Patients In Advanced Phase Research Articles

Chimeric antigen-receptor (CAR) engineered natural killer cells in a chronic myeloid leukemia (CML) blast crisis model.

During the last two decades, the introduction of tyrosine kinase inhibitors (TKIs) to the therapy has changed the natural history of CML but progression into accelerated and blast phase (AP/BP) occurs in 3-5% of cases, especially in patients resistant to several lines of TKIs. In TKI-refractory patients in advanced phases, the only curative option is hematopoietic stem cell transplantation. We and others have shown the relevance of the expression of the Interleukin-2-Receptor α subunit (IL2RA/CD25) as a biomarker of CML progression, suggesting its potential use as a therapeutic target for CAR-based therapies. Here we show the development of a CAR-NK therapy model able to target efficiently a blast crisis cell line (K562). The design of the CAR was based on the scFv of the clinically approved anti-CD25 monoclonal antibody (Basiliximab). The CAR construct was integrated into NK92 cells resulting in the generation of CD25 CAR-NK92 cells. Target K562 cells were engineered by lentiviral gene transfer of CD25. In vitro functionality experiments and in vivo leukemogenicity experiments in NSG mice transplanted by K562-CD25 cells showed the efficacy and specificity of this strategy. These proof-of-concept studies could represent a first step for further development of this technology in refractory/relapsed (R/R) CML patients in BP as well as in R/R acute myeloblastic leukemias (AML).

Factors influencing cognitive function in patients with Huntington's disease from China: A cross-sectional clinical study.

Huntington's disease (HD) is an autosomal dominant inherited neurodegenerative disorder caused by CAG repeats expansion. Cognitive decline contributes to the loss of daily activity in manifest HD. We aimed to examine the cognition status in a Chinese HD cohort and explore factors influencing the diverse cognitive domains. A total of 205 participants were recruited in the study with the assessment by neuropsychological batteries, including the mini-mental state examination (MMSE), Stroop test, symbol digit modalities test (SDMT), trail making test (TMT), verbal fluency test (VFT), and Hopkins verbal learning test-revised, as well as motor and psychiatric assessment. Pearson correlation and multiple linear regression models were applied to investigate the correlation. Only 41.46% of patients had normal global function first come to our center. There was a significantly difference in MMSE, Stroop test, SDMT, TMT, and VFT across each stage of HD patients (p<.05). Apathy of PBA-s was correlated to MMSE, animal VFT and Stroop-interference tests performance. Severity of motor symptoms, functional capacity, age, and age of motor symptom onset were correlated to all neuropsychological scores, whereas education attainment and diagnostic delay were correlated to most neuropsychological scores except TMT. Severity of motor symptoms, functional capacity, and education attainment showed independent predicting effect (p<.05) in diverse cognitive domains. Cognitive impairment was very common in Chinese HD patients at the first visit and worse in the patients in advanced phase. The severity of motor symptoms and functional capacity were correlated to the diverse cognitive domains.

Tuberculosis Research Trends in Indonesian Health Scientific Journals: From Research Design to Data Analysis

This study aims to analyze various tuberculosis articles that have been published in health scientific journals in Indonesia. These involve the frequency of the number of publications per year, type of research, research subjects, and topics that are often raised by the researchers in their research. This research method used the principle of content analysis which focused on findings from various studies on tuberculosis that have been published in scientific journals in Indonesia. Data were collected from content analysis in journals related to tuberculosis. The results of the journal’s content analysis published in SINTA-1 with the tuberculosis subject area in the last ten years as a whole show the progress from year to year. There are four things that become the subjects of study analysis, namely the number of publications per year (the publication of tuberculosis articles in the SINTA 1 journal decreased in 2019 because of the emergence of the Coronavirus in that year and began to plague in the following years); research type (in this study the results obtained that of the 27 articles analyzed, 23 of them were quantitative types). Subject (tuberculosis patients sampled in this study included the intensive phase and the advanced phase patients) and research topic (topics around knowledge are still the variables that researchers are most interested in).

Delirium in nursing homes: the continued case of B.M.

