Identifying molecular markers that predict relapse after therapy discontinuation inchronic myeloid leukemia.

识别预测慢性粒细胞白血病治疗停止后复发的分子标记。

• 批准号: 10291794
• 负责人: Elizabeth Ann Eklund
• 金额: --
• 依托单位: JESSE BROWN VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-04-01 至 2023-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10291794
• 关键词: Adult; Aftercare; Apoptosis; Blast Phase; Bone Marrow; Bone Marrow Cells; Bone Marrow Diseases; Bone Marrow Transplantation; Calpain; Cells; Characteristics; Chronic; Chronic Myeloid Leukemia; Chronic Phase; Clinical; Clinical Practice Guideline; Clinical Trials; Development; Disease remission; Elderly; Future; Generations; Genes; Goals; Guidelines; Healthcare Systems; Human; Imatinib; In complete remission; Incidence; Individual; Innate Immune Response; Malignant - descriptor; Modeling; Molecular; Mus; Mutation; Myeloid Leukemia; National Comprehensive Cancer Network; Newly Diagnosed; Ontology; Outcome; Pathway interactions; Patients; Population; Production; Prognostic Marker; Regulation; Relapse; Research Personnel; Resistance; Ribonucleases; Sampling; Secondary to; Signal Transduction; Transcript; Translating; Transplantation; Tyrosine Kinase Inhibitor; abl Oncogene; calpain inhibitor; cellular transduction; cost; cytokine; discontinuation study; follow-up; fusion gene; glycogen synthase kinase 3 beta inhibitor; inhibitor/antagonist; interest; leukemic stem cell; middle age; molecular marker; mouse model; patient derived xenograft model; pre-clinical; preclinical study; prevent; relapse patients; relapse prediction; relapse risk; response; side effect; single-cell RNA sequencing; standard of care; survivin; therapeutic target; tool; transcriptome; transcriptome sequencing; transplant model

Clinical outcomes in chronic myeloid leukemia (CML) were revolutionized by development of imatinib (IM) and later generation tyrosine kinase inhibitors (TKIs) that target the Bcr-abl oncogene. Currently, ~55% patients with newly diagnosed CML achieve a major molecular response to TKI treatment (MMR) and 17% a complete molecular response (CMR). Because CML patients survive many years, there is interest in identifying those who can discontinue treatment. This interest is encouraged by the 30% incidence of side effects in during long term TKI therapy and the substantial costs of chronic TKI treatment to patients and healthcare systems. Unfortunately, ~60% of subjects with sustained MMR/CMR relapsed after TKI discontinuation in several clinical trials. Given favorable rates results of TKI re-induction with after relapse, a therapy discontinuation attempt is a part of the National Comprehensive Cancer Network (NCCN) guidelines for patients with prolonged CMR. These discontinuation studies suggest some leukemia stem cells (LSCs) persist in remission. Persistent LSCs do not have mutation or duplication of the BCRABL fusion gene, as is seen with overt TKI resistance, but provide a reservoir of cells susceptible to acquiring such mutations, or those leading to blast crisis (BC). Current clinical tools are inaccurate in predicting the likelihood of relapse vs sustained remission post TKI discontinuation. We developed a murine bone marrow transplantation model to define characteristics associated with successful TKI discontinuation. In this model, primary recipients of Bcr-abl transduced syngeneic bone marrow (in chronic phase; CP) were donors to secondary recipients. Secondary recipients were treated with TKIs + other agents, and mice with an MMR were donors for tertiary recipients. Tertiary recipients were followed without treatment. We found a 64% relapse rate in recipients of bone marrow from mice with IM-induced MMR that did not correlate with number of Bcr-abl+ cells from the treated donors or Bcr-abl transcript copies/cell. In prior studies, we found increased expression of Fap1 (a Fas and Gsk3β inhibitor) contributed to Fas resistance and βcatenin/survivin activity in CML-LSCs. We found that the addition of an inhibitor of Fap1 or survivin to IM treatment prevented relapse in Bcr-abl+ bone marrow recipients. Importantly, no tertiary recipients of bone marrow from IM + Fap1 or survivin inhibitor treated mice relapsed over 24 wks of observation (equivalent to 15+ human years). We found a 50x increase Bcr-abl transcript copies/GFP+ cell in the bone marrow of mice treated with IM vs IM + Fap1 or survivin inhibitor. This reflected differences in bone marrow populations in these mice. In transcriptome analysis of bone marrow from mice treated with TKI + a survivin inhibitor, we identified differences in pathways involved in positive regulation of the innate immune response, NOD-like signaling, cytokine production, and regulation of ribonuclease activity. We hypothesize that identifying pathways which are associated with relapse will permit selection of CML subjects able to safely discontinue treatment. Such pathways may be rationale therapeutic targets to permit more subjects to discontinue treatment, or regain an MMR. We will investigate this through two Aims; Aim 1: Identify molecular markers associated with relapse in CMR-CML patients undergoing a therapy discontinuation attempt. TKI treatment will be discontinued per NCCN guidelines. A clinical trial will correlate molecular markers in the subject’s bone marrow with relapse vs sustained therapy free remission. Aim 2: Define characteristics that predispose to relapse after TKI discontinuation in a murine CML model. We will investigate molecular mechanisms predisposing to relapse after TKI discontinuation in patient derived xenografts or murine bone marrow transplants. Implicated pathways will be targeted in pre-clinical studies. In these studies, we employ a pre-clinical murine model to study TKI discontinuation. Results will be translated to inform studies in human CML subjects. The goal is to identify pathways associated with relapse after TKI discontinuation as prognostic indicators and potential future therapeutic targets.

