Tyrosine Kinase Inhibitor Drugs Research Articles

ZBTB46, SPDEF, and ETV6: Novel Potential Biomarkers and Therapeutic Targets in Castration-Resistant Prostate Cancer.

Prostate cancer (PCa) is the second most common killer among men in Western countries. Targeting androgen receptor (AR) signaling by androgen deprivation therapy (ADT) is the current therapeutic regime for patients newly diagnosed with metastatic PCa. However, most patients relapse and become resistant to ADT, leading to metastatic castration-resistant PCa (CRPC) and eventually death. Several proposed mechanisms have been proposed for CRPC; however, the exact mechanism through which CRPC develops is still unclear. One possible pathway is that the AR remains active in CRPC cases. Therefore, understanding AR signaling networks as primary PCa changes into metastatic CRPC is key to developing future biomarkers and therapeutic strategies for PCa and CRPC. In the current review, we focused on three novel biomarkers (ZBTB46, SPDEF, and ETV6) that were demonstrated to play critical roles in CRPC progression, epidermal growth factor receptor tyrosine kinase inhibitor (EGFR TKI) drug resistance, and the epithelial-to-mesenchymal transition (EMT) for patients treated with ADT or AR inhibition. In addition, we summarize how these potential biomarkers can be used in the clinic for diagnosis and as therapeutic targets of PCa.

Cell-penetrable nanobodies (transbodies) that inhibit the tyrosine kinase activity of EGFR leading to the impediment of human lung adenocarcinoma cell motility and survival.

Most patients suffering from non-small cell lung cancer (NSCLC) have epidermal growth factor receptor (EGFR) overexpression. Currently, EGFR tyrosine kinase inhibitors (TKIs) that act as the ATP-analogs and monoclonal antibodies (MAbs) to EGFR-ectodomain that block intracellular signaling are used for the treatment of advanced NSCLC. Unfortunately, adverse effects due to the TKI off-target and drug resistance occur in a significant number of the treated patients while some NSCLC genotypes do not respond to the therapeutic MAbs. Thus, a more effective remedy for the treatment of EGFR-overexpressed cancers is deemed necessary. In this study, VH/VH H displayed-phage clones that are bound to recombinant EGFR-TK were fished-out from a humanized-camel VH/VH H phage display library. VH/VH H of three phage-infected Escherichia coli clones (VH18, VH H35, and VH36) were linked molecularly to nonaarginine (R9) for making them cell penetrable. R9-VH18, R9-VH H35, and R9-VH36 were cytotoxic to human adenocarcinomic alveolar basal epithelial cells (A549) at the fifty percent inhibitory concentration (IC50 ) 0.181 ± 0.132, 0.00961 ± 0.00516, and 0.00996 ± 0.00752 μM, respectively, which were approximately 1000-fold more effective than small molecular TKIs. R9-VH18 and R9-VH36 also delayed cancer cell migration in a scratch-wound assay. Computerized homology modeling and intermolecular docking revealed that VH18 and VH H35 used CDR3 to interact with EGFR-TK residues close to the catalytic site, which might sterically hinder the ATP-binding of the TK; VH36 used CDR2 to bind at the asymmetric dimerization surface, which might disrupt EGFR dimerization leading to inhibition of intracellular signaling. The humanized-cell penetrable nanobodies have a high potential for developing further towards a clinical application.

Detection of BCR-ABL gene in Chronic Myeloid Leukemia patients treated with Tyrosine Kinase Inhibitors Drugs by Gene Expert System

Chronic myeloid leukaemia (CML) is one of the human fatalities caused by genetic mutation and chromosomal translocation, a BCR-ABL fusion gene and as a result, Philadelphia chromosome is formed. The irregular tyrosine kinase activity of the encoded protein by this gene causes the establishment of the disease. This study was conducted at the period from September 2016 to February 2017,100 Iraqi CML patients were divided into two groups, first group of 50 patients were received Imatinib 400-800 mg/day, second group of another 50 patients were received 800 mg/day Nilotinib, WBC were microscopically counted using improved Neubauer ruled hemocytometer counting chamber. The results of WBC count in different disease duration and stages of treatment in the group of patients treated with Imatinib showed that highest WBC count was observed in newly diagnosed patients while there was a significant reduction in the WBC count after one month, after one year and final dose of treatment were 11.8, 6.4 and 8.1 respectively, on the other hand the results of WBC count in the group of patients treated with Nilotinib showed that the highest WBC count was observed in newly diagnosed patients 87.54± 8.71 whereas the WBC count after one month, one year and at the final dose of treatment were 7.3, 6.8, 7.9 respectively with significant reduction in the WBC count. The results of the CML patient’s distribution according to BCR-ABL gene analysis in the patient's group treated with Imatinib showed that high concentration in newly diagnosed patients 4.753 as compared with significant reduction with other stages of treatment after one month and after one year 0.94 and 0.09 respectively.