This article considers current contemporaneous practical issues of de-lirium care in nursing homes with reference to a hypothetical case study B.M. I introduce the diagnosis and management of delirium-superim-posed-on-dementia (DSD), being relatively common in patients in advanced phases of illness of many nursing home residents. General principles are discussed, although this article applies mainly to high-er income countries. There is inevitably much palliative and end-of-life care in nursing homes, necessitating rigorous advance care planning. Nursing home residents are especially prone to acquiring infections. Urinary tract infections (UTIs) are traditionally the most commonly treat-ed infection among nursing home residents and, indeed, the accurate diagnosis of a UTI poses significant and distinctive challenges in the nursing home setting. There is no denying, however, that recently the global coronavirus (SARS-CoV-2) pandemic has posed an existential threat to both staff and residents of nursing homes. Resident-focused factors are striking. Psychotropic drugs are the most frequently prescribed medications in European nursing homes, but medication errors in nursing homes in general are relatively prevalent. Contributing factors to a high burden from pain for residents include residents belief set that age-related pain is inevitable, as well as un-der-recognition of pain and inappropriate pain assessment by clini-cians. Dehydration is associated with frailty, poor cognition, falls, de-lirium, disability, and mortality. Issues relating to the environment also matter. It is also impossible to ignore the organisational constraints on the provision of high quality care. Faced with widespread staffing short-ages, and many economies in financial distress, one partial solution is to retain current staff longer in nursing homes. Research on nursing home staffing has expanded beyond just staffing levels to include mul-tiple other staffing issues of concern.

Chronic Myeloid Leukemia: Part II—Cost of Care Among Patients in Advanced Phases or Later Lines of Therapy in Chronic Phase in the United States from a Commercial Perspective

Background: Tyrosine kinase inhibitors (TKIs) are the standard-of-care treatment for chronic myeloid leukemia in chronic phase (CML-CP). Despite advances in therapy, there remains a proportion of patients with CML-CP that are refractory/intolerant to TKIs, and these patients cycle through multiple lines of therapy. Moreover, even with TKIs, some patients progress to accelerated phase/blast crisis (AP/BC), which is associated with particularly poor clinical outcomes. Objectives: To describe real-world treatment patterns, healthcare resource utilization (HRU), and costs of patients with CML-CP reaching later lines of therapy or progressing to AP/BC in the United States. Methods: Adult CML patients from administrative claims data (January 1, 2000–June 30, 2019) were classified by health state: on third-line (CML-CP On Treatment), on fourth or later lines (CML-CP Post-Discontinuation), or progressed to AP/BC (CML-AP/BC). Outcomes were assessed by health state. Results: There were 296 (4620 patient-months), 83 (1644 patient-months), and 949 (25 593 patient-months) patients classified in the CML-CP On Treatment, CML-CP Post-Discontinuation, and CML-AP/BC cohorts, respectively. Second-generation TKIs (nilotinib, dasatinib, and bosutinib) were most commonly used in the CML-CP On Treatment (69.1% of patient-months) and CML-CP Post-Discontinuation cohorts (59.1% of patient-months). Three-month outpatient incidence rates (IRs) were 7.6, 8.3, and 7.0 visits in the CML-CP On Treatment, CML-CP Post-Discontinuation, and CML-AP/BC cohort, respectively, with mean costs of $597 per service. Three-month inpatient IRs were 0.6, 0.7, and 1.4 days in the CML-CP On Treatment, CML-CP Post-Discontinuation, and CML-AP/BC cohort, respectively, with mean costs of $5892 per day. Mean hematopoietic stem cell transplantation cost was $352 333; mean 3-month terminal care cost was $107 013. Discussion: Cost of CML care is substantial among patients with CML reaching third-line, fourth or later lines, or progressing to AP/BC, suggesting that the disease is associated with a significant economic and clinical burden. From third-line to fourth or later lines, HRU was observed to increase, and the incidence of inpatient days was particularly high for those who progressed to AP/BC. Conclusion: In this study, patients with CML cycling through TKIs in later lines of therapy or progressing to AP/BC experienced substantial HRU and costs, suggesting unmet treatment needs.

Chronic Myeloid Leukemia: Part II-Cost of Care Among Patients in Advanced Phases or Later Lines of Therapy in Chronic Phase in the United States from a Commercial Perspective.

