Tyrosine Kinase Inhibitor Targeting Research Articles

Targeting GSTP1 as Therapeutic Strategy against Lung Adenocarcinoma Stemness and Resistance to Tyrosine Kinase Inhibitors.

Glutathione S-transferasepi(GSTP1), a phase II detoxification enzyme, is known to be overexpressed and mediates chemotherapeutic resistance in lung cancer. However, whether GSTP1 supports cancer stem cells (CSCs) and the underlying mechanisms in lung adenocarcinoma (LUAD) remain largely unknown. This studyunveiled that GSTP1 is upregulated in lung CSCs and supports tumor self-renewal, metastasis, and resistance to targeted tyrosine kinase inhibitors of LUAD both in vitro and in vivo. Mechanistically, CaMK2A (calcium/calmodulin-dependent protein kinase 2 isoform A)/NRF2 (nuclear factor erythroid 2-related factor 2)/GSTP1 is uncovered as a regulatory axis under hypoxia. CaMK2A increased GSTP1 expression through phosphorylating the Sersine558 residue of NRF2 and promoting its nuclear translocation, a novel mechanism for NRF2 activation apart from conventional oxidization-dependent activation. Upregulation of GSTP1 in turn suppressed reactive oxygen species levels and supported CSC phenotypes. Clinically, GSTP1 analyzed by immunohistochemistry is upregulated in a proportion of LUAD and serves as a prognostic marker for survival. Using patient-derived organoids from an ALK-translocated LUAD, the therapeutic potential of a specific GSTP1 inhibitor ezatiostat in combination treatment with the ALK inhibitor crizotinib is demonstrated. This study demonstrates GSTP1 to be a promising therapeutic target for long-term control of LUAD through targeting CSCs.

Alvespimycin Inhibits Heat Shock Protein 90 and Overcomes Imatinib Resistance in Chronic Myeloid Leukemia Cell Lines.

Heat shock protein 90 (HSP90) facilitates folding and stability and prevents the degradation of multiple client proteins. One of these HSP90 clients is BCR-ABL, the oncoprotein characteristic of chronic myeloid leukemia (CML) and the target of tyrosine kinase inhibitors, such as imatinib. Alvespimycin is an HSP90 inhibitor with better pharmacokinetic properties and fewer side effects than other similar drugs, but its role in overcoming imatinib resistance is not yet clarified. This work studied the therapeutic potential of alvespimycin in imatinib-sensitive (K562) and imatinib-resistant (K562-RC and K562-RD) CML cell lines. Metabolic activity was determined by the resazurin assay. Cell death, caspase activity, mitochondrial membrane potential, and cell cycle were evaluated by means of flow cytometry. Cell death was also analyzed by optical microscopy. HSPs expression levels were assessed by western blotting. Alvespimycin reduced metabolic activity in a time-, dose-, and cell line-dependent manner. Resistant cells were more sensitive to alvespimycin with an IC50 of 31 nM for K562-RC and 44 nM for K562-RD, compared to 50 nM for K562. This drug induced apoptosis via the mitochondrial pathway. In K562 cells, alvespimycin induced cell cycle arrest in G0/G1. As a marker of HSP90 inhibition, a significant increase in HSP70 expression was observed. Our results suggest that alvespimycin might be a new therapeutic approach to CML treatment, even in cases of resistance to imatinib.

EPHA2 is a Potential Target for the Treatment of NF2-/-Vestibular Schwannoma

Neurofibromatosis type 2 (NF2) is an autosomal dominant cancer predisposition syndrome characterized by the development of bilateral vestibular (VS) and spinal schwannomas secondary to loss of heterozygosity of NF2 in Schwann cells or their precursors. While these tumors are largely benign, they can cause considerable morbidity due to compromised auditory, vestibular, facial, and vertebral nerve function. This may result in deafness, vertigo, facial muscle weakness, chronic neuropathic pain, and even death.There are currently no pharmacotherapies for VS, and surgical resection remains the standard of care, which is associated with significant morbidity. Thus, there is an urgent need to develop pharmaceutical approaches to halt or reverse the progression of tumor growth in NF2 patients who develop VS. Our lab previously identified the receptor tyrosine kinase inhibitors brigatinib and dasatinib as potentially efficacious agents for the treatment of VS and demonstrated that both agents targeted the Ephrin A2 receptor (EPHA2). EPHA2is a transmembrane receptor tyrosine kinase thatis involved in cell contact-mediated motility, adhesion,and migration. Additionally, EPHA2 modulates axon guidance, and synaptogenesis in developing brain. Here we demonstrate that EPHA2expression is increased in NF2-/-Schwanncells and NF2-/-cancers. We identify ponatinib, a receptor tyrosine kinase inhibitor targeting ABL1 that is FDA-approved for CML, as an additional agent that targets EPHA2. We demonstrate that ponatinib treatment impairs the viability of both human and murine NF2-/-Schwanncells in vitro and decreases EPHA2 protein expression. Accordingly, pharmacologic,and siRNA-mediated inhibition of EPHA2 also impaired the growth of human NF2-/-Schwann cells in vitro. Lastly, we demonstrate that both ponatinib and EPHA2 inhibition induce morphological changes in NF2-/-Schwann cells. Our findings suggest that ponatinib or the direct targeting of EPHA2 may be efficacious for the treatment of NF2-associated vestibular schwannoma. Future in vivo efficacystudies are warranted.

