Dasatinib and azacitidine followed by haploidentical stem cell transplant for chronic myeloid leukemia with evolving myelodysplasia: A case report and review of treatment options.

BACKGROUND: CML presenting with a variant Philadelphia translocation, atypical BCR-ABL transcript, additional chromosomal aberrations, and evolving MDS is uncommon and therapeutically challenging. The prognostic significance of these genetic findings is uncertain, even as singular aberrations, with nearly no data on management and outcome when they coexist. MDS evolving during the course of CML may be either treatment-associated or an independently coexisting disease, and is generally considered to have an inferior prognosis. Tyrosine kinase inhibitors (TKI) directed against BCR-ABL are the mainstay of treatment for CML, whereas treatment modalities that may be utilized for MDS and CML include allogeneic stem cell transplant and – at least conceptually – hypomethylating agents. CASE REPORT: Here, we describe the clinical course of such a patient, demonstrating that long-term combined treatment with dasatinib and azacitidine for coexisting CML and MDS is feasible and well tolerated, and may be capable of slowing disease progression. This combination therapy had no deleterious effect on subsequent potentially curative haploidentical bone marrow transplantation. CONCLUSIONS: The different prognostic implications of this unusual case and new therapeutic options in CML are discussed, together with a review of the current literature on CML presenting with different types of genomic aberrations and the coincident development of MDS. Additionally, this case gives an example of long-term combined treatment of tyrosine kinase inhibitors and hypomethylating agents, which could be pioneering in CML treatment

Allosterische Kinaseinhibitoren

Background. Inhibition of the kinase activity of the BCR-ABL1 oncoprotein by an allosteric mechanism of action facilitates alternative treatment options for chronic myeloid leukemia (CML) patients who cannot be adequately treated with conventional catalytic site-directed tyrosine kinase inhibitor (TKI). Objectives. Pathophysiologic role of the BCR-ABL1 oncogene, mechanisms of action of catalytic site-directed TKI, clinical need for new therapies in BCR-ABL1 positive leukemias, mechanism of allosteric inhibition, development of the first clinically applicable allosteric ABL inhibitor ABL001 (asciminib), preclinical data, clinical development. Methods. Mechanistic and preclinical studies published to date and clinical results of the initial phase 1 dose escalation trial are summarized. Result. ABL001 is a potent, highly selective inhibitor of BCR-ABL, with a resistance profile distinct from that of ATP-competitive TKI. In murine models, combination studies demonstrate pronounced antileukemic efficacy with complete and sustained leukemia regression and confirmation of the non-overlapping mechanisms of resistance. In the first phase 1 study in humans, ABL001 exhibits rapid antileukemic activity and appears well tolerated to date in a heavily pretreated subgroup of patients with CML. Conclusions. Proof of principle of the effectiveness of allosteric inhibition of BCR-ABL kinase activity with ABL001 as the first-in-class compound holds promise as a novel therapeutic option for treatment of CML patients who respond insufficiently to or are intolerant of conventional TKI, and may contribute to further improving treatment of CML

Auswirkung des Crosslinking der Kornea mittels UV-A-Strahlung und Riboflavin auf den intraokularen Druck und die Ultrastruktur am Vorderkammermodell des Schweins