Background: Tyrosine kinase inhibitors (TKIs) are the standard-of-care treatment for chronic myeloid leukemia in chronic phase (CML-CP). Despite advances in therapy, there remains a proportion of patients with CML-CP that are refractory/intolerant to TKIs, and these patients cycle through multiple lines of therapy. Moreover, even with TKIs, some patients progress to accelerated phase/blast crisis (AP/BC), which is associated with particularly poor clinical outcomes.Objectives: To describe real-world treatment patterns, healthcare resource utilization (HRU), and costs of patients with CML-CP reaching later lines of therapy or progressing to AP/BC in the United States.Methods: Adult CML patients from administrative claims data (January 1, 2000–June 30, 2019) were classified by health state: on third-line (CML-CP On Treatment), on fourth or later lines (CML-CP Post-Discontinuation), or progressed to AP/BC (CML-AP/BC). Outcomes were assessed by health state.Results: There were 296 (4620 patient-months), 83 (1644 patient-months), and 949 (25 593 patient-months) patients classified in the CML-CP On Treatment, CML-CP Post-Discontinuation, and CML-AP/BC cohorts, respectively. Second-generation TKIs (nilotinib, dasatinib, and bosutinib) were most commonly used in the CML-CP On Treatment (69.1% of patient-months) and CML-CP Post-Discontinuation cohorts (59.1% of patient-months). Three-month outpatient incidence rates (IRs) were 7.6, 8.3, and 7.0 visits in the CML-CP On Treatment, CML-CP Post-Discontinuation, and CML-AP/BC cohort, respectively, with mean costs of $597 per service. Three-month inpatient IRs were 0.6, 0.7, and 1.4 days in the CML-CP On Treatment, CML-CP Post-Discontinuation, and CML-AP/BC cohort, respectively, with mean costs of $5892 per day. Mean hematopoietic stem cell transplantation cost was $352 333; mean 3-month terminal care cost was $107 013.Discussion: Cost of CML care is substantial among patients with CML reaching third-line, fourth or later lines, or progressing to AP/BC, suggesting that the disease is associated with a significant economic and clinical burden. From third-line to fourth or later lines, HRU was observed to increase, and the incidence of inpatient days was particularly high for those who progressed to AP/BC.Conclusion: In this study, patients with CML cycling through TKIs in later lines of therapy or progressing to AP/BC experienced substantial HRU and costs, suggesting unmet treatment needs.

A 10-year review of malignant otitis externa: a new insight.

This study aims to assess the clinical trends of malignant otitis externa (MOE) and classify MOE based on the findings related to high-resolution computed tomography (HRCT) of the temporal bone and 99-Tech3-Phase Bone Scintigraphy (TPBS). We also reconstruct a treatment algorithm for MOE in our institution. A 10-year retrospective review was carried out on MOE in a single otology institution from January 2011 to December 2020. The MOE was classified based on proposed Tengku's radiological stratification according to HRCT and TBPS findings. Phase I is defined as inflammation limited to the soft tissue in the external auditory canal, without involvement of the bone. Phase II is the inflammation beyond the soft tissue, involving bone, but limited to the mastoid. Phase III is when the inflammation extends medially, involving the petrous temporal bone or temporomandibular joint, with or without parapharyngeal soft tissue involvement. Phase IV refers to inflammation extending medially to involve the nasopharynx, with or without abscess formation. Finally, Phase V is inflammation that further extends to the contralateral base of the skull. A sample of 49 patients was involved in this study. Majority of the patients were having Phase III (36.7%) of the disease, followed by Phase V (24.5%), Phase II (18.4%), Phase IV (16.3%), and Phase I (4.1%). A comprehensive treatment algorithm was drafted based on our institution's experience in managing MOE. The mortality rate was low (8.2%), mainly involving patients in advanced phase of the disease (Phases IV and V). This study has revealed the evidence of progression of MOE based on the proposed radiological stratification. This stratification is simple and practically applicable in clinical settings. We suggest the use of our proposed treatment algorithm as a standard diagnostic and treatment protocol for MOE.

PCN50 Cost of Chronic Myeloid Leukemia Care Among Patients in Advanced Phases or on Later Lines of Therapy in Chronic Phase in the United States From a Commercial and Medicare Perspective