New Systemic Therapies for Advanced Hepatocellular Carcinoma

Since the approval of sorafenib for patients with advanced hepatocellular carcinoma (HCC) in 2007, many drugs have failed in the first and second-line setting. Fortunately, during the recent 2 years, between 2017 and 2018, four drugs (regorafenib, lenvatinib, cabozantinib, and ramucirumab) were found to be effective and tolerable for patients with HCC as the first- or second-line therapy. Regorafenib, a multi-kinase inhibitor, has a similar structure to sorafenib, and was shown to improve the survival of patients who progressed after sorafenib treatment compared to the placebo control. According to the phase III trial of regorafenib, it became the first approved systemic therapy for patients with progression after sorafenib. Lenvatinib is also a tyrosine kinase inhibitor (TKI), and in a phase III trial comparing sorafenib and lenvatinib, the primary end-point of non-inferior survival was met. Based on the trial results, lenvatinb has become another systemic therapy for treatment-na?ve patients with advanced HCC. Cabozantinib is a dual inhibitor of Mesenchymal-Epithelial Transition factor/Vascular Endothelial Growth Factor Receptor2, and was shown to prolong the overall survival in patients who progressed after sorafenib compared to the placebo. Ramucirumab is a monoclonal antibody to inhibit a single target of VEGFR2. First, this drug failed to improve the survival of patients who progressed after sorafenib failure. On the other hand, it was effective in patients with baseline AFP ≥400 ng/mL, In a subsequent clinical trial that enrolled only patients with AFP ≥400 ng/mL, ramucirumab was also found to improve the overall survival compared to placebo. Thus, ramucirumab became the first biomarker-driven systemic treatment. Another category of drugs that are attracting considerable interest are immune checkpoint inhibitors, such as anti-programmed cell death protein (PD) 1 or anti-PD-ligand 1. This review provides a synopsis of new systemic therapies, including TKI, monoclonal antibody, and immune-oncology drugs.

Interleukin 1 Beta As a Promising Therapeutic Target in ABL Tyrosine Kinase Inhibitor Resistant Chronic Myeloid Leukemia Cells

Introduction: Although ABL tyrosine kinase inhibitor (TKI), imatinib, nilotinib and dasatinib have demonstrated the potency against chronic myeloid leukemia (CML) and Philadelphia chromosome (Ph) positive acute lymphoblastic leukemia (Ph+ALL) patients, resistance to ABL TKI can develop in the many patients. It has already reported that ABL kinase domain mutations have been implicated in the pathogenesis of ABL TKI resistance, however, it is fully not known the molecular mechanism of drug resistance ABL TKIs. Therefore, new approach against ABL TKI resistant cells may improve the outcome of Ph-positive leukemia patients. Interleukin-1 (IL-1) is a proinflammatory cytokine and central mediator of innate immunity. IL-1β also controls essential cell responses. Because enhanced IL-1β signaling is reported in patients of hematological malignancies, IL-1β may be the promising therapeutic value in ABL TKI resistant CML patients.Materials and methods: In this study, we established ABL TKI-resistant in vitro cell line models (K562 imatinib-R, K562 nilotinib-R, K562 dasatinib-R, K562 ponatinib-R). We also investigated whether IL-1β was involved in ABL TKI resistant Ph-positive leukemia cells and cytokines were induced by IL-1β in human umbilical vein endothelial cells (HUVEC).Results: We analyzed the relationship of IL-1β signaling pathways and ABL TKI sensitivity by microarray gene expression data from the online Gene Expression Omnibus (GEO). IL-1β is related to imatinib sensitivity and resistant in CML patients from the public microarray datasets of GSE14671. We next examined ABL TKI resistant cell lines (K562 imatinib-R, K562 nilotinib-R, K562 dasatinib-R, K562 ponatinib-R) in this study. BCR-ABL point mutation was not found in ABL TKI resistant cells. BCR-ABL expression levels were not increased in ABL TKI resistant K562 cells. These cells were highly resistant to ABL TKIs compare to K562 cells (K562 imatinib-R: imatinib 2μM, nilotinib-R: nilotinib 2μM, dasatinib-R: dasatinib 100nM, ponatinib-R: ponatinib 50nM). We investigated gene expression profiles in cultured ABL TKI resistant K562 cells by DNA microarray. We found gene expression of IL-1β and IL-1β mediated signaling pathway was increased ABL TKI resistant K562 cells. IL-1β gene amplification was confirmed by RT-PCR analysis. Nuclear Factor kappa-light-chain-enhancer of activated B cells (NF-kB) acts as a central mediator of inflammatory responses. Because bortezomib is a proteasome inhibitor whose anti-cancer action is partly mediated through inhibition of NF-κB, we examined the bortezomib in ABL TKI resistant cells. Combined treatment of ABL TKI resistant cells with ponatinib or imatinib and bortezomib caused more cytotoxicity than each drug alone. Caspase 3/7 activity and cellular cytotoxicity was also increased. ABL TKIs are also associated with vascular adverse events (VAEs) in CML, we next investigated the in vitro effects of ABL TKIs on cultured HUVEC. We found gene expression of IL-1β was increased after ABL TKI especially dasatinib and ponatinib treatment. IL-1β was increased in the cell culture supernatant after ABL TKIs treatment. In the immunoblot analysis, p38 mitogen-activated protein kinase (MAPK) and c-Jun N-terminal kinase (JNK) phosphorylation was increased by IL-1β in the time dependent manner. We also found that gene expression of IL-6, IL-8, intercellular adhesion molecule 1 (ICAM1) and monocyte chemotactic protein-1 (MCP-1) was enhanced by IL-1β stimulation.Conclusion: The IL-1β signaling pathway is involved in ABL TKI sensitivity and drug resistant in CML cells and plays a key role in cytokine production of the HUVEC. We also provide the promising clinical relevance as a candidate drug for treatment of ABL TKI resistant leukemia patients. DisclosuresOhyashiki:Asahikase: Research Funding; Taiho Pharmaceutical KK: Honoraria, Research Funding; Dainippon Sumitomo KK,: Honoraria, Research Funding; MSD,: Honoraria, Research Funding; Bristol Meyer Squibb KK,: Honoraria, Research Funding; Ono Pharmaceutical KK,: Honoraria, Research Funding; Celegene KK,: Honoraria, Research Funding; Pfizer KK,: Honoraria, Research Funding; Kyowakko Kirin KK,: Research Funding; Nihon-Seiyaku,: Research Funding; Eizai,: Research Funding; Chugai KK,: Honoraria, Research Funding; Takeda Pharmaceutical KK,: Honoraria, Research Funding; Asteras KK,: Research Funding; Jansen Pharma KK,: Research Funding; Nippon-shinyaku,: Honoraria, Research Funding; Novartis KK,: Honoraria, Research Funding.

