicities in our cohort. Pharmacogenetics has proven to be a useful tool in the individualization of treatment in adult patients with AML treated with cytarabine and idarubicin, and allows selecting the most appropriate regimen for each patient based on their genetic variants, increasing its effectiveness and reducing potential toxicity

Use of 2-Hydroxypropyl-Beta-Cyclodextrin for Niemann-Pick Type C Disease

Niemann-Pick disease type C (NPD-C) is a rare neurodegenerative disorder characterized by a lysosomal storage disorder. Treatment has been supportive and symptomatic. In animal studies, 2-hydroxypropyl-β-cyclodextrin (HP-β-CD) showed a significant decrease in cerebellar damage, neurological progression, and higher lifespan. Based on these results, HP-β-CD has been tested in NPD-C patients for last 8 years. The first compassionate uses of intravenous HP-β-CD obtained a limited improvement in neurological symptoms, probably associated to the non-permeation of the blood-brain barrier. The change or combination with intrathecal administrations of HP-β-CD achieved higher benefits, especially improvement or stabilization of NPD-C progression. Biomarkers of neurological cholesterol homeostasis are being investigated in order to quantify the response of HP-β-CD treatment. The results of a clinical trial recently published have reproduced the slowing of NPD-C progression in 14 patients treated with a dose-escalation protocol of HP-β-CD intrathecal monthly infusions, with respect to a historical comparison cohort. The safety profile of this therapy is acceptable, being the loss of hearing as the most frequent adverse event. However, some severe toxicities have been reported in relation with HP-β-CD, including chemical meningitis and fever. The short experience with HP-β-CD suggested that it could be effective in the management of NPD-C

Genetic interaction between PLK1 and downstream MCPH proteins in the control of centrosome asymmetry and cell fate during neural progenitor division

Alteration of centrosome function and dynamics results in major defects during chromosome segregation and is associated with primary autosomal microcephaly (MCPH). Despite the knowledge accumulated in the last few years, why some centrosomal defects specifically affect neural progenitors is not clear. We describe here that the centrosomal kinase PLK1 controls centrosome asymmetry and cell fate in neural progenitors during development. Gain- or loss-of-function mutations in Plk1, as well as deficiencies in the MCPH genes Cdk5rap2 (MCPH3) and Cep135 (MCPH8), lead to abnormal asymmetry in the centrosomes carrying the mother and daughter centriole in neural progenitors. However, whereas loss of MCPH proteins leads to increased centrosome asymmetry and microcephaly, deficient PLK1 activity results in reduced asymmetry and increased expansion of neural progenitors and cortical growth during mid-gestation. The combination of PLK1 and MCPH mutations results in increased microcephaly accompanied by more aggressive centrosomal and mitotic abnormalities. In addition to highlighting the delicate balance in the level and activity of centrosomal regulators, these data suggest that human PLK1, which maps to 16p12.1, may contribute to the neurodevelopmental defects associated with 16p11.2–p12.2 microdeletions and microduplications in children with developmental delay and dysmorphic features.JGM and DMA received predoctoral contracts from the Ministry of Education of Spain (FPI grant BES-2016-077901). This work was supported by Grant PID2019-104763RB-I00 and Ramón y Cajal contract (RYC-2014-15991), both from MINECO/AEI/FEDER (EU) to EP; and grants from the European Commission Seventh Framework Programme (ERA-NET NEURON8-Full-815-094), AEI-MICIU/FEDER (RTI2018-095582-B-I00 and RED2018-102723- T), and the iLUNG programme from the Comunidad de Madrid (B2017/BMD-3884) to MM. CNIO is a Severo Ochoa Center of Excellence (AEI-MICIU CEX2019-000891-S)

Pharmacogenetics of Immunosuppressants in Solid Organ Transplantation: Time to Implement in the Clinic

Our aim in this chapter is to present the state of the art, including our own group research, in the field of immunosuppressant pharmacogenetics in the four main types of solid organ transplantation: kidney, heart, lung, and liver. The main focus will be on those findings in the field that have been widely investigated and then in those that are close to clinical implementation, mainly CYP3A5 genotyping for the adjustment of the initial tacrolimus dose. This recommendation will be discussed in more detail, explaining its clinical potential as well as its limitations. To end, a short opinion about the feasibility of implementation in the health systems as well as discussion about private companies selling pharmacogenetic tests will be presented

Differences in ex-vivo Chemosensitivity to Anthracyclines in First Line Acute Myeloid Leukemia

Induction schedules in acute myeloid leukemia (AML) are based on combinations of cytarabine and anthracyclines. The choice of the anthracycline employed has been widely studied in multiple clinical trials showing similar complete remission rates. Using an ex vivo test we have analyzed if a subset of AML patients may respond differently to cytarabine combined with idarubicin, daunorubicin or mitoxantrone. Bone marrow (BM) samples of 198 AML patients were incubated for 48 hours in 96 well plates, each well containing different drugs or drug combinations at different concentrations. Ex vivo drug sensitivity analysis was made using the PharmaFlow platform maintaining the BM microenvironment. Drug response was evaluated as depletion of AML blast cells in each well after incubation. Annexin V-FITC was used to quantify the ability of the drugs to induce apoptosis, and pharmacological responses were calculated using pharmacokinetic population models. Similar dose-respond graphs were generated for the three anthracyclines, with a slight decrease in EC with idarubicin (p=1.462E-06), whereas the interpatient variability of either drug was large. To identify those cases of selective sensitivity to anthracyclines, potency was compared, in terms of area under the curve. Differences in anthracycline monotherapy potency greater than 30% from 3 pairwise comparisons were identified in 28.3% of samples. Furthermore, different sensitivity was detected in 8.2% of patients comparing combinations of cytarabine and anthracyclines. A third of the patients could benefit from the use of this test in the first line induction therapy selection, although it should be confirmed in a clinical trial specifically designed