Tyrosine kinase inhibitors (TKIs) are standard-of-care treatment for chronic myeloid leukemia-chronic phase (CML-CP). Since many patients reach later lines due to resistance/intolerance or progress to accelerated phase/blast crisis (AP/BC), a better understanding of cost of care is needed. Adult patients with CML were identified in the IBM MarketScan (Q1/2001-Q2/2019) and SEER-Medicare (Q1/2006-Q4/2016) databases. Healthcare resource utilization (HRU: inpatient [IP] days and outpatient [OP] services) were measured among patients with (a) CML-CP on third-line therapy (CML-CP-3L), (b) CML-CP on fourth-line therapy or later (CML-CP-4L+), and (c) CML-AP/BC. Three-month incidence rates (IR) and event-level costs ($2019 USD), including 3-month terminal care and stem-cell transplant (SCT in IP settings) costs, were reported from a payer’s perspective. In commercial claims, 296 (4,620 patient-months), 83 (1,644 patient-months), and 949 (25,593 patient-months) patients were identified in CML-CP-3L, CML-CP-4L+, and CML-AP/BC, respectively. Three-month OP IR were 7.6, 8.3, and 7.0 services in CML-CP-3L, CML-CP-4L+, and CML-AP/BC, respectively, with mean costs of $597 per service. Three-month IP IR were 0.6, 0.7, and 1.4 days in CML-CP-3L, CML-CP-4L+, and CML-AP/BC, respectively, with mean costs of $5,892 per day. Mean costs were $107,013 for terminal care and $352,333 for SCT. In SEER-Medicare, 53 (738 patient-months), 12 (180 patient-months), and 222 patients (5,740 patient-months) were identified in CML-CP-3L, CML-CP-4L+, and CML-AP/BC, respectively. Three-month OP IR were 13.7, 20.0, and 13.8 services in CML-CP-3L, CML-CP-4L+, and CML-AP/BC, respectively, with mean costs of $230 per service. Three-month IP IR were 3.1, 1.5, and 3.6 days in CML-CP-3L, CML-CP-4L+, and CML-AP/BC, respectively, with mean costs of $2,945 per day. Mean costs were $54,793 for terminal care and $139,991 for SCT. Cost of CML care in the US is substantial among patients with CML who are in later lines of therapy or who progressed to AP/BC, suggesting unmet treatment needs.

Analysis of IFN-gamma and IL-10 Levels as Markers of Inflammation and Response Therapy of Anti-Tuberculosis in MDR Lung TB Patients

Multidrug-Resistant Tuberculosis (MDR TB) is caused by an organism that is resistant to at least isoniazid and rifampisin, the two most potent TB drug. Immune response to against Mycobacterum tuberculosis infection is related to the function of immunity. The function of interferon-γ (pro-inflammatory) is to activate macrophages, to stimulate antimicrobial molecules (to reactive oxygen species and nitric oxide), and to inhibits interleukin-10. Interleukin-10 function is to triggers humoral immunity, to inhibit IFN- γ. This study aimed to analyze level changes and the correlation with clinical data, also months of MDR TB patients who received standard OAT therapy. This was an observational study using cross sectional design. There were 29 patients who received standard MDR TB OAT therapy from 1-24 months, who met the inclusion criteria. Then, the patients were divided based on duration of the therapy, which are the initial/intensive and advanced phase. The initial phase divided into 2: first one is for 1-4 months therapy’s time (5 patients) and the second one is for more than 4-8 months (6 patients). Then, the advanced group divided into two groups again, which are third group with more than 8-16 months (13 patients) and fouth group with more than 16-24 months (5 patients). Then, measured serum concentration IFN-γ, IL-10 at the start of the study and 4 weeks later with the ELISA method. This research during the period July-December (6 months). IFN-γ post concentrations were decreased by 39.14 ± 139.12 pg/mL (p &gt; 0.05). The concentration of IL-10 was decreased by 33.93 ± 109.20pg/mL (p&gt;0.05). Based on the TB score bandim method during pre and posts results were 1 patient experienced severity change from severity class 1 to 2, 1 patient from severity class 2 to 1, 1 patient remained in severity 2 and 26 patient remained in severity 1. The results showed that serum IFN-γ and IL-10 levels in initial/intensive and advanced phase patients who received MDR TB regiment after four weeks did not changed,

Incidence and prevalence of pressure ulcers in cancer patients admitted to hospice: A multicentre prospective cohort study.

Pressure ulcers lead to discomfort for patients and may have an important impact on a patient's quality of life. Measure the incidence and prevalence of pressure ulcers in a Hospice environment; evaluate the risk factors associated with pressure ulcers; and calculate the incidence of Kennedy Terminal Pressure Ulcers. This multicentre prospective cohort study enrolled 440 cancer patients in advanced phase, consecutively admitted to five hospices of the AUSL della Romagna (Italy), during a period of 1 year. Five hundred more patients were excluded from the study because of inability to sign the consent form or refusal to participate. All patients were adults above 18 years of age. The National Pressure Advisory Panel Classification System was used to evaluate the pressure ulcers. Potential risk predictors were evaluated through the Braden Scale, the Numerical Scale, and the Pain Assessment in Advanced Dementia Scale. Starting in September 2016, 214 (48.6%) females and 226 (51.4%) males were analysed. The incidence of pressure ulcers in the total population was 17.3%. The risk factors that influence the development of pressure ulcers were age, proximity to death, and duration of stay in Hospice. The incidence of Kennedy Terminal Pressure Ulcers was 2.7%. This study demonstrates that 17.3% of all patients admitted to a hospice setting developed a pressure ulcer. The longer the patients stay in hospice and the clinical condition deteriorates, the higher the risk of developing a pressure ulcer.