Russian Experience of Bosutinib Use in Chronic Myeloid Leukemia Patients in Routine Clinical Practice

Background. The treatment of chronic myeloid leukemia (CML) with tyrosine kinase inhibitors (TKI) have diminished death probability and have changed the disease course. Achievement of complete cytogenetic response (CCyR) and major molecular response (MMR) are serve as warranties for freedom of progression and death from CML. There are many of CML patients are needed to change of initial TKI therapy with choice of the most efficient and safe drug for continuous life-long therapy to reach the optimal results of CML treatment. The newest of registered TKI drug in Russia is Bosutinib which has dual BCR-ABL and SRC kinase inhibitory activity and had showed good tolerability and efficacy in case of other TKIs resistance or intolerance.Aim. To analyze of own Bosutinib experience in patients with chronic myeloid leukemia with other TKIs resistance or intolerance and to make comparison with clinical trial results.Materials and methods. Clinical trials results from peer-reviewed journals. Outpatients charts of 51 patients (25 male and 26 females) with CML. Disease phase at the moment of Bosutinib therapy initiation was as follows: chronic - 37; acceleration - 8, blastic - 6. Bosutinib was used in the next lines of TKI therapy: second - 10; third - 18; fourth - 23. The indications for Bosutinib therapy were: intolerance to previous TKI - 21; resistance to previous TKI - 30.Results. Median of therapy duration was 6 months (1-50 months). The adverse events and tolerability of Bosutinib were similar with clinical trials data. The treatment was withdrawn by the adverse event only in 5 (10%) patients. The rates of the responses in the whole group of patients were as follows: CHR - 88%, stable in 76%; CCyR - 39%, stable in 37%, MMR - 31% and was 25% at the last follow-up. The Bosutinib efficacy in real life settings was slightly higher than clinical trials data. The factors influencing treatment responses were: disease phase, cause of switching to Bosutinib, line of therapy and presence and kind of BCR-ABL mutations, Therapy was continued in 22 (43%) patients, most them achieved stable optimal treatment response (CCyR and MMR).Conclusions. Bosutinib is a real alternative to other tyrosine kinase inhibitors and has its own mechanism of action and adverse events profile. The use of Bosutinib in real life clinical practice settings showed its efficacy and tolerability and could serve as base for recommendation to apply Bosutinib in hematology practice in Russia. DisclosuresNo relevant conflicts of interest to declare.