Hintergrund: Der Keratokonus ist eine meist bilaterale, nicht-entzündliche Ektasie der Kornea, die im meist progredienten Verlauf eine starke Einschränkung der Sehleistung verursacht. Meist sind jüngere Patienten betroffen, die Erkrankungsgipfel liegen zwischen dem 17. und 49. Lebensjahr. Bisherige Therapien waren rein symptomatisch wie die Anpassung ausgleichender Sehhilfen oder letztlich eine Keratoplastik mit entsprechenden Risiken. Seit mehreren Jahren nun wird mittels Crosslinking (Cxl) ein vielversprechender Ansatz verfolgt der das Fortschreiten des Keratokonus kausal aufhalten kann. Da es sich um meist sehr junge Patienten mit entsprechendem Langzeitverlauf handelt ist das Verständnis der möglichen Komplikationen und Nebenwirkungen sehr wichtig. Mehrere Studien haben sich bereits mit diesen beschäftigt; unter anderem mit der Problematik des IOP (intraokulärer Druck) und dessen Messung. Hier lagen bisher sehr unterschiedliche Ergebnisse vor. Ziel dieser Arbeit war es zu klären ob es im Modell intraokular zu einer Druckerhöhung nach Cxl kommt. Methoden: Es wurden insgesamt 35 Schweineaugen bzw. die Vorderkammer im Perfusionsmodell nach Johnsen und Tschumper untersucht. 20 Augen wurden mittels Cxl behandelt, 15 Augen dienten als Methodenkontrolle. Die Auswertung erfolgte in Kohorten zu je 5 Augen. Die Dauer der Nachbeobachtung betrug 48 h. Darüber hinaus wurden 8 Vorderkammern, jeweils 4 nach Cxl und 4 nach Methodenkontrolle, mittels Elektronenmikroskop auf ultrastrukturelle Veränderungen untersucht. Mit der TUNEL-Färbung wurde die Funktion des Modells überprüft. Des Weiteren wurden, zu verschiedenen Zeiten, Zellen für eine Zellkultur aus dem Trabekelmaschenwerk isoliert. Ergebnisse: Druckmessung: Der Mittelwert der Messungen aller Interventionskohorten lag für die Messungen vor Cxl bei 16,07 mmHg(± 3,17 mmHg), der Wert nach Cxl lag bei 14,83 mmHg (± 3,07 mmHg). Bei den Kontrollkohorten ergaben sich folgende Werte: Messung vor Cxl 14,78 mmHg (± 4,85 mmHg) und nach Cxl 12,60 mmHg (± 2,75 mmHg). Die Untersuchung der Ultrastruktur zeigte keine Veränderung durch das Cxl oder durch die Perfusionskammer. Die TUNEL-Färbung zeigte im Mittel 3,95 % (± 1,84 %) apoptotische Zellen in den Augen die im Perfusionsmodell waren. Die Anzüchtung der Zellkulturen aus den Druckversuchen gelang nicht. Bei den Nativen Augen nur nach max. 12-stündiger Inkubation ins Medium. Schlussfolgerung: Es konnte nicht nachgewiesen werden dass es durch das Cxl intraokulär zu einem signifikanten Anstieg des IOP im Beobachtungszeitraum kommt. Im Einzelfall jedoch waren auch höhere Werte zu beobachten. Insgesamt scheint v.a. die klinische Messmethode mittels Applanationstonometern durch die Erkrankung und die Folgen der Cxl-Behandlung affektiert zu sein. Auch Ultrastrukturell fanden sich keine Hinweise auf eine Veränderung durch das Cxl im Beobachtungszeitraum

p185(BCR/ABL) has a lower sensitivity than p210(BCR/ABL) to the allosteric inhibitor GNF-2 in Philadelphia chromosome-positive acute lymphatic leukemia