Analysis of IFN- And IL-10 Levels as Markers of Inflamation and Response Therapy of Anti-Tuberculosis in MDR Lung TB Patients

Multidrug-Resistant Tuberculosis (MDR TB) is caused by an organism that is resistant to at least isoniazid and rifampisin, the two most potent TB drug. Immune response to against Mycobacterum tuberculosis infection is related to the function of immunity. The function of interferon-γ (pro-inflammatory) is to activate macrophages, to stimulate antimicrobial molecules (to reactive oxygen species and nitric oxide), and to inhibits interleukin-10. Interleukin-10 function is to triggers humoral immunity, to inhibit IFN- γ. This study aimed to analyze level changes and the correlation with clinical data, also months of MDR TB patients who received standard OAT therapy. This was an observational study using cross sectional design. There were 29 patients who received standard MDR TB OAT therapy from 1-24 months, who met the inclusion criteria. Then, the patients were divided based on duration of the therapy, which are the initial/intensive and advanced phase. The initial phase divided into 2: first one is for 1-4 months therapy’s time (5 patients) and the second one is for more than 4-8 months (6 patients). Then, the advanced group divided into two groups again, which are third group with more than 8-16 months (13 patients) and fouth group with more than 16-24 months (5 patients). Then, measured serum concentration IFN-γ, IL-10 at the start of the study and 4 weeks later with the ELISA method. This research during the period July-December (6 months). IFN-γ post concentrations were decreased by 39.14 ± 139.12 pg/mL (p &gt; 0.05). The concentration of IL-10 was decreased by 33.93 ± 109.20pg/mL (p&gt;0.05). Based on the TB score bandim method during pre and posts results were 1 patient experienced severity change from severity class 1 to 2, 1 patient from severity class 2 to 1, 1 patient remained in severity 2 and 26 patient remained in severity 1. The results showed that serum IFN-γ and IL-10 levels in initial/intensive and advanced phase patients who received MDR TB regiment after four weeks did not changed.

PB2195 ASSESSMENT OF PLATELET MEMBRANE ALTERATION IN PATIENTS WITH MYELOID METAPLASIA WITH MYELOFIBROSIS

Background:Patients with Myeloid Metaplasia with Myelofibrosis (MMM) present at the onset or during evolution thrombotic complications. In the assessment of thrombosis risk are important the presence of JAK2 mutation as well as platelet function. Receptors that define the status of activated platelets (CD62P, CD36) are better expressed in chronic myeloproliferative neoplasms (MPNs) patients with thrombotic complications. Numerous studies have shown a high oxidative status in MPNs patients, a situation that correlates with a higher thrombotic risk.Aims:The aim of our study was to determine if resting membrane potential could be correlated with alterations in expression of platelet receptors and reactive species production (ROS)MethodsThis retrospective study included 35 patients with MMM (16 male and 19 female), median age 61.1 (95% CI of median 60,71‐72) as well as 15 healthy volunteers. The diagnosis of MMM was made according to World Health Organization (WHO) classification of MPNs. We evaluated the flow cytometry markers of platelet adhesion (CD42a, CD42b), aggregation (CD41, CD61) and CD36. Production of reactive species (ROS) was examined using fluorescence method with DCFDA and was assessed by aria under curve (AUC) in serial measurements during 900 sec. The determination of platelet membrane potential was done by fluorescence method using 3,3′‐dipropyl‐2,2′‐thiadicarbocyanine iodide (DiSC3‐5)Results:The ROS production is significantly higher in MMM group: median value of AUC patient group 12780882862,5000 compared with controls 11621365017,5000, p= 0.04. Patients in advanced phase (grade 5 Hackett of splenomegaly) has high level of ROS production compared with patients diagnosed in early stage (grade 1 or 2 Hackett of splenomegaly) median value: 13178014970 vs 12303298585, p = 0.001. There are no differences between groups that was splitted by type of treatment Ruxolitinib/Hydroxiureea or type of mutation diagnosed JAK2V617F/CALR/no mutation. Patients with MMM present higher resting membrane potential (RMP) compared with controls (median value ‐ 63 mV vs–57.5 mV, p = 0.05). The expression of CD36 receptor was higher in MMM group vs controls: median value 27.91 vs 20.91, p = 0.003. Number of microparticle (MP) derivated from platelet, erythrocyte and endothelial cells are no different between patient and control group. We obtain only lower receptor expression on MP surface for CD41/CD61, CD42b and GlyA in patient group compared with control group, p &lt; 0.05. There are significant correlation between resting membrane potential and expression of CD42b (r ‐0.45, p = 0.04) and GlyA receptors (r ‐0.45, p = 0.04).Summary/Conclusion:Patients with MMM especially those with have a higher level of ROS production especially in advanced phase. The hyperpolarisation of cell macrophages membrane could be associated with high ROS production, no reports are regarding platelet membrane. In our study we did not obtain any significant correlation between RMP and ROS production. The expression of CD 36 is higher in MMM patients but was not correlated with ROS production. It was proved that generation of intracellular ROS is associated with CD36 signaling and represent one start point for thrombosis. Low expression of CD42b and GlyA of microparticle surface is associated with lower RMP that correspond to activated status of platelet membrane. We have to verify these results in higher number of patients in order to find significant correlations