Early Molecular Response with Generic Imatinib Therapy in Sokal/Hasford Intermediate- & High-Risk Chronic Phase Chronic Myeloid Leukemia Patients: A Single Institution Experience from India

Introduction: Chronic myeloid leukemia (CML) is the commonest adult leukemia in India. Prognostication of newly diagnosed patients of chronic phase CML (CML-CP) is done by calculating pre-treatment risk scores as per Sokal and Hasford scoring systems, and patients are categorized into low-, intermediate- & high-risk groups. According to the latest NCCN guidelines, CML-CP patients with intermediate- or high-risk Sokal or Hasford score may preferentially benefit from second generation tyrosine kinase inhibitor (TKI) treatment. The two second generation TKI drugs available in India are dasatinib & nilotinib. Unfortunately, majority of CML-CP patients in India cannot afford upfront second generation TKI therapy, and generic imatinib is the mainstay of treatment even for intermediate-risk & high-risk patients. Achievement of early molecular response (EMR), defined as BCR-ABL1 (international scale, IS) ≤ 10% after 3 months of first-line TKI therapy, has emerged as one of the most important predictors of favourable long-term outcomes in CML-CP. The present study describes the rate of EMR achievement with first-line generic imatinib therapy in Sokal & Hasford intermediate- & high-risk patients.Objectives: To study the early molecular response rates with generic imatinib therapy at 400 mg/day dose in CML-CP patients with intermediate-risk & high-risk Sokal or Hasford scores.Methods: Our study enrolled 73 newly diagnosed CML-CP patients with intermediate- or high-risk Sokal/Hasford scores between March 2016 and March 2018. All the patients hailed from poor socio-economic background with severe financial constraint, and none of them had any medical insurance. All the patients were treated with generic imatinib mesylate 400 mg/day which was available free of cost at the hospital. None of the patients could afford dasatinib or nilotinib, despite adequate counseling & information regarding the efficacy of 2nd generation TKIs. Treatment response was monitored and defined as per European LeukemiaNet 2013 recommendations. Hematological response was assessed at 3 months for achievement of complete hematologic response (CHR). Molecular response was assessed at 3 months of first-line treatment by quantitative real-time PCR for BCR-ABL1 (IS). Complete data of 65 patients who were compliant to imatinib treatment for at least 3 months were available for analysis. Eight patients were lost to follow up.Results: The median age of patients was 35 years (age range 17 - 72 years; 40 male). CHR was achieved in 92% patients (60 out of 65 patients). Early molecular response at 3 months (BCR-ABL1, IS) ≤ 10%) was documented in 68% (44 out of 65) patients. The range of BCR-ABL1 transcript level at 3 months was 0.01% - 10% in patients who achieved EMR. EMR was not achieved in about 60% of Sokal high-risk patients and 30% of Hasford high-risk patients.Conclusion: The real scenario of CML treatment in developing countries with resource-constrained settings is very much different from that in the developed countries. The response rates to generic Imatinib therapy in Sokal/Hasford intermediate-risk & high-risk CML-CP patients are not impressive. There is scope for significant improvement in treatment response with upfront 2nd generation TKI therapy in intermediate- & high-risk CML-CP patients, if the drugs can be made available at affordable costs in developing countries. DisclosuresNo relevant conflicts of interest to declare.

ALK Fusion Partners Impact Response to ALK Inhibition: Differential Effects on Sensitivity, Cellular Phenotypes, and Biochemical Properties.

Oncogenic tyrosine kinase fusions involving the anaplastic lymphoma kinase (ALK) are detected in numerous tumor types. Although more than 30 distinct 5' fusion partner genes have been reported, treatment of ALK-rearranged cancers is decided without regard to which 5' partner is present. There is little data addressing how the 5' partner affects the biology of the fusion or responsiveness to ALK tyrosine kinase inhibitors (TKI). On the basis of the hypothesis that the 5' partner influences the intrinsic properties of the fusion protein, cellular functions that impact oncogenic potential, and sensitivity to ALK TKIs, clonal 3T3 cell lines stably expressing seven different ALK fusion variants were generated. Biochemical and cellular assays were used to assess the efficacy of various ALK TKIs in clinical use, transformative phenotypes, and biochemical properties of each fusion. All seven ALK fusions induced focus formation and colonies in soft agar, albeit to varying degrees. IC50s were calculated for different ALK TKIs (crizotinib, ensartinib, alectinib, lorlatinib) and consistent differences (5-10 fold) in drug sensitivity were noted across the seven ALK fusions tested. Finally, biochemical analyses revealed negative correlations between kinase activity and protein stability. These results demonstrate that the 5' fusion partner plays an important biological role that affects sensitivity to ALK TKIs.Implications: This study shows that the 5' ALK fusion partner influences ALK TKI drug sensitivity. As many other kinase fusions are found in numerous cancers, often with overlapping fusion partners, these studies have ramifications for other kinase-driven malignancies. Mol Cancer Res; 16(11); 1724-36. ©2018 AACR.

Mast cells and neutrophils mediate peripheral motor pathway degeneration in ALS.