A clinically compatible drug-screening platform based on organotypic cultures identifies vulnerabilities to prevent and treat brain metastasis

We report a medium‐throughput drug‐screening platform (METPlatform) based on organotypic cultures that allows to evaluate inhibitors against metastases growing in situ. By applying this approach to the unmet clinical need of brain metastasis, we identified several vulnerabilities. Among them, a blood–brain barrier permeable HSP90 inhibitor showed high potency against mouse and human brain metastases at clinically relevant stages of the disease, including a novel model of local relapse after neurosurgery. Furthermore, in situ proteomic analysis applied to metastases treated with the chaperone inhibitor uncovered a novel molecular program in brain metastasis, which includes biomarkers of poor prognosis and actionable mechanisms of resistance. Our work validates METPlatform as a potent resource for metastasis research integrating drug‐screening and unbiased omic approaches that is compatible with human samples. Thus, this clinically relevant strategy is aimed to personalize the management of metastatic disease in the brain and elsewhere

Formación de los tutores de las prácticas externas como herramienta eficaz en la mejora del aprendizaje del estudiante y su inserción laboral

El objetivo del proyecto es mejorar la calidad de la tutorización de las prácticas externas y fomentar las buenas prácticas que garanticen el proceso de enseñanza-aprendizaje. Están implicados tutores académicos, externos, instituciones y estudiante

Systematic Review of Pharmacogenetics of ABC and SLC Transporter Genes in Acute Myeloid Leukemia

Antineoplastic uptake by blast cells in acute myeloid leukemia (AML) could be influenced by influx and efflux transporters, especially solute carriers (SLCs) and ATP-binding cassette family (ABC) pumps. Genetic variability in SLC and ABC could produce interindividual differences in clinical outcomes. A systematic review was performed to evaluate the influence of SLC and ABC polymorphisms and their combinations on efficacy and safety in AML cohorts. Anthracycline intake was especially influenced by SLCO1B1 polymorphisms, associated with lower hepatic uptake, showing higher survival rates and toxicity in AML studies. The variant alleles of ABCB1 were related to anthracycline intracellular accumulation, increasing complete remission, survival and toxicity. Similar findings have been suggested with ABCC1 and ABCG2 polymorphisms. Polymorphisms of SLC29A1, responsible for cytarabine uptake, demonstrated significant associations with survival and response in Asian populations. Promising results were observed with SLC and ABC combinations regarding anthracycline toxicities. Knowledge of the role of transporter pharmacogenetics could explain the differences observed in drug disposition in the blast. Further studies including novel targeted therapies should be performed to determine the influence of genetic variability to individualize chemotherapy schemes

Systematic Review of Pharmacogenetics of ABC and SLC Transporter Genes in Acute Myeloid Leukemia

Antineoplastic uptake by blast cells in acute myeloid leukemia (AML) could be influenced by influx and efflux transporters, especially solute carriers (SLCs) and ATP-binding cassette family (ABC) pumps. Genetic variability in SLC and ABC could produce interindividual differences in clinical outcomes. A systematic review was performed to evaluate the influence of SLC and ABC polymorphisms and their combinations on efficacy and safety in AML cohorts. Anthracycline intake was especially influenced by SLCO1B1 polymorphisms, associated with lower hepatic uptake, showing higher survival rates and toxicity in AML studies. The variant alleles of ABCB1 were related to anthracycline intracellular accumulation, increasing complete remission, survival and toxicity. Similar findings have been suggested with ABCC1 and ABCG2 polymorphisms. Polymorphisms of SLC29A1, responsible for cytarabine uptake, demonstrated significant associations with survival and response in Asian populations. Promising results were observed with SLC and ABC combinations regarding anthracycline toxicities. Knowledge of the role of transporter pharmacogenetics could explain the differences observed in drug disposition in the blast. Further studies including novel targeted therapies should be performed to determine the influence of genetic variability to individualize chemotherapy schemes

Healthcare Resource Utilization among Patients between 60–75 Years with Secondary Acute Myeloid Leukemia Receiving Intensive Chemotherapy Induction: A Spanish Retrospective Observational Study

Background: Information regarding the impact on healthcare systems of secondary acute myeloid leukemia (sAML) is scarce. Methods: A retrospective review of medical charts identified patients aged 60–75 years with sAML between 2010 and 2019. Patient information was collected from diagnosis to death or last follow-up. Outpatient resource use, reimbursement, frequency and duration of hospitalization, and transfusion burden were assessed. Forty-six patients with a median age of 64 years were included. Anthracycline plus cytarabine regimens were the most common induction treatment (39 patients, 85%). The ratio of the total days hospitalized between the total follow-up was 29%, with a sum of 204 hospitalizations (average four/patient; average duration 21 days). The total average reimbursement was EUR 90,008 per patient, with the majority (EUR 77,827) related to hospital admissions (EUR 17,403/hospitalization). Most hospitalizations (163, mean 22 days) occurred in the period before the first allogeneic hematopoietic stem cell transplant (alloHSCT), costing EUR 59,698 per patient and EUR 15,857 per hospitalization. The period after alloHSCT (in only 10 patients) had 41 hospitalizations (mean 21 days), and a mean reimbursement cost of EUR 99,542 per patient and EUR 24,278 per hospitalization. In conclusion, there is a high consumption of economic and healthcare resources in elderly patients with sAML receiving active treatments in Spain