ABCB1 and BMI1 mRNA expression in patients with chronic myeloid leukemia: impact on imatinib efficacy.

BackgroundATP-binding cassette transporters are important in the mechanism of multidrug resistance. ABCB1 displays a high affinity for imatinib. BMI1 is a polycomb group protein thought to be overexpressed in leukemic cells.MethodsThis study was conducted to investigate the prognostic value of ABCB1 and BMI1 expressions in chronic myeloid leukemia (CML). Expression levels were measured in 81 patients newly diagnosed with CML and 20 healthy controls by real time reverse transcription- PCR.ResultsThe ABCB1 expression levels did not differ between patients with CML and controls. Low ABCB1 mRNA levels were observed in patients who achieved an optimal response compared to suboptimal and resistant cases (P=0.005). Non-responders showed the highest ABCB1 levels. ABCB1 expression did not affect the progression-free survival (PFS) of patients. BMI1 expression was higher in patients than that in controls (P=0.001). Patients in advanced phases expressed higher levels of BMI1 than those in the chronic phase (P=0.004). High BMI1 expression was associated with a shorter PFS.ConclusionABCB1 mRNA expression may serve as a predictor of the optimal response to imatinib treatment in patients with CML. BMI1 expression was higher in the accelerated and blastic crisis phases of CML and associated with a shorter PFS.

Impact of Additional Chromosomal Aberrations on the Disease Progression of Chronic Myelogenous Leukemia.

The emergence of additional chromosomal abnormalities (ACAs) in Philadelphia chromosome/BCR-ABL1 positive chronic myeloid leukemia (CML), is considered to be a feature of disease evolution. However, their frequency of incidence, impact on prognosis and treatment response effect in CML is not conclusive. In the present study, we performed a chromosome analysis of 489 patients in different clinical stages of CML, using conventional GTG-banding, Fluorescent in situ Hybridization and Spectral Karyotyping. Among the de novo CP cases, ACAs were observed in 30 patients (10.20%) with lowest incidence, followed by IM resistant CP (16.66%) whereas in AP and BC, the occurrence of ACAs were higher, and was about 40.63 and 50.98%, respectively. The frequency of occurrence of ACAs were compared between the study groups and it was found that the incidence of ACAs was higher in BC compared to de novo and IM resistant CP cases. Likewise, it was higher in AP patients when compared between de novo and IM resistant CP cases, mirroring the fact of cytogenetic evolution with disease progression in CML. In addition, we observed 10 novel and 10 rare chromosomal aberrations among the study subjects. This study pinpoints the fact that the genome of advanced phase patients was highly unstable, and this environment of genomic instability is responsible for the high occurrence of ACAs. Treatment response analysis revealed that compared to initial phases, ACAs were associated with an adverse prognostic effect during the progressive stages of CML. This study further portrayed the cytogenetic mechanism of disease evolution in CML.