Systemic and Targeted Therapies in Adenoid Cystic Carcinoma.

Adenoid cystic carcinoma (ACC) is an often-indolent type of salivary gland cancer (SGC). A subset of patients develops progression or aggressive disease warranting systemic therapy in the recurrent/metastatic (R/M) setting. We recommend genomic testing for all patients with R/M disease to aid with prognostication and eligibility for potential experimental therapies. Here, we review the currently available treatment options (cytotoxic chemotherapies and vascular endothelial growth factor receptor (VEGFR)-targeting tyrosine kinase inhibitors (TKIs)). Based on limited data, we nominate regimens which may have more favorable efficacy profiles. Among the cytotoxic chemotherapies, several regimens are acceptable when incorporating a platinum agent. Among the VEGFR-targeting TKIs, lenvatinib and axitinib are the preferred options. Larger, randomized studies prioritizing combinations with mechanistic synergism are needed. Predictive biomarkers are critical, as there is currently little evidence to guide sequencing of available options for individual patients. Immunotherapy is an available option, but has been associated with only modest benefit in ACC. We go on to review other therapies that have been studied and nominate those with promise based on early clinical data.

Цитокиновый статус больных хроническим миелолейкозом

Introduction. Altered cytokine secretion has been described in many types of cancer. Being a key mediator of intercellular interactions, they can contribute to the development of resistance to targeted therapy and cytostatic drugs in chronic myeloid leukemia (CML). Aim. To evaluate the relationship between cytokine spectrum indicators in patients with CML and the effectiveness of targeted tyrosine kinase inhibitors (TKI) therapy. Materials and methods. Quantitative determination of the concentration of cytokines TNF-α, IL-1β, IL-2, IL-4, IL-6, IL-10, IL-18, IFN-α in blood serum of patients with CML (n = 60) and apparently healthy blood donors (n = 22) was carried out using enzyme-linked immunosorbent assay (ELISA). The phase of the disease and the depth of molecular response were determined according to criteria of the European Leukemia Net 2020. Stratification of CML patients by risk groups was carried out according to the Sokal (1984), EUTOS long-term survival (ELTS) (2016) scores. Hematological and non-hematological toxicity was assessed according to the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE v.5.0, 2017). Results. It was found that the serum concentration of a number of cytokines in the group of patients with CML was significantly higher compared to the control group: TNF-α – 2.80 and 0.70 pg/ml, p < 0.001, IL-6 – 3.10 and 0.70 pg/ml, p < 0.001, IL-18 – 296.40 and 122.10 pg/ml, p < 0.001, IL-10 – 5.15 and 0.95 pg/ml, p < 0.001, IFN-α – 5.60 and 4.00 pg/ml, p = 0.006, respectively. Among patients with CML, the level of cytokines varied depending on the level of molecular response and the type of TKI. Patients who did not achieve a major molecular response (MMR) were characterized by a significantly greater increase in the secretion of TNF-α, IL-6 and IL-1β (6.65 and 2.30 pg/ml, p = 0.004, 9.40 and 2.80 pg/ml, p < 0.001, 3.69 and 0.88 pg/ml, p = 0.004, respectively) compared with patients with MMR. However, only IL-6 was a statistically significant prognostic factor influencing the achievement of MMR (odds ratio 1.131, confidence interval 1.015–1.260, p = 0.025). Among patients receiving imatinib therapy, the level of TNF-α was lower compared to patients receiving nilotinib, dasatinib and bozutinib (2.10, 4.00, 6.85 and 4.25 pg/ml, respectively, p = 0.013). Conclusion. The results of the research demonstrated increased secretion of TNF-α, IL-6, IL-18, IL-10, and IFN-α in CML patients, which may indicate an important role in the pathogenesis of CML. TNF-α, IL-6, and IL-1 levels were higher in patients who did not achieve MMR, and IL-6 was a statistically significant predictor the achievement of MMR.

Cellular immunotherapy combined with platinum-based chemotherapy prolongs survival for non-small cell lung cancer patients.