Neuroinflammation is a recognized pathogenic mechanism underlying motor neuron degeneration in amyotrophic lateral sclerosis (ALS), but the inflammatory mechanisms influencing peripheral motor axon degeneration remain largely unknown. A recent report showed a pathogenic role for c-Kit-expressing mast cells mediating inflammation and neuromuscular junction denervation in muscles from SOD1G93A rats. Here, we have explored whether mast cells infiltrate skeletal muscles in autopsied muscles from ALS patients. We report that degranulating mast cells were abundant in the quadriceps muscles from ALS subjects but not in controls. Mast cells were associated with myofibers and motor endplates and, remarkably, interacted with neutrophils forming large extracellular traps. Mast cells and neutrophils were also abundant around motor axons in the extensor digitorum longus muscle, sciatic nerve, and ventral roots of symptomatic SOD1G93A rats, indicating that immune cell infiltration extends along the entire peripheral motor pathway. Postparalysis treatment of SOD1G93A rats with the tyrosine kinase inhibitor drug masitinib prevented mast cell and neutrophil infiltration, axonal pathology, secondary demyelination, and the loss of type 2B myofibers, compared with vehicle-treated rats. These findings provide further evidence for a yet unrecognized contribution of immune cells in peripheral motor pathway degeneration that can be therapeutically targeted by tyrosine kinase inhibitors.

Research progress of immune factors associated with patients discontinuing of tyrosine kinase inhibitor for chronic myeloid leukemia

Tyrosine kinase inhibitor (TKI) therapy has significant improved the survival and prognosis of patients with chronic myeloid leukemia(CML). Long-term therapy of TKI drugs not only has produced a heavy financial burden of patients, but also results in chronic adverse effects. At present, the treatment-free remission (TFR) has been gradually regarded as the new treatment target for patients with CML.The key to recurrence of CML patients who discontinued of TKI is dependent whether the immune system maintains a sustained TFR. In this paper, immune factors associated with discontinuation of TKI for patients with CML, such as natural killer (NK) cells, killer-cell immunoglobulin-like receptor (KIR), proteinase-1 specific cytotoxic T lymphocyte (PR1-CTL), myeloid derived suppressor cells (MDSC), regulatory T cells (Treg), CD86+ plasmacytoid dendritic cells(pDC), L-selectin(CD62L) and soluble CD62L(sCD62L) were reviewed. Key words: Leukemia, myelogenous, chronic, BCR-ABL positive; Tyrosine kinase inhibitor; Drug resistence, neoplasm; Treatment-free remission; Immunity cellular; Discontinuation

Mechanisms, monitoring, and management of tyrosine kinase inhibitors-associated cardiovascular toxicities.

The tyrosine kinase inhibitor (TKI) drug class is a prominently used option in the treatment of various cancers. Safety evaluation of these drugs has shown evidence of cardiotoxicity of varying frequency and severity between agents; concern has led to updated labeling, warning prescribers of such. This review seeks to clarify the present dangers and investigate cardiotoxic mechanisms of action for each discussed TKI. Dasatinib was connected primarily with an incidence of fluid retention, edema, QT prolongation, and pulmonary hypertension in clinical studies. It is theorized that this is due to a combination of off-target kinase binding and on-target binding of Bcr-Abl, and less likely, mitochondrial induced apoptosis. Studies showed sorafenib to carry the risk of hypertension, QT prolongation, and myocardial infarction. Proposed mechanisms for these side effects include inhibition of proteins, vascular endothelium growth factor receptor, hERG potassium channels, and the RAF/MERK/ERK pro-survival pathway. Finally, lapatinib showed evidence of decreased left ventricular ejection fraction (LVEF) and QT prolongation in clinical studies. The literature attributes these as side effects of on-target ErbB2 binding leading to mitochondrial induced apoptosis. The concern warranted by these findings is in question. Pooled safety data suggest that the overall risk for cardiotoxicity is minimal in dasatinib and lapatinib. Sorafenib seems to carry a moderate concern. For the discussed agents, recommendations agree that routine monitoring via methods such as electroencephalogram, cardiac biomarkers, and blood pressure is warranted during the course of treatment, in addition to a comprehensive collection of past medical history and risk factors to identify those at heightened risk for cardiovascular events.

In vitro UGT1A1 inhibition by tyrosine kinase inhibitors and association with drug-induced hyperbilirubinemia.