BCR\u2013ABL1-induced downregulation of WASP in chronic myeloid leukemia involves epigenetic modification and contributes to malignancy

Chronic myeloid leukemia (CML) is a myeloproliferative disease caused by the BCR–ABL1 tyrosine kinase (TK). The development of TK inhibitors (TKIs) revolutionized the treatment of CML patients. However, TKIs are not effective to those at advanced phases when amplified BCR–ABL1 levels and increased genomic instability lead to secondary oncogenic modifications. Wiskott–Aldrich syndrome protein (WASP) is an important regulator of signaling transduction in hematopoietic cells and was shown to be an endogenous inhibitor of the c-ABL TK. Here, we show that the expression of WASP decreases with the progression of CML, inversely correlates with the expression of BCR–ABL1 and is particularly low in blast crisis. Enforced expression of BCR–ABL1 negatively regulates the expression of WASP. Decreased expression of WASP is partially due to DNA methylation of the proximal WASP promoter. Importantly, lower levels of WASP in CML advanced phase patients correlate with poorer overall survival (OS) and is associated with TKI response. Interestingly, enforced expression of WASP in BCR–ABL1-positive K562 cells increases the susceptibility to apoptosis induced by TRAIL or chemotherapeutic drugs and negatively modulates BCR–ABL1-induced tumorigenesis in vitro and in vivo. Taken together, our data reveal a novel molecular mechanism that operates in BCR–ABL1-induced tumorigenesis that can be used to develop new strategies to help TKI-resistant, CML patients in blast crisis (BC).

Epigenetics in Cancer: A Hematological Perspective.

For several decades, we have known that epigenetic regulation is disrupted in cancer. Recently, an increasing body of data suggests epigenetics might be an intersection of current cancer research trends: next generation sequencing, immunology, metabolomics, and cell aging. The new emphasis on epigenetics is also related to the increasing production of drugs capable of interfering with epigenetic mechanisms and able to trigger clinical responses in even advanced phase patients. In this review, we will use myeloid malignancies as proof of concept examples of how epigenetic mechanisms can trigger or promote oncogenesis. We will also show how epigenetic mechanisms are related to genetic aberrations, and how they affect other systems, like immune response. Finally, we will show how we can try to influence the fate of cancer cells with epigenetic therapy.

Characteristics of the TCR Vbeta Repertoire and Identical Clonally Expanded T Cells in Chronic Myeloid Leukemia Patients in Advanced Phase with ABL Mutations

AbstractTumor specific or related antigen cytotoxic lymphocyte (CTL) have been identified in chronic myeloid leukemia patients, however, whether they are constituted by specific type of T cell receptor chains has not been illustrated so far. Previous studies have reported abnormal TCR repertoires and clonally expanded TCR Vβ T cells in chronic myeloid leukemia in chronic phase (CP-CML). In this study, we investigated the distribution and clonality of the TCR Vβ repertoire in 5 CML patients in blast crisis (BC-CML) and one in acceleration phase (AP-CML) with ABL kinase domain mutations (KDMs) including T315I, E255K, F317L+S417Y, Y-253F and L387M+T-315A. Examination of TCR Vβ expression and clonality was performed by reverse transcription-polymerase chain reaction (RT-PCR) combined with GeneScan analysis. Significantly skewed TCR Vβ repertoires were observed in those patients, and 4 to 8 oligoclonally expanded TCR Vβ subfamilies could be identified in each sample, which distributed in 15/24 different subfamilies (TCR Vβ4, Vβ5, Vβ6, β8, Vβ9, Vβ10, Vβ15, Vβ16, Vβ17, Vβ18, Vβ19, Vβ21, Vβ22, Vβ23, Vβ24). Intriguingly, a relatively highly expanded Vβ9 clone with the same length as CDR3 (139 bp) was found in all three CML patients in lymphoid blast crisis (LBC-CML) who had different KDMs, but the clone was not detected in the other two CML patient in myeloid blast crisis (MBC-CML) or the one CML patients in accelerated phase. In conclusion, restricted TCR Vβ repertoire expression and decreased clone complexity was a general phenomenon in the BC-CML patients with different KDMs, indicating the T-cell immunodeficiency status of these patients, and clonally expanded Vβ9 T cell clones may represent a specific immune response to leukemia-associated antigens in LBC-CML patients. DisclosuresLi:The Foundation for High-level Talents in Higher Education of Guangdong, China ([2013]246-54),and the Guangzhou Science and Technology Project Foundation (201510010211): Research Funding; National Natural Science Foundation of China (81270604, U1301226, and 81400109), the Guangdong Natural Science Foundation (S2013040016151 and S2013020012863): Research Funding.

Mutations in the BCR-ABL1 Kinase Domain and Elsewhere in Chronic Myeloid Leukemia.