Platinum-based chemotherapy is the primary treatment option for advanced non-small cell lung cancer (NSCLC) patients without a driver gene mutation, but its efficacy is still modest. Through a potential synergistic effect, autologous cellular immunotherapy (CIT) composed of cytokine-induced killer (CIK, natural killer (NK), and T cells) might enhance it. NK cells exhibited in vitro cytotoxicity toward lung cancer cells (A549 cells) following platinum therapy. Using flow cytometry, the expression of MICA, MICB, DR4, DR5, CD112, and CD155 on lung cancer cells was assessed. In this retrospective cohort study, there were included 102 previously untreated stage IIIB/IV NSCLC patients ineligible for tyrosine kinase inhibitor (TKI) target therapy who received either chemotherapy alone (n = 75) or combination therapy (n = 27). The cytotoxicity of NK cells for A549 cells was increased obviously and a time-dependent enhancement of this effect was also observed. After platinum therapy, the levels of MICA, MICB, DR4, DR5, CD112, and CD155 on the surface of A549 cells were increased. In the combination group, the median PFS was 8.3 months, compared to 5.5 months in the control group (p = 0.042); the median overall survival was 18.00 months, compared to 13.67 months in the combined group (p = 0.003). The combination group had no obvious immune-related adverse effects. The combination of NK cells with platinum showed synergistic anticancer effects. Combining the two strategies increased survival with minor adverse effects. Incorporating CIT into conventional chemotherapy regimens may improve NSCLC treatment. However, additional evidence will require multicenter randomized controlled trials.

The second-generation tyrosine kinase inhibitor afatinib inhibits IL-1β secretion via blocking assembly of NLRP3 inflammasome independent of epidermal growth factor receptor signaling in macrophage

Chronic inflammation might lead to many malignancies, and inadequate resolution could play a crucial role in tumor invasion, progression and metastases. Afatinib is a second-generation tyrosine kinase inhibitor targeting epidermal growth factor receptor in non-small cell lung cancer. Few studies showed the correlation of afatinib and the innate immune system especially macrophage. Our study showed that afatinib could block the activation of NLRP3 inflammasome in a dose-dependent manner in macrophage, and that afatinib could prevent the assembly of NLRP3 inflammasome. Besides, afatinib could inhibit NLRP3 inflammasome activation independent of EGFR signaling. Moreover, afatinib was able to alleviate the LPS-induced sepsis in vivo. These investigations provide significant experimental evidence in afatinib as therapeutic drug for non-small cell lung cancer or other tumors and NLRP3-related diseases, and explore new target for afatinib in macrophage.

Future treatment of Diabetes - Tyrosine Kinase inhibitors.

Diabetes mellitus (DM) is a group of metabolic disorders that have an increased risk of macro and micro-vascular complications due to lipid dysfunction. The present drug treatments for the management of DM either have numerous side effects or do not have long-lasting therapeutic effects. So it is essential to find a newer class of drug for DM treatment. Broad information has been researched regarding Tyrosine kinase Inhibitors (TKIs) and their mechanism of action. They are proven for the management of various kinds of cancers. TKIs produce anti-hyperglycemic effects by acting on multiple targets such as c-Abl, Platelet-Derived Growth Factor Receptor (PDGFR), Vascular Endothelial Growth Factor Receptor (VEGFR), Epidermal Growth Factor Receptor (EGFR), and c-Kit. This family of drugs blocks numerous tyrosine kinases by acting as a partial agonist of PPAR-γ receptors and results in an anti-diabetic effect by improving insulin sensitivity and glucose disposal rate. Therefore, it is said that TKI drugs will be great potential for the treatment of Diabetes. This review summarizes the possible targets of TKIs and TKIs being a potential drug class in the management of Diabetes mellitus.

ASK120067 (limertinib) exerts pre-clinical anti-tumor activity by inhibiting EGFR exon20 insertion

Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) are classic strategies for the individualized treatment for patients with non-small cell lung cancer (NSCLC). However, EGFR exon20 insertion (EGFR 20ins) mutations, accounting for 6%–12% of all EGFR mutant cases in NSCLC, are generally resistant to the reversible EGFR TKIs (such as gefitinib and erlotinib), which makes them challenging drug-targets in lung cancer. In our previous study, we identified ASK120067 (limertinib) as a novel 3rd-generation EGFR TKI targeting EGFR T790M mutation with promising clinical activities. Here, we accessed the potency of ASK120067 on EGFR 20ins activation and evaluated its in vitro and in vivo anti-tumor activity against EGFR 20ins driven tumor models. We found that ASK120067 showed potent inhibitory activity on TKI-resistant EGFR 20ins kinase. In TKI-resistant EGFR 20ins-dependent BaF3 cells, it dose-dependently suppressed EGFR phosphorylation, impeded cell proliferation, and induced cell apoptosis with much superior efficacy to gefitinib and erlotinib. Moreover, oral administration of ASK120067 decreased the level of phospho-EGFR 20ins and caused significant tumor regression in EGFR 20ins BaF3 xenograft model. These results presented the pre-clinical anti-tumor efficacy of ASK120067 in EGFR 20ins models and highlighted the potential value of ASK120067 for the treatment of NSCLC patients harboring EGFR 20ins mutations.

Galectin-1 and Galectin-3 in B-Cell Precursor Acute Lymphoblastic Leukemia.