Background: The t(9;22) translocation leads to the formation of the chimeric breakpoint cluster region/c-abl oncogene 1 (BCR/ABL) fusion gene on der22, the Philadelphia chromosome. The p185(BCR/ABL) or the p210(BCR/ABL) fusion proteins are encoded as a result of the translocation, depending on whether a "minor" or "major" breakpoint occurs, respectively. Both p185(BCR/ABL) and p210(BCR/ABL) exhibit constitutively activated ABL kinase activity. Through fusion to BCR the ABL kinase in p185(BCR/ABL) and p210(BCR/ABL) "escapes" the auto-inhibition mechanisms of c-ABL, such as allosteric inhibition. A novel class of compounds including GNF-2 restores allosteric inhibition of the kinase activity and the transformation potential of BCR/ABL. Here we investigated whether there are differences between p185(BCR/ABL) and p210(BCR/ABL) regarding their sensitivity towards allosteric inhibition by GNF-2 in models of Philadelphia chromosome-positive acute lymphatic leukemia. Design and methods: We investigated the anti-proliferative activity of GNF-2 in different Philadelphia chromosome-positive acute lymphatic leukemia models, such as cell lines, patient-derived long-term cultures and factor-dependent lymphatic Ba/F3 cells expressing either p185(BCR/ABL) or p210(BCR/ABL) and their resistance mutants. Results: The inhibitory effects of GNF-2 differed constantly between p185(BCR/ABL) and p210(BCR/ABL) expressing cells. In all three Philadelphia chromosome-positive acute lymphatic leukemia models, p210(BCR/ABL)-transformed cells were more sensitive to GNF-2 than were p185BCR/ABL-positive cells. Similar results were obtained for p185(BCR/ABL) and the p210(BCR/ABL) harboring resistance mutations. Conclusions: Our data provide the first evidence of a differential response of p185(BCR/ABL)- and p210(BCR/ABL)- transformed cells to allosteric inhibition by GNF-2, which is of importance for the treatment of patients with Philadelphia chromosome-positive acute lymphatic leukemia

Targeting the phosphoinositide 3-kinase pathway in hematologic malignancies

The phosphoinositide 3-kinase pathway represents an important anticancer target because it has been implicated in cancer cell growth, survival, and motility. Recent studies show that PI3K may also play a role in the development of resistance to currently available therapies. In a broad range of cancers, various components of the phosphoinositide 3-kinase signaling axis are genetically modified, and the pathway can be activated through many different mechanisms. The frequency of genetic alterations in the phosphoinositide 3-kinase pathway, coupled with the impact in oncogenesis and disease progression, make this signaling axis an attractive target in anticancer therapy. A better understanding of the critical function of the phosphoinositide 3-kinase pathway in leukemias and lymphomas has led to the clinical evaluation of novel rationally designed inhibitors in this setting. Three main categories of phosphoinositide 3-kinase inhibitors have been developed so far: agents that target phosphoinositide 3-kinase and mammalian target of rapamycin (dual inhibitors), pan-phosphoinositide 3-kinase inhibitors that target all class I isoforms, and isoform-specific inhibitors that selectively target the α, -β, -γ, or -δ isoforms. Emerging data highlight the promise of phosphoinositide 3-kinase inhibitors in combination with other therapies for the treatment of patients with hematologic malignancies. Further evaluation of phosphoinositide 3-kinase inhibitors in first-line or subsequent regimens may improve clinical outcomes. This article reviews the role of phosphoinositide 3-kinase signaling in hematologic malignancies and the potential clinical utility of inhibitors that target this pathway

Allosteric inhibition enhances the efficacy of ABL kinase inhibitors to target unmutated BCR-ABL and BCR-ABL-T315I

Background: Chronic myelogenous leukemia (CML) and Philadelphia chromosome-positive (Ph+) acute lymphatic leukemia (Ph + ALL) are caused by the t(9;22), which fuses BCR to ABL resulting in deregulated ABL-tyrosine kinase activity. The constitutively activated BCR/ABL-kinase "escapes" the auto-inhibition mechanisms of c-ABL, such as allosteric inhibition. The ABL-kinase inhibitors (AKIs) Imatinib, Nilotinib or Dasatinib, which target the ATP-binding site, are effective in Ph + leukemia. Another molecular therapy approach targeting BCR/ABL restores allosteric inhibition. Given the fact that all AKIs fail to inhibit BCR/ABL harboring the 'gatekeeper' mutation T315I, we investigated the effects of AKIs in combination with the allosteric inhibitor GNF2 in Ph + leukemia. Methods: The efficacy of this approach on the leukemogenic potential of BCR/ABL was studied in Ba/F3 cells, primary murine bone marrow cells, and untransformed Rat-1 fibroblasts expressing BCR/ABL or BCR/ABL-T315I as well as in patient-derived long-term cultures (PDLTC) from Ph + ALL-patients. Results: Here, we show that GNF-2 increased the effects of AKIs on unmutated BCR/ABL. Interestingly, the combination of Dasatinib and GNF-2 overcame resistance of BCR/ABL-T315I in all models used in a synergistic manner. Conclusions: Our observations establish a new approach for the molecular targeting of BCR/ABL and its resistant mutants using a combination of AKIs and allosteric inhibitors

