Abstract
For patients with chronic myelogenous leukemia who fail first-line therapy, several factors should be considered for the decision of the next treatment option. Second-generation tyrosine kinase inhibitors (TKIs) dasatinib, nilotinib, and bosutinib offer improved potency and a high likelihood of success for these patients. Overall, efficacy data are comparable for these agents, and so physicians should consider the BCR-ABL1 mutation profile and the patient’s history to make a decision on the best choice. Only a few BCR-ABL1 mutations seem to be less responsive to any of the three drugs, and it is recommended to choose the second-line TKI that has shown clinical activity against the specific mutation in these cases. For patients with all other mutations and for patients with no mutations, it is recommended to choose the second-generation TKI based on the patient’s disease history. The third-generation TKI ponatinib is available after dasatinib or nilotinib failure or for patients with T315I mutations. However, optimal dose of ponatinib is still under investigation. Overall, it is recommended to select a drug that minimizes the likelihood of worsening the patient’s past side effects or comorbid conditions. In any case, chance and risk of allogeneic stem cell transplantation should be compared with the long-term outcome of TKI therapy in patients eligible for this procedure.
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References
Hochhaus A, La Rosée P (2004) Imatinib therapy in chronic myelogenous leukemia: strategies to avoid and overcome resistance. Leukemia 18:1321–1331
Ernst T, Hochhaus A (2012) Chronic myeloid leukemia: clinical impact of BCR-ABL1 mutations and other lesions associated with disease progression. Semin Oncol 39:58–66
Hanfstein B, Müller MC, Hehlmann R, Erben P, Lauseker M, Fabarius A et al (2012) Early molecular and cytogenetic response is predictive for long-term progression-free and overall survival in chronic myeloid leukemia (CML). Leukemia 26:2096–2102
Jabbour E, Deininger M, Hochhaus A (2011) Management of adverse events associated with tyrosine kinase inhibitors in the treatment of chronic myeloid leukemia. Leukemia 25:201–210
Weisberg E, Manley PW, Cowan-Jacob SW, Hochhaus A, Griffin JD (2007) Second generation inhibitors of BCR-ABL for the treatment of imatinib-resistant chronic myeloid leukaemia. Nat Rev Cancer 7:345–356
Puttini M, Coluccia AM, Boschelli F, Cleris L, Marchesi E, Donella-Deana A et al (2006) In vitro and in vivo activity of SKI-606, a novel Src-Abl inhibitor, against imatinib-resistant Bcr-Abl+ neoplastic cells. Cancer Res 66:11314–11322
O’Hare T, Shakespeare WC, Zhu X, Eide CA, Rivera VM, Wang F et al (2009) AP24534, a pan-BCR-ABL inhibitor for chronic myeloid leukemia, potently inhibits the T315I mutant and overcomes mutation-based resistance. Cancer Cell 16:401–412
Lindauer M, Hochhaus A (2014) Dasatinib. Recent Results Cancer Res 201:27–65
Sprycel® (dasatinib) capsules [prescribing information]. Princeton, NJ: Bristol-Myers Squibb Company; 2014
Tokarski JS, Newitt JA, Chang CY, Cheng JD, Wittekind M, Kiefer SE et al (2006) The structure of dasatinib (BMS-354825) bound to activated ABL kinase domain elucidates its inhibitory activity against imatinib-resistant ABL mutants. Cancer Res 66:5790–5797
O’Hare T, Walters DK, Stoffregen EP, Jia T, Manley PW, Mestan J et al (2005) In vitro activity of Bcr-Abl inhibitors AMN107 and BMS-354825 against clinically relevant imatinib-resistant Abl kinase domain mutants. Cancer Res 65:4500–4505
Talpaz M, Shah NP, Kantarjian H, Donato N, Nicoll J, Paquette R et al (2006) Dasatinib in imatinib-resistant Philadelphia chromosome-positive leukemias. N Engl J Med 354:2531–2541
Hochhaus A, Kantarjian H (2013) The development of dasatinib as a treatment for chronic myeloid leukemia (CML): from initial studies to application in newly diagnosed patients. J Cancer Res Clin Oncol 139:1971–1984