Acute lymphoblastic leukemias arising from the malignant transformation of B-cell precursors (BCP-ALLs) are protected against chemotherapy by both intrinsic factors as well as by interactions with bone marrow stromal cells. Galectin-1 and Galectin-3 are lectins with overlapping specificity for binding polyLacNAc glycans. Both are expressed by bone marrow stromal cells and by hematopoietic cells but show different patterns of expression, with Galectin-3 dynamically regulated by extrinsic factors such as chemotherapy. In a comparison of Galectin-1 x Galectin-3 double null mutant to wild-type murine BCP-ALL cells, we found reduced migration, inhibition of proliferation, and increased sensitivity to drug treatment in the double knockout cells. Plant-derived carbohydrates GM-CT-01 and GR-MD-02 were used to inhibit extracellular Galectin-1/-3 binding to BCP-ALL cells in co-culture with stromal cells. Treatment with these compounds attenuated migration of the BCP-ALL cells to stromal cells and sensitized human BCP-ALL cells to vincristine and the targeted tyrosine kinase inhibitor nilotinib. Because N-glycan sialylation catalyzed by the enzyme ST6Gal1 can regulate Galectin cell-surface binding, we also compared the ability of BCP-ALL wild-type and ST6Gal1 knockdown cells to resist vincristine treatment when they were co-cultured with Galectin-1 or Galectin-3 knockout stromal cells. Consistent with previous results, stromal Galectin-3 was important for maintaining BCP-ALL fitness during chemotherapy exposure. In contrast, stromal Galectin-1 did not significantly contribute to drug resistance, and there was no clear effect of ST6Gal1-catalysed N-glycan sialylation. Taken together, our results indicate a complicated joint contribution of Galectin-1 and Galectin-3 to BCP-ALL survival, with different roles for endogenous and stromal produced Galectins. These data indicate it will be important to efficiently block both extracellular and intracellular Galectin-1 and Galectin-3 with the goal of reducing BCP-ALL persistence in the protective bone marrow niche during chemotherapy.

Development of optimized pyrimido-thiazole scaffold derivatives as anticancer and multitargeting tyrosine kinase inhibitors using computational studies

Cancer is one of the frontier causes of leading death ratesglobally and one of the most researched domains. Despite many drugs available in the market currently, their effectiveness towards resistance, randomly mutating cancer targets, and side effects initiate the necessity of developing target selective and effective anti-cancer drugs.This study aimed to develop a congeneric series of fused pyrimidine and thiazole-containing hybrid series and evaluate its anticancer potential using in-silico tools. Molecular modeling strategies were used to develop various derivatives of fused thiazole-pyrimidines as anticancer agents for target-based drug discovery. Strategically, based on Structural Activity Relationship (SAR), of the synthesized or studied compounds, a combinatorial library was generated using the lead grow tool to develop a possible combination of various derivatives. Using Swiss ADME and Osiris; the ADMETproperties were predicted and screened molecules were docked using Auto-dock vina and Swiss Dockto obtain possible interactions with 5 listed targets of Tyrosine Kinase Inhibitors (TKI's) namely BCR-ABL kinase (PDB- 2GQG), c-ABL Kinase (PDB-3PYY), EGFR(PDB-1M17), VEGFR(PDB- 4ASD), and BRAF inhibitors (PDB- 2FB8). SAR of the pyrimido-thiazole molecules was derived from the literature survey and substitutions that enhance the anticancer activity were incorporated into the Combilib to generate a library of 221 compounds. This library of compounds was subjected to a Lipinski Filter. About 45 compounds were screened and tested for their drug-likeliness parameters. The 24 compounds that qualified with good absorption, drug-likeliness, and ADME were tested for their toxicity for developing relatively safe drugs with low side effects. These molecules were docked intofivedifferent PDB's and their binding affinity scores along with prominent interactions were noted. Compound 33 has shown comparable binding affinity and key interactions with all the five PDB's and thus can be used as a lead for further investigations. These studies have helped to optimize the relationship between fused pyrimidine and thiazoles as anticancer Tyrosine Kinase Inhibitors.

Genetic Associations of Visfatin Polymorphisms with EGFR Status and Clinicopathologic Characteristics in Lung Adenocarcinoma.

Lung adenocarcinoma (LUAD) is the most common histologic type of lung cancer. Mutations of the epidermal growth factor receptor (EGFR) gene are among the most common genetic alterations in LUAD and are the targets of EGFR tyrosine kinase inhibitors. The enzyme visfatin is involved in the generation of the oxidized form of nicotinamide adenine dinucleotide (NAD+) and regulation of intracellular adenosine triphosphate (ATP), critical processes in cancer cell survival and growth. This study explored the relationship between visfatin single nucleotide polymorphisms (SNPs) with EGFR status and the clinicopathologic development of LUAD in a cohort of 277 Taiwanese men and women with LUAD. Allelic discrimination of four visfatin SNPs rs11977021, rs61330082, rs2110385 and rs4730153 was determined using a TaqMan Allelic Discrimination assay. We observed higher prevalence rates of advanced (T3/T4) tumors and distant metastases in EGFR wild-type patients carrying the rs11977021 CT + TT and rs61330082 GA + AA genotypes, respectively, compared with patients carrying the CC and GG genotypes. EGFR wild-type patients carrying the rs11977021 CT + TT genotypes were also more likely to develop severe (stage III/IV) malignancy compared with patients carrying the CC genotype. An analysis that included all patients found that the association persisted between the rs11977021 CT + TT and rs61330082 GA + AA genotypes and the development of T3/T4 tumors compared with patients carrying the rs11977021 CC and rs61330082 GG genotypes. In conclusion, these data indicate that visfatin SNPs may help to predict tumor staging in LUAD, especially in patients with EGFR wild-type status.

