Die Rolle von Influx- und Effluxkanälen in der Prädiktion der therapiefreien Remission bei Patienten mit chronischer myeloischer Leukämie

In kürzlich publizierten Studien konnte gezeigt werden, dass bei CML-Patienten mit tiefem molekularem Ansprechen ein Absetzversuch der Tyrosinkinase Inhibitor (TKI)-Therapie unter bestimmten Voraussetzungen als sicher eingestuft werden kann. Als Prädiktoren für eine therapiefreie Remission gelten die vorherige Dauer der Therapie und die Dauer des tiefen molekularen Ansprechens. Alter, BCR-ABL Transkript-Level, Geschlecht und Risko-Scores hingegen scheinen keinen Einfluss auf die TFR zu haben. Darüber hinaus scheint das Immunsystem eine übergeordnete Rolle zu spielen, da die Anzahl von NK-Zellen und CD86+ dendritischen Zellen signifikant mit dem Erhalt der TFR korrelieren. Bislang wurde jedoch der Einfluss der Pharmakogenetik auf die TFR noch nicht analysiert. Die In- und Effluxkanäle ABCG2, ABCB1 und OCT1 sind bekannt für ihre Rolle in der CML Progression bzw. Resistenzentwicklung. In dieser Arbeit wurde anhand des ABCG2/ABCB1/OCT1-Transkript-Levels getestet, ob eine konstitutionelle Disposition für eine TFR bei CML Patienten besteht. In unserer Kohorte haben 132 CML Patienten den TKI (davon 87% mit Imatinib in Erstlinientherapie) im Rahmen der EURO-SKI abgesetzt. Zum Zeitpunkt des Absetzens wurde die Expression von ABCG2, ABCB1 und OCT1 anhand absoluter Quantifizierung mittels Plasmidstandards (Referenzgen: GUSB) an Leukozyten-RNA aus dem peripheren Blut gemessen. Mittels der minimal p-value Methode und nach Bonferroni-Adjustierung wurden jeweils die signifikanten Cutoffs eruiert. Im Rahmen eines multivariaten Cox Regressionsmodel wurden die einzelnen Variablen auf ihre Unabhängigkeit bezüglich der TFR Prädiktivität hin getestet. Als Relapse wurde der Zeitpunkt des MMR Verlustes definiert. Die teilnehmenden 132 CML Patienten wiesen in dieser Substudie eine TFR-Rate von 54% nach TKI-Absetzen auf. Die Cutoff-Analysen ergaben nur für den Effluxkanal ABCG2 eine signifikante Risikostratifizierung. Bei Patienten mit einem ABCG2/GUSB Transkript-Level über 4.5‰ (n=93) verbleiben 30 Monate nach Absetzen des TKI 47% in TFR. Bei Patienten mit einer ABCG2 Expression unter oder gleich 4.5‰ (n=39) beträgt die TFR-Rate 30 Monate nach Absetzen des TKI 67% (p=0.043). ABCB1 und OCT1 zeigen, im Gegensatz zu ABCG2, eine signifikant differentielle Transkriptexpression im Vergleich zu gesunden Probanden. ABCG2 war das einzige Transporter-Gen das in den Multivariatanalysen als unabhängiger Prädiktor verblieb. Im Cox Regressionsmodel hatten Patienten mit einem ABCG2 Cutoff über 4.5‰ ein zweifach erhöhtes Relapse-Risiko. Ein weiterer unabhängiger Prädiktor in der Multivariatanalyse, war die Transkriptvariante e13a2, welche auch eine signifikante Risikostratifizierung in Bezug auf Relapse erlaubte (p=0.015). Die e13a2 Transkriptvariante zeigte wie ABCG2 ein zweifach erhöhtes Relapse-Risiko (HR 1.90 versus 2.00, CI 1.05-3.70 versus 1.14-3.30). Die Suche nach neuen Biomarkern bzw. potentiellen BCR-ABL-Surrogatmarkern wird zukünftige CML Forschungsinitiativen entscheidend prägen. ABCG2 und die Transkriptvariante e13a2 können vielversprechende Biomarker für ein zukünftiges molekulares TFR-Screening von CML Patienten sein