Hyperbilirubinemia has been observed in patients treated with tyrosine kinase inhibitor (TKI) drugs. Therefore, it would be beneficial to understand whether there is a relationship between inhibition of uridine-5'-diphosphate glucuronosyltransferase (UGT) 1A1 activity and observed bilirubin elevations in TKI drug-treated patients. UGT1A1 is responsible for the glucuronidation of bilirubin which leads to its elimination in the bile. To examine this question, an in vitro glucuronidation assay was developed to determine the inhibitory effect of TKI drugs employing human liver microsomes (HLM) with varying UGT1A1 activity. Utilizing β-estradiol as the UGT1A1 probe substrate, 20 TKI drugs were evaluated at concentrations that represent clinical plasma levels. Adverse event reports were searched to generate an empirical Bayes geometric mean (EGBM) score for clinical hyperbilirubinemia with the TKI drugs. Erlotinib, nilotinib, regorafenib, pazopanib, sorafenib and vemurafenib had IC50 values that were lower than their clinical steady-state Cmax concentrations. These TKI drugs had high incidences of hyperbilirubinemia and higher EBGM scores. The IC50 values and Cmax/IC50 ratios correlated well with EBGM scores for hyperbilirubinemia (P < 0.005). For the TKI drugs with higher incidence of hyperbilirubinemia in Gilbert syndrome patients, who have reduced UGT1A1 activity, six of eight had smaller ratios in the low UGT1A1 activity microsomes than the wild-type microsomes for drugs, indicating greater sensitivity to the drugs in this phenotype. These results suggest that in vitro UGT1A1 inhibition assays have the potential to predict clinical hyperbilirubinemia.

Clinical value of droplet digital polymerase chain reaction method in detecting plasma circulating tumor deoxyribonucleic acid epidermal growth factor receptor mutations in advanced pulmonary adenocarcinoma patients

Objective: To determine the clinical value of droplet digital polymerase chain reaction (ddPCR) method to detect plasma circulating tumor DNA (ctDNA) epidermal growth factor receptor (EGFR) mutations in advanced pulmonary adenocarcinoma. Methods: One hundred and thirty six patients with advanced pulmonary adenocarcinoma diagnosed in the Beijing Chest Hospital were collected from May 2015 to April 2017 for initial treatment. EGFR gene mutation in the plasma ctDNA was detected by both ddPCR and amplification refractory mutation system (ARMS) assays. EGFR gene mutation in the tumor tissue was detected by ARMS assay. Patients with EGFR sensitive mutations received first-line oral treatment with EGFR tyrosine kinase inhibitor (EGFR-TKI) drugs. The Kaplan-Meier survival analysis was used to compared the progression-free survival (PFS) in EGFR gene mutated patients detected with different methods. Results: Total of 111 samples (81.6%) were detected with EGFR gene mutations in 136 tumor tissue samples. In the 111 samples, 48 samples were found with exon21 L858R mutation (48/111, 43.2%), 59 samples were found with exon19 deletion mutations (59/111, 53.2%), and 4 cases were found with other mutations (4/111, 3.6%). Using tumor specimens as the gold standard, the sensitivity, specificity, and concordance rate of ARMS assay were 58.6%, 96.0%, and 65.4%, respectively; and those in ddPCR assay were 79.3%, 100%, and 83.1%, respectively; the coincidence rate was 83.1% (Kappa=0.685, P<0.001). Kaplan-Meier survival analysis showed that patients with EGFR gene mutation detected by both ddPCR and ARMS methods had shortest PFS when compared with those in patients detected positive with a single method of ddPCR or ARMS assay (11.6 moths vs 14.8 months, χ(2)=2.517, P=0.026). Conclusions: ddPCR is a reliable technology with high sensitivity and high specificity to detect EGFR gene mutations in plasma ctDNA in patients with advanced pulmonary adenocarcinoma. Plasma EGFR gene mutation may predict the efficacy of EGFR-TKI drugs.

Aberrant DNA methylation at HOXA4 and HOXA5 genes are associated with resistance to imatinib mesylate among chronic myeloid leukemia patients.

Imatinib mesylate is a molecularly targeted tyrosine kinase inhibitor drug. It is effectively used in the treatment of chronic myeloid leukemia (CML) patients. However, development of resistance to imatinib mesylate as a result of BCR-ABL dependent and BCR-ABL independent mechanisms has emerged as a daunting problem in the management of CML patients. Between these mechanisms, BCR-ABL independent mechanisms are still not robustly understood. To investigate the correlation of HOXA4 and HOXA5 promoter DNA hypermethylation with imatinib resistance among CML patients. Samples from 175 Philadelphia positive CML patients (83 good response and 92 BCR-ABL non-mutated imatinib resistant patients) were subjected to Methylation Specific High Resolution Melt Analysis for methylation levels quantification of the HOXA4 and HOXA5 promoter regions. Receiver operating characteristic curve analysis was done to elucidate the optimal methylation cut-off point followed by multiple logistic regression analysis. Log-Rank analysis was done to measure the overall survival difference between CML groups. The optimal methylation cut-off point was found to be at 62.5% for both HOXA4 and HOXA5. Chronic myeloid leukemia patients with ≥63% HOXA4 and HOXA5 methylation level were shown to have 3.78 and 3.95 times the odds, respectively, to acquire resistance to imatinib. However, overall survival of CML patients that have ≤62% and≥63% methylation levels of HOXA4 and HOXA5 genes were found to be not significant (P-value=0.126 for HOXA4; P-value=0.217 for HOXA5). Hypermethylation of the HOXA4 and HOXA5 promoter is correlated with imatinib resistance and with further investigation, it could be a potential epigenetic biomarker in supplement to the BCR-ABL gene mutation in predicting imatinib treatment response among CML patients but could not be considered as a prognostic marker.