Comparison of Generic Dasatinib Versus Imatinib in Newly Diagnosed Chronic Phase Chronic Myeloid Leukemia with Reference to Early Molecular Response: Results from a Single-Center, Randomized Controlled Study from India

Background: Chronic myeloid leukemia (CML) is the commonest leukemia in adult population in India. The advent of tyrosine kinase inhibitors (TKI) targeting BCR-ABL1 fusion transcript in CML has dramatically improved survival of CML patients. Generic formulations of imatinib mesylate have been the mainstay of TKI therapy in Indian CML patients for more than a decade, due to prohibitive costs of 2nd generation TKIs and poor socio-economic status of majority of patients. However, with the availability of generic dasatinib in India since March 2021, the cost of dasatinib therapy has become comparable to that of generic imatinib treatment, thereby enabling more extensive use of dasatinib as first-line TKI therapy in CML patients in India. Achievement of early molecular response (EMR) after 3 months of first-line TKI therapy, defined as blood BCR-ABL1 transcript level ≤ 10% [international scale (IS)], has emerged as an important predictor of favorable long-term outcome in CML-CP. There is scarcity of data on efficacy & safety of generic formulations of dasatinib vis-à-vis generic imatinib in CML-CP patients in India, which the present study has attempted to explore at a tertiary care hospital in India. Objectives: The objectives of the study were to compare early molecular response (EMR) [defined as BCR-ABL1 transcript level ≤ 10%, I.S.] at 3 months of therapy with generic dasatinib versus generic imatinib in newly diagnosed CML-CP patients and to compare treatment-related adverse effects in the two groups. Methods: This randomized controlled study enrolled newly diagnosed CML-CP patients after obtaining institutional ethics committee approval & informed consent. Inclusion Criteria:Newly diagnosed patients with chronic phase CML.Age ≥ 12 years. Exclusion Criteria:Patients with de novo accelerated phase or blast phase CML.Pregnancy & lactation.Patients with pre-existing pleural effusion, grade ≥ 3 lung disease, or pulmonary arterial hypertension.Patients with angina, or grade ≥ 3 cardiac disease [as defined by the New York Heart Association (NYHA) criteria] at diagnosis.Patients with prolonged QTc interval (> 480 msec) at baseline. The EUTOS long-term survival (ELTS) risk score was calculated at diagnosis. Patients were randomized to one of the two following treatment groups: Group A: Dasatinib 100 mg p.o. once daily (60 mg/m2/day for age <18 years). Group B: Imatinib 400 mg p.o. once daily (340 mg/m2/day for age < 18 years). Follow up & monitoring of patients was done every 2 weekly till completion of 3 months of TKI therapy, followed by assessment of hematological response & molecular response as per standard criteria. Results: A total of 61 consecutive CML patients were screened between June 2021 and March 2022, out of which 54 patients with confirmed diagnosis of CML-CP were enrolled in the study and were randomized to receive generic dasatinib or generic imatinib as first-line therapy and were followed up for 3 months for EMR and complete hematological response (CHR). Four patients were lost to follow up and data was analyzed for 50 patients for whom EMR results at 3 months was available. Out of these 50 patients, 24 patients received dasatinib & 26 patients received imatinib. The median age of patients was 33 years (range 18-64 years), with male: female ratio of 1.3: 1. Achievement of CHR was documented in 96% of patients in both dasatinib & imatinib treatment arms. EMR at 3 months was achieved in overall 72% patients in study [19/24 patients (79%) in dasatinib arm & 17/26 patients (65%) in imatinib arm]. However, the difference was not statistically significant (p = 0.27). Notably, EMR rates in ELTS intermediate-risk group was 86% in dasatinib arm versus 42% in imatinib arm, and EMR rates in ELTS high-risk group was 82% in dasatinib arm versus 57% in imatinib arm (p = 0.33). The incidence of grade 3-4 adverse events was not significantly different in the two treatment groups. The patient characteristics & treatment results are summarized in Table 1 & Figure 1. Conclusion: The results of the present study suggested that generic formulations of dasatinib were well-tolerated and were associated with improved early molecular response rates compared to generic imatinib in CML-CP patients in India. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Trends in Frontline Treatment and Overall Survival in the Era of Targeted Tyrosine Kinase Inhibitor Therapy for Chronic Myeloid Leukemia