FOXM1 predicts disease progression in non-muscle invasive bladder cancer

The proto-oncogene forkhead box M1 (FOXM1) is associated with poor survival in many cancers. The impact of FOXM1 expression on progression-free survival (PFS) of non-muscle invasive bladder cancer (NMIBC) has not yet been investigated. The differential expression of FOXM1 between the different molecular NMIBC subtypes has further been assessed. Transcript levels of FOXM1 and MKI67 were determined in 460 NMIBC patients (UROMOL cohort) by RNA-Seq and validated in silico by the Chungbuk and Lund cohort (n = 277). FOXM1 and MKI67 cutoffs were identified by the minimal p value method. Variables were evaluated by multivariable Cox regression analyses in order to identify independent predictors. FOXM1 is an independent predictor for PFS superior to current histological, clinical and molecular staging methods. Patients with high FOXM1 expression have a 6- to 8-fold higher risk of progression in multivariable analysis (p < 0.03). Highest transcript levels were found in the Class 2 and genomically unstable molecular NMIBC subtype (p < 0.03). The proto-oncogene further positively correlated with tumor grade and stage. NMIBCs with high FOXM1 expression showed a PFS advantage when treated with intravesical BCG instillation. FOXM1 is a highly prognostic marker for disease progression of NMIBC superior to current histological, clinical and molecular staging methods and MKI67. It is mainly expressed in the Class 2 and genomically unstable molecular bladder cancer subtypes. Its role in drug resistance development makes FOXM1 valuable biomarker for NMIBC risk stratification

FOXM1 predicts overall and disease specific survival in muscle-invasive urothelial carcinoma and presents a differential expression between bladder cancer subtypes

Forkhead box M1 (FOXM1) is a late cell cycle gene that plays a crucial role in carcinogenesis and chemotherapeutic drug resistance. In this study, the impact of FOXM1 expression on patient outcome was investigated for the first time in formalin fixed and paraffin embedded (FFPE) samples of chemotherapy naive muscle-invasive bladder cancer (MIBC) patients. Expression analyses were performed on the Mannheim cohort (n= 84) and validated on the independent Chungbuk cohort (n= 61). In a Cox' proportional hazards model, a distinct FOXM1 expression cut-off dividing both cohorts in a 'high-risk' and 'low-risk' group has been determined. Multivariate analyses showed that FOXM1 is an independent risk factor for outcome prediction superior to the TNM system. The FOXM1 'high-risk' group had a 4-to 7-fold increased risk of death (p< 0.03) and presented further an overexpression of MKI67. Recent studies showed that MIBCs can be subclassified in breast cancer-like subtypes: basal, luminal and p53-like. Here we demonstrated that FOXM1 was differentially expressed between MIBC subtypes concordant to its subtype specific expression in breast cancer. Since the proto-oncogene FOXM1 is known to play an important role in cisplatin resistance and to be a promising drug target, this study supports FOXM1 as a crucial biomarker in the personalization of MIBC therapy and urges prospective translational studies

FOXM1 overexpression is associated with adverse outcome and predicts response to intravesical instillation therapy in stage pT1 non-muscle-invasive bladder cancer

ObjectiveTo investigate the role of forkhead box protein M1 (FOXM1) mRNA expression and its prognostic value in stage pT1 non-muscle-invasive bladder cancer (NMIBC). Patients and MethodsClinical data and formalin-fixed paraffin-embedded tissues from transurethral resection of the bladder from patients with stage pT1 NMIBC, treated with an organ-preserving approach, were analysed retrospectively. Total RNA was isolated using commercial RNA extraction kits, and mRNA expression of FOXM1, MKI67, KRT20 and KRT5 was measured by single-step quantitative RT-PCR using RNA-specific TaqMan Assays. Statistical analysis was performed using Spearman's Rho, Wilcoxon or Kruskal-Wallis tests, Kaplan-Meier estimates of recurrence-free (RFS), progression-free (PFS) and cancer-specific survival (CSS) and Cox regression analysis. ResultsData from 296 patients (79.4% men, median age 72 years) were available for the final evaluation. Spearman correlation analysis showed that mRNA expression of FOXM1 was significantly correlated with MKI67 (: 0.6530, P < 0.001) and with the luminal subtype, reflected by the positive correlation with KRT20 (: 0.2113, P < 0.001). Furthermore, there was also a strong correlation of FOXM1 expression with adverse clinical and pathological variables, such as concomitant carcinoma in situ (P = 0.05), multifocal tumours (P = 0.005) and World Health Organization 1973 grade 3 disease (P < 0.001). Kaplan-Meier analysis showed overexpression of FOMX1 to be associated with worse PFS (P = 0.028) and worse CSS (P = 0.015). FOXM1 overexpression was also shown to be a predictive risk factor for CSS (hazard ratio 1.61 [1.13-2.34], L-R chi-squared: 7.19, P = 0.007). FOXM1 overexpression identified a subgroup of patients within the luminal subtype with worse RFS (P = 0.017), PFS (P < 0.001) and CSS (P = 0.015). Patients with low FOXM1 expression had better outcomes, irrespective of instillation therapy, whereas patients with high FOXM1 expression benefitted from intravesical chemotherapy with mitomycin C. ConclusionHigh FOXM1 expression was associated with adverse clinical and pathological features and worse outcomes, and predicted response to intravesical instillation therapy in patients with stage pT1 NMIBC