伊马替尼 (IM) 的开发彻底改变了慢性粒细胞白血病 (CML) 的临床结果 以及针对 Bcr-abl 癌基因的新一代酪氨酸激酶抑制剂 (TKI)。目前，约 55% 的患者 新诊断的 CML 患者对 TKI 治疗 (MMR) 产生主要分子反应，并且 17% 的患者达到完全缓解 分子反应（CMR）。由于 CML 患者可以存活很多年，因此人们有兴趣确定那些 可以停止治疗。长期治疗期间 30% 的副作用发生率鼓励了这种兴趣 TKI 治疗以及长期 TKI 治疗给患者和医疗保健系统带来的巨额费用。很遗憾， 在多项临床试验中，约 60% 持续 MMR/CMR 的受试者在 TKI 停用后复发。给定 复发后 TKI 重新诱导的良好结果，尝试停止治疗是治疗的一部分 国家综合癌症网络 (NCCN) 针对 CMR 延长患者的指南。 这些停药研究表明一些白血病干细胞（LSC）持续缓解。执着的 LSC 没有 BCRABL 融合基因的突变或重复，如明显的 TKI 耐药性所见，但 提供易于获得此类突变或导致急变危机（BC）的细胞库。当前的 临床工具在预测 TKI 停药后复发与持续缓解的可能性方面并不准确。 我们开发了一种小鼠骨髓移植模型来定义与 TKI 成功停药。在此模型中，Bcr-abl 转导的同基因骨髓的主要受体 （慢性期；CP）是次要受者的捐赠者。次要接受者接受 TKI + 其他治疗 试剂和具有 MMR 的小鼠是第三级受体的供体。第三次接受者的跟踪没有 治疗。我们发现，IM 诱导的 MMR 小鼠骨髓受者的复发率为 64% 与来自治疗供体的 Bcr-abl+ 细胞数或 Bcr-abl 转录本拷贝/细胞数不相关。 在之前的研究中，我们发现 Fap1（一种 Fas 和 Gsk3β 抑制剂）的表达增加有助于 Fas CML-LSC 中的耐药性和 β 连环蛋白/生存素活性。我们发现添加 Fap1 或 生存素 IM 治疗可预防 Bcr-abl+ 骨髓受者的复发。重要的是，没有第三次接收者 IM + Fap1 或生存素抑制剂治疗小鼠的骨髓在 24 周观察后复发（相当于 到 15 岁以上）。我们发现小鼠骨髓中的 Bcr-abl 转录本拷贝数/GFP+ 细胞增加了 50 倍 IM 治疗与 IM + Fap1 或生存素抑制剂治疗。这反映了这些人骨髓种群的差异 老鼠。在对接受 TKI + 生存素抑制剂治疗的小鼠的骨髓进行转录组分析时，我们发现 参与先天免疫反应正向调节、NOD 样信号传导、 细胞因子的产生和核糖核酸酶活性的调节。 我们假设确定与复发相关的途径将允许选择 CML 受试者能够安全地停止治疗。这些途径可能是合理的治疗靶点，以允许更多 受试者停止治疗，或恢复 MMR。我们将通过两个目标对此进行调查； 目标 1：识别与接受治疗的 CMR-CML 患者复发相关的分子标志物 中止尝试。根据 NCCN 指南，TKI 治疗将停止。临床试验将关联 复发与持续无治疗缓解的受试者骨髓中的分子标记。 目标 2：定义小鼠 CML 模型中 TKI 停用后易复发的特征。 我们将研究源自患者的 TKI 停用后易复发的分子机制 异种移植或鼠骨髓移植。临床前研究将针对相关途径。 在这些研究中，我们采用临床前小鼠模型来研究 TKI 停药。结果将是 翻译为人类 CML 受试者的研究提供信息。目标是确定与复发相关的途径 TKI 停用后作为预后指标和潜在的未来治疗目标。