Introduction The treatment of chronic myeloid leukemia (CML) was revolutionized in 2001 with the introduction of the BCR-ABL tyrosine kinase inhibitor (TKI), imatinib. In 2006, dasatinib was approved, shortly followed by nilotinib in 2007 for the treatment of CML patients (pts) who developed resistance or intolerance to imatinib. In the following years, dasatinib and nilotinib were approved for newly diagnosed CML. Two other TKIs, bosutinib and ponatinib were approved in 2012. Dasatinib, nilotinib and bosutinib are effective against all imatinib resistant mutations except the gatekeeper mutation, T315I. Ponatinib approval provided a TKI option for pts with T315I mutation. In this study we examine how survival has improved in CML pts over time with the availability of multiple TKI options and identify traditionally disadvantaged socioeconomic and demographic groups which continue to have disparate survival outcomes. Methods The National Cancer Database was used to identify CML pts by histology code 9863 & 9875, who were diagnosed between 2004-2019. Demographic and treatment characteristics were compared by era of TKI availability. Pts diagnosed from 2004-2005 were considered to be treated in the imatinib era, 2006-2011 as having access to dasatinib and nilotinib, and from 2012 on to have access to bosutinib and ponatinib. Pts who received allogeneic transplant were excluded in survival analysis. Kaplan Meier and Cox regression analysis were used to compare overall survival (OS) for the entire cohort and by year (yr) of diagnosis, with adjustment by age, Charleson-Deyo comorbidity, race, sex, insurance, and quartile of income and education level of the patient's zip code to identify demographic and socioeconomic features associated with poor survival outcomes. Results Of the 38,763 CML pts identified, 55.5% were male and 81% were white, with a median age of 57 yrs (interquartile range 44-70). The portion of pts who were untreated, either due to comorbidity, death, or contraindication, decreased from 17.4% in the imatinib era to only 8.6% from 2012 on, p<0.001. Though the rate of upfront transplant was low (1.6%), it decreased with the advent of new therapies, from a rate of 3.4% from 2004-2005, to 1.4% from 2012 on, p<0.001. The median OS of CML pts since 2004 is 14.4 years (yrs) (95% confidence interval (CI) 14.0-14.9). For pts diagnosed from 2004-2005 median OS was 12.0 yrs (95% CI 11.1-13.0). This increased to 13.8 yrs (95% CI 13.4-14.2), with a hazard ratio (HR) of 0.88 (95% CI 0.84-0.94) for pts diagnosed 2006-2011 when referenced to the initial time period, p<0.001. Median OS was not reached for the latest time period, with a HR of 0.71 (95% CI 0.66-0.75, p<0.001) referenced to 2004-2006. Survival at 1-, 5- & 10-yrs was improved for each subsequent time period of diagnosis, with a 5-yr OS of 66%, 71%, and 76% for each subsequent diagnosis period, p<0.001. On multivariate cox regression adjusted for yr of diagnosis, features associated with reduced OS included age (HR 1.05 [95% CI 1.05-1.06], p<0.001), increased comorbidity burden (HR 1.34 [95% CI 1.30-1.37], p<0.001), uninsured status (HR 1.95 [95% CI 1.75-2.16], p<0.001), Medicaid (HR 2.2 [95% CI 2.0-2.4], p<0.001), and living in a zip code with median income in the lowest quartile (HR 1.15 [95% CI 1.06-1.25], p<0.001) and lowest education quartile (HR 1.19 [95% CI 1.10-1.29], p<0.001). Features associated with improved survival include female sex (HR 0.80 [0.77-0.84], p<0.001), and subsequent diagnosis year (HR 0.96 [95% CI 0.95-0.96], p<0.001). Discussion Overall survival for CML pts has significantly improved during the last 18 years, with improvements seen with the availability of each additional TKI. While treatment data is very limited in this dataset, this improvement is likely related to increased availability of multiple TKIs for pts with resistance or intolerance to prior TKI therapies. Additional TKI options, particularly approval of ponatinib for pts with T315I mutation also have a secondary benefit of decreasing the utilization of allogenic transplant, a high-risk procedure in itself. Though survival has improved for all pts, pts from traditionally underserved populations, including those who are underinsured or from low-income or low-education areas, have reduced survival. Continued advances in treatment and efforts to improve access to care for underserved populations is vital in the goal to achieve equitable survival outcomes in CML. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Implementing RNAi Therapy Targeting FLT3 in Acute Myeloid Leukemia (AML)