Chronic myeloid leukemia (CML) has been the first human malignancy to be associated, more than 50 years ago, with a consistent chromosomal abnormality--the t(9;22)(q34;q11) chromosomal translocation. The resulting BCR-ABL1 fusion gene, encoding a tyrosine kinase with deregulated activity, has a central role in the pathogenesis of CML. Ancestral or additional genetic events necessary for CML to develop have long been hypothesized but never really demonstrated. CML can successfully be treated with tyrosine kinase inhibitors (TKIs). Mutations in the BCR-ABL1 kinase domain might arise, however, that confer resistance to 1 or more of the currently available TKIs. Hence, the critical role of BCR-ABL1 mutation screening for optimal therapeutic management, with the current gold standard technique, conventional sequencing, likely to be replaced soon by ultra-deep sequencing. Mutations in genes other than BCR-ABL1 include ASXL1, TET2, RUNX1, DNMT3A, EZH2, and TP53 in chronic phase patients and RUNX1, ASXL1, IKZF1, WT1, TET2, NPM1, IDH1, IDH2, NRAS, KRAS, CBL, TP53, CDKN2A, RB1, and GATA-2 mutations in advanced phase patients. The latter also display additional cytogenetic abnormalities, including submicroscopic regions of gain or loss that only single nucleotide polymorphism arrays or array comparative genomic hybridization can detect. Whether whole genome/exome sequencing studies will uncover novel mutations relevant for pathogenesis, progression, and risk-adapted therapy is still unclear.

Second-Generation Tyrosine Kinase Inhibitors Combined With Stem Cell Transplantation in Patients With Imatinib-Refractory Chronic Myeloid Leukemia

BackgroundAllogeneic stem cell transplantation (allo-SCT) remains a curative therapy for chronic myeloid leukemia with advanced diseases, but limited data exist on the efficacy of short-time 2nd-generation tyrosine kinase inhibitors (TKIs) used before and after allo-SCT for patients failing imatinib therapy. MethodsWe present a single-center report of a series of 12 imatinib-refractory patients in advanced phases, 9 of whom harbored BCR-ABL1 mutations. All of them were treated with 2nd TKI, followed by allo-SCT. ResultsDasatinib or nilotinib reinduced complete hematologic responses in 11 patients and complete cytogenetic responses in 4 patients. All patients engrafted successfully. Five patients experienced acute graft-versus-host-disease (GvHD), including 4 with grade iii-iv disease. Four patients experienced chronic GvHD, including 1 with extensive disease. Post-transplant prophylactic dasatinib or nilotinb was administrated in 9 patients and discontinued 1 year later, all of whom sustained complete molecular remission, even after a median follow-up of 13 months after withdrawal of the TKI. No hematologic relapse was observed. Four patients died: 1 of primary disease and 3 of transplant-related complications. After a median follow-up of 28 months (range, 12-37 months) after SCT, 8 (66.7%) of 12 patients are alive, including 7 with complete molecular remission. ConclusionsAllo-SCT has a satisfactory outcome when combined with 2nd-generation TKI, which could provide a good quality of remission before transplantation and prevent relapse after transplantation.

Incidence of Bcr-Abl kinase domain mutations in imatinib refractory chronic myeloid leukemia patients from South India.

Mutations in the Bcr-Abl kinase domain (KD) are a major cause for acquired resistance to imatinib (IM) treatment and have been associated with progression and poor prognosis in chronic myeloid leukemia patients. The present study includes 63 patients resistant to standard imatinib dose of 400 mg according to ELN guidelines. Direct sequencing method is used for mutational analysis. The present study revealed 15 exonic mutations in 46.03 % of patients; among them, seven cases (24.13 %) had multiple mutations. Mutations were found to be higher in sokal high- (45.0 %) and intermediate- (68.42 %) compared to low-risk (29.16 %) group. Mutations were observed in 38.09 % of patients with EUTOS (European Treatment and Outcome Study) high risk and in 50.0 % with low risk. The frequency of mutations was 50.0 % in advanced phase, 47.36 % in late chronic-phase, and 43.33 % in chronic-phase patients. 42.10 % of patients with primary resistance and 52.0 % with secondary resistance had mutations. P-loop and T315I mutations were associated with poor survival in advanced phase patients (85.71 %) (P = 0.03). No significant variation was observed with Bcr-Abl transcript levels between the patients with the presence or absence of mutations (P = 0.73). Bcr-Abl levels were found to be significantly elevated in P-loop and T315I mutation carriers (P = 0.001) and also in T315I mutation-positive patients (P = 0.01). P-loop mutations and T315I are frequent in advanced phases and strongly associated with poor prognosis and survival. Hence, the identification of mutations in IM-resistant CML patients will help in treatment optimization with 2nd- or 3rd-generation tyrosine kinase inhibitors (TKIs).