High-risk additional chromosomal abnormalities at low blast counts herald death by CML.

Blast crisis is one of the remaining challenges in chronic myeloid leukemia (CML). Whether additional chromosomal abnormalities (ACAs) enable an earlier recognition of imminent blastic proliferation and a timelier change of treatment is unknown. One thousand five hundred and ten imatinib-treated patients with Philadelphia-chromosome-positive (Ph+) CML randomized in CML-study IV were analyzed for ACA/Ph+ and blast increase. By impact on survival, ACAs were grouped into high risk (+8, +Ph, i(17q), +17, +19, +21, 3q26.2, 11q23, -7/7q abnormalities; complex) and low risk (all other). The presence of high- and low-risk ACAs was linked to six cohorts with different blast levels (1%, 5%, 10%, 15%, 20%, and 30%) in a Cox model. One hundred and twenty-three patients displayed ACA/Ph+ (8.1%), 91 were high risk. At low blast levels (1-15%), high-risk ACA showed an increased hazard to die compared to no ACA (ratios: 3.65 in blood; 6.12 in marrow) in contrast to low-risk ACA. No effect was observed at blast levels of 20-30%. Sixty-three patients with high-risk ACA (69%) died (n = 37) or were alive after progression or progression-related transplantation (n = 26). High-risk ACA at low blast counts identify end-phase CML earlier than current diagnostic systems. Mortality was lower with earlier treatment. Cytogenetic monitoring is indicated when signs of progression surface or response to therapy is unsatisfactory

FOXA1 Gene Expression for Defining Molecular Subtypes of Muscle-Invasive Bladder Cancer after Radical Cystectomy

It remains unclear how to implement the recently revealed basal and luminal subtypes of muscle-invasive bladder cancer (MIBC) into daily clinical routine and whether molecular marker panels can be reduced. The mRNA expression of basal (KRT5) and luminal (FOXA1, GATA3, KRT20) markers was measured by reverse transcription quantitative real-time polymerase chain reaction (RT-qPCR) and correlated to clinicopathological features, recurrence-free survival (RFS), disease-free survival (DFS), and overall survival (OS) in 80 patients with MIBC who underwent radical cystectomy. Additionally, the correlation of single markers with the basal and non-basal subtypes defined by a 36-gene panel was examined and then validated in the TCGA (The Cancer Genome Atlas) cohort. High expression of FOXA1 (p = 0.0048) and KRT20 (p = 0.0317) was associated with reduced RFS. In the multivariable analysis, only FOXA1 remained an independent prognostic marker for DFS (p = 0.0333) and RFS (p = 0.0310). FOXA1 expression (AUC = 0.79; p = 0.0007) was closest to the combined marker expression (AUC = 0.79; p = 0.0015) in resembling the non-basal subtype defined by the 36-gene panel. FOXA1 in combination with KRT5 may be used to distinguish the basal and non-basal subtypes of MIBC

Correction: High-risk additional chromosomal abnormalities at low blast counts herald death by CML (Leukemia, (2020), 34, 8, (2074-2086), 10.1038/s41375-020-0826-9)

An amendment to this paper has been published and can be accessed via a link at the top of the paper