Approximately 25% of newly diagnosed AML patients display an internal tandem duplication (ITD) in the fms-like tyrosine kinase 3 (FLT3) gene. Although both multi-targeted and FLT3 specific tyrosine kinase inhibitors (TKIs) are being utilized for clinical therapy, drug resistance, short remission periods, and high relapse rates are challenges that still need to be tackled (Gebru et. al. J. Hematol. Oncol. 2020). RNA interference (RNAi), mediated by short interfering RNA (siRNA) presents a novel therapeutic platform with the potential of personalization due to its gene sequence-driven mechanism of action. The success of RNAi therapy to a great extent is dictated by the siRNA delivery vehicle employed. This study explored the use of a lipid-substituted low molecular weight polyethyleneimine (lipopolymer) for delivering FLT3 siRNA in FLT3-ITD positive AML models and assess the efficacy of combining this treatment with chemotherapeutic drugs currently used in clinic. Low molecular weight polyethyleneimine (PEI) polymers were modified with aliphatic lipids to yield lipopolymers that self-assembled into nanocomplexes with siRNA. Treatment of MV4-11 cells with lipopolymer/FLT3 siRNA nanocomplexes resulted in ~50% reduction in cell proliferation rates (p<0.001), as determined by taking direct cell counts after the siRNA treatment. Quantitative analysis of relative mRNA transcript levels conducted by qPCR revealed downregulation of FLT3 gene by 30% (p<0.01). Furthermore, a similar decline (~35%, p<0.005) in FLT3 protein levels was observed when measured by flow cytometry through immunostaining with an anti-FLT3 antibody. Evaluation of apoptosis by FITC-Annexin V/propidium iodide (PI) staining showed a 3-fold increase in percentage of cells in the late apoptosis stage after FLT3 specific siRNA treatment (p<0.005). The effect of combining lipopolymer/FLT3 siRNA treatment with daunorubucin manifested as a decline in cell proliferation rates as well as 3-fold increase in apoptosis (p<0.05). To assess the impact of combination treatment on stem cells, colony forming ability was measured by seeding treated cells in methylcellulose and the colonies generated subsequently were counted after two weeks. A notable drop in colony counts was observed in the combination relative to individual treatments. However, similar analyses with the FLT3 targeting TKI midostaurin led to only a modest augmentation of anti-leukemic activity. Subsequently, the more recently approved FLT3 targeting TKI gilteritinib was explored in combination with lipopolymer/FLT3 siRNA nanocomplexes both in vitro and in vivo. For in vivo studies, lipopolymer/FLT3 siRNA nanocomplexes were administered via tail-vein injection at a siRNA dose of 25 µg per mouse (~1 mg/kg) once the tumor volume was ≥50mm3 in AML MV4-11 subcutaneous xenograft models created in male NCG (ABL/VAF) mice. Four injections of the nanocomplexes were administered, each 72 hours apart with simultaneous measurements of the tumor volume. Gilteritinib was administered four times intraperitonially at a dose of 5 mg/kg, with a spacing of 72 hours between doses. A significant reduction in tumor volume was observed in the combination treated tumors compared to gilteritinib alone treated tumors. Refractory/relapsed tumors underwent a second round of treatment (with both nanocomplexes and gilteritinib being administered four times each). The combination therapy significantly increased median survival to 65 days as compared to 45 days with gilteritinib treatment alone (p<0.05). These findings demonstrate the promising potential of RNAi implemented with lipopolymer nanocomplexes for AML molecular therapy. The study prospectively supports the addition of RNAi therapy to current treatment modalities available to target the heterogeneity prevalent in AML.

Adjuvant therapy options in renal cell carcinoma - targeting the metastatic cascade.

Localized renal cell carcinoma (RCC) is primarily managed with nephrectomy, which is performed with curative intent. However, disease recurs in ~20% of patients. Treatment with adjuvant therapies is used after surgery with the intention of curing additional patients by disrupting the establishment, maturation or survival of micrometastases, processes collectively referred to as the metastatic cascade. Immune checkpoint inhibitors and vascular endothelial growth factor receptor (VEGFR)-targeting tyrosine kinase inhibitors (TKIs) have shown efficacy in the treatment of metastatic RCC, increasing the interest in the utility of these agents in the adjuvant setting. Pembrolizumab, an inhibitor of the immune checkpoint PD1, is now approved by the FDA and is under review by European regulatory agencies for the adjuvant treatment of patients with localized resected clear cell RCC based on the results of the KEYNOTE-564 trial. However, the optimal use of immunotherapy and VEGFR-targeting TKIs for adjuvant treatment of RCC is not completely understood. These agents disrupt the metastatic cascade at multiple steps, providing biological rationale for further investigating the applications of these therapeutics in the adjuvant setting. Clinical trials to evaluate adjuvant therapeutics in RCC are ongoing, and clinical considerations must guide the practical use of immunotherapy and TKI agents for the adjuvant treatment of localized resected RCC.

Machine learning based personalized drug response prediction for lung cancer patients

Lung cancers with a mutated epidermal growth factor receptor (EGFR) are a major contributor to cancer fatalities globally. Targeted tyrosine kinase inhibitors (TKIs) have been developed against EGFR and show encouraging results for survival rate and quality of life. However, drug resistance may affect treatment plans and treatment efficacy may be lost after about a year. Predicting the response to EGFR-TKIs for EGFR-mutated lung cancer patients is a key research area. In this study, we propose a personalized drug response prediction model (PDRP), based on molecular dynamics simulations and machine learning, to predict the response of first generation FDA-approved small molecule EGFR-TKIs, Gefitinib/Erlotinib, in lung cancer patients. The patient’s mutation status is taken into consideration in molecular dynamics (MD) simulation. Each patient’s unique mutation status was modeled considering MD simulation to extract molecular-level geometric features. Moreover, additional clinical features were incorporated into machine learning model for drug response prediction. The complete feature set includes demographic and clinical information (DCI), geometrical properties of the drug-target binding site, and the binding free energy of the drug-target complex from the MD simulation. PDRP incorporates an XGBoost classifier, which achieves state-of-the-art performance with 97.5% accuracy, 93% recall, 96.5% precision, and 94% F1-score, for a 4-class drug response prediction task. We found that modeling the geometry of the binding pocket combined with binding free energy is a good predictor for drug response. However, we observed that clinical information had a little impact on the performance of the model. The proposed model could be tested on other types of cancers. We believe PDRP will support the planning of effective treatment regimes based on clinical-genomic information. The source code and related files are available on GitHub at: https://github.com/rizwanqureshi123/PDRP/.