Targeting the oligomerization of BCR/ABL by membrane permeable competitive peptides inhibits the proliferation of Philadelphia Chromosome positive leukemic cells

The BCR/ABL fusion protein is the hallmark of Philadelphia Chromosome positive (Ph+) leukemia. The constitutive activation of the ABL-kinase in BCR/ABL cells induces the leukemic phenotype. Targeted inhibition of BCR/ABL by small molecule inhibitors reverses the transformation potential of BCR/ABL. Recently, we definitively proved that targeting the tetramerization of BCR/ABL mediated by the N-terminal coiled-coil domain (CC) using competitive peptides, representing the helix-2 of the CC, represents a valid therapeutic approach for treating Ph+ leukemia. To further develop competitive peptides for targeting BCR/ABL, we created a membrane permeable helix-2 peptide (MPH-2) by fusing the helix-2 peptide with a peptide transduction tag. In this study, we report that the MPH-2: (i) interacted with BCR/ABL in vivo; (ii) efficiently inhibited the autophosphorylation of BCR/ABL; (iii) suppressed the growth and viability of Ph+ leukemic cells; and (iv) was efficiently transduced into mononuclear cells (MNC) in an in vivo mouse model. This study provides the first evidence that an efficient peptide transduction system facilitates the employment of competitive peptides to target the oligomerization interface of BCR/ABL in vivo

Differential effects of selective inhibitors targeting the PI3K/AKT/mTOR pathway in acute lymphoblastic leukemia

Purpose: Aberrant PI3K/AKT/mTOR signaling has been linked to oncogenesis and therapy resistance in various malignancies including leukemias. In Philadelphia chromosome (Ph) positive leukemias, activation of PI3K by dysregulated BCR-ABL tyrosine kinase (TK) contributes to the pathogenesis and development of resistance to ABL-TK inhibitors (TKI). The PI3K pathway thus is an attractive therapeutic target in BCR-ABL positive leukemias, but its role in BCR-ABL negative ALL is conjectural. Moreover, the functional contribution of individual components of the PI3K pathway in ALL has not been established. Experimental design: We compared the activity of the ATP-competitive pan-PI3K inhibitor NVP-BKM120, the allosteric mTORC1 inhibitor RAD001, the ATP-competitive dual PI3K/mTORC1/C2 inhibitors NVP-BEZ235 and NVP-BGT226 and the combined mTORC1 and mTORC2 inhibitors Torin 1, PP242 and KU-0063794 using long-term cultures of ALL cells (ALL-LTC) from patients with B-precursor ALL that expressed the BCR-ABL or TEL-ABL oncoproteins or were BCR-ABL negative. Results: Dual PI3K/mTOR inhibitors profoundly inhibited growth and survival of ALL cells irrespective of their genetic subtype and their responsiveness to ABL-TKI. Combined suppression of PI3K, mTORC1 and mTORC2 displayed greater antileukemic activity than selective inhibitors of PI3K, mTORC1 or mTORC1 and mTORC2. Conclusions: Inhibition of the PI3K/mTOR pathway is a promising therapeutic approach in patients with ALL. Greater antileukemic activity of dual PI3K/mTORC1/C2 inhibitors appears to be due to the redundant function of PI3K and mTOR. Clinical trials examining dual PI3K/mTORC1/C2 inhibitors in patients with B-precursor ALL are warranted, and should not be restricted to particular genetic subtypes