Characteristics of Trials and Regulatory Pathways Leading to US Approval of Innovative vs. Non-Innovative Oncology Drugs

Background: Successful first-generation drugs can be updated or copied with small alterations to make drugs, which are less expensive to develop and carry less financial risk for manufacturers, since the mechanism of action has been validated and a well-defined consumer market exists. We compared the pivotal clinical trials and FDA approval pathways for first- and second-generation cancer drugs. Methods: Among cancer drugs approved in the US from 1994-2014, we found four classes of oncology drugs in which second-generation products followed many years after the first-generation agents: BCR-ABL tyrosine kinase inhibitors for treatment of chronic myelogenous leukemia, ALK tyrosine kinase inhibitors for non-small cell lung cancer, CD20 monoclonal antibodies for chronic lymphocytic leukemia and HER2 monoclonal antibodies for breast cancer. From information on these 13 drugs available in documents published by FDA at the time of approval, we extracted the following characteristics: approval pathway, pivotal trial design, number of participants, efficacy endpoints, and outcomes. Findings: The first-generation and 3 out of 4 second-generation BCR-ABL tyrosine kinase inhibitor drugs were granted expedited approval, while all 4 drugs were approved based on single-arm pivotal trials. Both ALK tyrosine kinase inhibitor drugs were based on single-arm trials and expedited regulatory review. The first-generation CD20 monoclonal antibody drug was approved based on single-arm trials, and 1 of the 2 second-generation drugs had pivotal trials that were randomized. All benefited from expedited approval. All 3 HER2 monoclonal antibodies in the sample were based on randomized trials and expedited pathways. Interpretation: Second-generation tyrosine kinase inhibitors and monoclonal antibodies used in cancer treatment were often approved through expedited approval pathways and studied in single-arm trials. Such pathways help facilitate the approval of these products for earlier use by patients, but are also associated with greater risk of post-approval safety-related labeling changes or unanticipated adverse events. Funding Statement: Dr. Kesselheim's work is funded by the Laura and John Arnold Foundation, with additional support from the Harvard Program in Therapeutic Science and the Engelberg Foundation. Dr. Vokinger's work is funded by the Swiss National Foundation. Declaration of Interest: The authors have declared no conflicts of interest.

Detection of BCR-ABL gene in Chronic Myeloid Leukemia patients treated with Tyrosine Kinase Inhibitors Drugs by Gene Expert System

Chronic myeloid leukemia (CML) is one of human malignancies caused by genetic mutation and chromosomal translocation, a BCR-ABL fusion gene and as result Philadelphia chromosome is formed. The irregular tyrosine kinase activity of encoded protein by this gene causes the establishment of the disease. Nilotinib are potent and well inhibitor for BCR-ABL tyrosine kinase. This study was conducted at the period from September 2016 to February 2017,100 Iraqi CML patients were divided into two groups, first group of 50 patients were received Imatinib 400-800 mg/day, second group of another 50 patients were received 800 mg/day Nilotinib, WBC were microscopically counted using improved Neubauer ruled hemocytometer counting chamber.BCR-ABL gene RNA transcript and endogenous control (house keeping gene ) RNA transcript were extracted and purified and then reverse transcripted to cDNA after that the product was amplified and quantified by q RT-PCR.&#x0D; The results first group patients distribution according to the gender were 56% and 44% for males and females respectively while the mean age of the patients was 45.82 ± 16.17,the result of WBC counting of this group in regard to disease duration showed that the highest value was observed in newly diagnosed and advanced stage 98.28 ± 89.28,77.11± 2.98 respectively.The WBC count return to normal level after the period of treatment with Imatinib with significant reduction after one year at p≤ 0.0001.The results of molecular technique and BCR-ABL analysis in newly diagnosed, advanced stage and cytogenetic failure patients were 10.05 ± 4.7,3.03± 0.94 and 28.4±0.09 respectively with significant decrease after one year of treatment at p ≤ 0.002.On the other hand the results of the second group of CML patients in relation to the gender were 45% and 55% of males and femalesrespectively,while the mean age group was 36.68 ±13.51. The results of WBC count according to disease distribution in newly diagnosed and advanced stage were 87.5 ± 8.71 and43±21.72 respectively. WBC count was return to normal level after one year of treatment with Nilotinib with significant decrease at p≤0.0001. While the molecular technique and BCR-ABL analysis in newly diagnosed, advanced stage and cytogenetic failure group were 7.77±4, 1, 16.17 ± 3.78 and 2.02±0.53 after one year of treatment with Nilotinib with significant decrease at p≤ 0.0001. We conclude that treatment with Imatinib was found tough in a high extent of patients, Nilotinib is extending specific tyrosine kinaseinhibitor possess greater and selectively activity for BCR-ABL.