Progression-free Survival After Second Line of Therapy for Metastatic Clear Cell Renal Cell Carcinoma in Patients Treated with First-line Immunotherapy Combinations

Immunotherapy (IO)-based combinations used to treat metastatic clear cell renal cell carcinoma (ccRCC) include dual immune checkpoint inhibition with ipilimumab and nivolumab (IO/IO) and several combinations of vascular endothelial growth factor receptor–targeting tyrosine kinase inhibitors (TKIs) with an immune checkpoint inhibitor (TKI/IO). IO/IO and TKI/IO approaches have not been compared directly, and it is unknown whether patients who do not respond to first-line IO/IO can salvage long-term survival by receiving a second-line TKI. Progression-free survival after second-line therapy (PFS-2) evaluates the ability to be salvaged by second-line therapy. We retrospectively evaluated 173 patients treated with first-line IO/IO or TKI/IO for metastatic ccRCC at Memorial Sloan Kettering Cancer Center and report PFS-2, overall survival, and response to second line of therapy (ORR2nd) for groups defined by first-line category. Although ORR2nd was significantly higher with IO/IO than with TKI/IO (47% vs 13%, p < 0.001), there was no significant difference in median PFS-2 for TKI/IO versus IO/IO (44 vs 23 mo, log-rank p = 0.1) or restricted mean survival time (RMST) for PFS-2 when adjusted for propensity score (33 vs 30 mo; difference 2.6 mo [95% confidence interval {CI}: –2.6, 7.9]; p = 0.3). There was also no significant difference in RMST for overall survival when adjusted for propensity score (38 vs 37 mo; group difference 1.0 mo [95% CI: –3.4, 5.5]; p = 0.7). These findings do not support a change in current utilization practices for IO/IO and TKI/IO treatment strategies for ccRCC. Patient summaryIn cases of metastatic clear cell renal cell carcinoma, no significant difference was observed in progression-free survival after second line of therapy between patients receiving ipilimumab plus nivolumab and those receiving a combination of a tyrosine kinase inhibitor and an immune checkpoint inhibitor.

The 8p11 myeloproliferative syndrome: Genotypic and phenotypic classification and targeted therapy

EMS(8p11 myeloproliferative syndrome, EMS) is an aggressive hematological neoplasm with/without eosinophilia caused by a rearrangement of the FGFR1 gene at 8p11-12. It was found that all cases carry chromosome abnormalities at the molecular level, not only the previously reported chromosome translocation and insertion but also a chromosome inversion. These abnormalities produced 17 FGFR1 fusion genes, of which the most common partner genes are ZNF198 on 13q11-12 and BCR of 22q11.2. The clinical manifestations can develop into AML (acute myeloid leukemia), T-LBL (T-cell lymphoblastic lymphoma), CML (chronic myeloid leukemia), CMML (chronic monomyelocytic leukemia), or mixed phenotype acute leukemia (MPAL). Most patients are resistant to traditional chemotherapy, and a minority of patients achieve long-term clinical remission after stem cell transplantation. Recently, the therapeutic effect of targeted tyrosine kinase inhibitors (such as pemigatinib and infigratinib) in 8p11 has been confirmed in vitro and clinical trials. The TKIs may become an 8p11 treatment option as an alternative to hematopoietic stem cell transplantation, which is worthy of further study.

Chronic Myeloid Leukemia: who should get a treatment-free trial and how?

Treatment with a BCR::ABL1 targeted tyrosine kinase inhibitor (TKI) has afforded a near-normal life expectancy for most patients with chronic myelogenous leukemia (CML). Approximately half of CML patients achieve a deep molecular response with TKI therapy and can discontinue treatment. In these patients, the CML can remain in prolonged remission, and patients can experience an improvement in quality of life.&#x0D; The European Leukemia Network (ELN) and the National Comprehensive Cancer Network (NCCN) provide the most up-to-date frameworks for treatment-free trials (TFTs), reflecting best practices from over 13 clinical trials published since the concept first entered the CML vernacular around 2010. Provincial guidelines also exist, such as those published in Quebec by the Groupe Québécois de Recherche en LMC-NMP (the Chronic Myeloid Leukemia and Myeloproliferative Neoplasms Quebec Research Group).&#x0D; The discontinuation of therapy for patients with CML in deep remission marks a potential shift from the management of CML as a chronic illness to the potential for a curative approach to CML. However, for now, only 50% of eligible patients have undergone successful TFT; optimal patient selection and monitoring is required to ensure the best outcomes with such a management strategy.