Efficacy and safety of targeting VEGFR drugs in treatment for advanced or metastatic gastric cancer: a systemic review and meta-analysis.

The value of targeting VEGFR (vascular endothelial growth factor receptor) drugs has demonstrated encouraging anti-cancer activity in advanced solid tumors within current clinical trials. This study aimed to serve as the first systemic review to assess their safety and efficacy according to biochemical characteristics of targeting VEGFR drugs in gastric cancer. We analyzed eight clinical trials on targeting VEGFR drugs in gastric cancer. Results showed that targeting VEGFR drugs significantly improved overall survival (OS) [Hazard Ratio (HR) 0.69, 95% confidence interval (CI) (0.55, 0.83), P < 0.001], progression free survival (PFS) [HR 0.50, 95% CI (0.34, 0.66), P < 0.001], disease control rate (DCR) [Odds Ratio (OR) 3.83, 95% CI (2.39, 6.15), P < 0.001] and significantly decreased the progressive disease rate(PDR)[OR 0.45, 95% CI (0.34, 0.59), P < 0.001], but not objective response rate (ORR) [OR 1.46, 95% CI (0.93, 2.29), P = 0.098]. Further subgroup revealed that VEGFR antibody (VEGFR-Ab) drugs were superior to VEGFR tyrosine kinase inhibitor (VEGFR-TKI) drugs in terms of the OS, PFS and PDR. To determine the toxic effect of targeting VEGFR drugs, the relative risk of adverse events (grade ≥ 3) of special interest(AESIs) were estimated. Most of these were predictable and manageable. Furthermore, less AESIs were observed in the VEGFR-Ab than the VEGFR-TKI drugs. In conclusion, VEGFR drugs were effective targeted therapy in advanced or metastatic gastric cancer, and its toxicity is within a controllable range. VEGFR-Ab drugs were more effective than VEGFR-TKI drugs in terms of the OS, PFS and PDR of gastric cancer patients with little toxicity.

Rituximab effectively reverses Tyrosine kinase inhibitors (TKIs) resistance through inhibiting the accumulation of rictor on mitochondria-associated ER-membrane (MAM).

Tyrosine kinase inhibitors (TKIs), a novel group of target-specific anti lung cancer drugs, have recently been found to resistant to some NSCLC cells which have the T790M EGFR mutation. However, recent investigations on the therapies of resistance to EGFR-TKIs are very limited. Therefore, it is important to develop more effective therapies to reverse EGFR-TKIs resistance. In our present study, erlotinib was used as the TKIs drug and the effects of the erlotinib on cell growth were evaluated. Cell viability and concentration dependent studies were performed using HCI-H1975 and HCI-H1299 cells alone with erlotinib, respectively. Further combined with rituximab, the results showed that erlotinib and rituximab were significantly inhibited the cell growth. Furthermore, the combination of erlotinib and rituximab greatly decreased the expression of p-mTOR and p-EGFR. Additional results from western blotting and immunofluorescence assays demonstrated that the accumulation of rictor was also decreased on MAM. Thus, all these results suggested that EGFR-TKIs combined with CD20 mono-antibody significantly decrease the cell growth of H1975 cells and H1299, with T790M EGFR mutation, and inhibit the localization of the key mTOR pathway proteins to MAM. So, it may be a promising strategy for overcoming EGFR TKI resistance in NSCLC patients.

The evaluation of the efficacy and toxicity of targeted treatment in non-small cell lung cancer patients – single centre experience

Introduction: Tyrosine kinase inhibitors (TKI) are the standard of treatment in patients with advanced non-small cell lung cancer (NSCLC) with EGFR (endothelial growth factor receptor) gene activating mutation. Objective: The evaluation of the efficacy and toxicity of TKI drugs in NSCLC patients treated in single centre. Material and methods: NSCLC patients treated with TKI (gefitinib, erlotynib, afatinib) between 2012– 2016 were retrospectively analysed. We evaluated: overall response rate (ORR) which is the sum of complete responses (CR) and partial remissions (PR), progression free survival (PFS), overall survival (OS) and adverse events (AE) according to CTCAE (Common Terminology Criteria for Adverse Events) scale. Results: The study group were 16 patients ORR was 50% (CR: 1, PR: 7). Median PFS and OS was 8,7 and 22,9 months respectively. Adverse events observed mainly in stage 1 and 2 were related to hyponatraemia, hyperbilirubinemia, skin toxicity and mucositis. There was one death reported due to infectious complications. Conclusion: The efficacy and toxicity of TKI in study group were found to be similar to those described in the literature.

Insulin autoimmune syndrome (Hirata Disease) triggered by a tyrosine kinase inhibitor drug in a Latin American patient

Insulin autoimmune syndrome (Hirata Disease) triggered by a tyrosine kinase inhibitor drug in a Latin American patient