Shah NP, Kantarjian HM, Kim DW, Réa D, Dorlhiac-Llacer PE, Milone JH (2008) Intermittent target inhibition with dasatinib 100 mg once daily preserves efficacy and improves tolerability in imatinib-resistant and intolerant chronic-phase chronic myeloid leukemia. J Clin Oncol 26:3204–3212
Shah NP, Kim DW, Kantarjian H, Rousselot P, Llacer PE, Enrico A (2010) Potent, transient inhibition of BCR-ABL with dasatinib 100 mg daily achieves rapid and durable cytogenetic responses and high transformation-free survival rates in chronic phase chronic myeloid leukemia patients with resistance, suboptimal response or intolerance to imatinib. Haematologica 95:232–240
Hochhaus A, Baccarani M, Deininger M, Apperley JF, Lipton JH, Goldberg SL (2008) Dasatinib induces durable cytogenetic responses in patients with chronic myelogenous leukemia in chronic phase with resistance or intolerance to imatinib. Leukemia 22:1200–1206
Quintás-Cardama A, Kantarjian H, Ravandi F, O’Brien S, Thomas D, Vidal-Senmache G et al (2009) Bleeding diathesis in patients with chronic myelogenous leukemia receiving dasatinib therapy. Cancer 115:2482–2490
Kantarjian HM, Giles FJ, Bhalla KN, Pinilla-Ibarz J, Larson RA, Gattermann N et al (2011) Nilotinib is effective in patients with chronic myeloid leukemia in chronic phase after imatinib resistance or intolerance: 24-month follow-up results. Blood 117:1141–1145
Gambacorti-Passerini C, Brümmendorf TH, Kim DW, Turkina AG, Masszi T, Assouline S et al (2014) Bosutinib efficacy and safety in chronic phase chronic myeloid leukemia after imatinib resistance or intolerance: Minimum 24-month follow-up. Am J Hematol 89:732–742
Kantarjian H, Pasquini R, Lévy V, Jootar S, Holowiecki J, Hamerschlak N et al (2009) Dasatinib or high-dose imatinib for chronic-phase chronic myeloid leukemia resistant to imatinib at a dose of 400 to 600 milligrams daily: two-year follow-up of a randomized phase 2 study (START-R). Cancer 115:4136–4147
Apperley JF, Cortes JE, Kim DW, Roy L, Roboz GJ, Rosti G et al (2009) Dasatinib in the treatment of chronic myeloid leukemia in accelerated phase after imatinib failure: the START A trial. J Clin Oncol 27:3472–3479
Cortes J, Kim DW, Raffoux E, Martinelli G, Ritchie E, Roy L et al (2008) Efficacy and safety of dasatinib in imatinib-resistant or intolerant patients with chronic myeloid leukemia in blast phase. Leukemia 22:2176–2183
Soverini S, Hochhaus A, Nicolini FE, Gruber F, Lange T, Saglio G et al (2011) BCR-ABL kinase domain mutation analysis in chronic myeloid leukemia patients treated with tyrosine kinase inhibitors: recommendations from an expert panel on behalf of European LeukemiaNet. Blood 118:1208–1215
Baccarani M, Deininger MW, Rosti G, Hochhaus A, Soverini S, Apperley JF et al (2013) European LeukemiaNet recommendations for the management of chronic myeloid leukemia: 2013. Blood 122:872–884
Mustjoki S, Auvinen K, Kreutzman A, Rousselot P, Hernesniemi S, Melo T et al (2013) Rapid mobilization of cytotoxic lymphocytes induced by dasatinib therapy. Leukemia 27:914–924
Weisberg E, Manley PW, Breitenstein W, Brüggen J, Cowan-Jacob SW, Ray A et al (2005) Characterization of AMN107, a selective inhibitor of native and mutant Bcr-Abl. Cancer Cell 7:129–141
Hochhaus A, La Rosée P, Müller MC, Ernst T, Cross NC (2011) Impact of BCR-ABL mutations on patients with chronic myeloid leukemia. Cell Cycle 10:250–260
Kantarjian H, Giles F, Wunderle L, Bhalla K, O’Brien S, Wassmann B et al (2006) Nilotinib in imatinib-resistant CML and Philadelphia chromosome-positive ALL. N Engl J Med 354:2542–2551
Giles FJ, le Coutre PD, Pinilla-Ibarz J, Larson RA, Gattermann N, Ottmann OG et al (2013) Nilotinib in imatinib-resistant or imatinib-intolerant patients with chronic myeloid leukemia in chronic phase: 48-month follow-up results of a phase II study. Leukemia 27:107–112
le Coutre P, Ottmann OG, Giles F, Kim DW, Cortes J, Gattermann N et al (2008) Nilotinib (formerly AMN107), a highly selective BCR-ABL tyrosine kinase inhibitor, is active in patients with imatinib-resistant or intolerant accelerated-phase chronic myelogenous leukemia. Blood 111:1834–1839
Giles FJ, Kantarjian HM, le Coutre PD, Baccarani M, Mahon FX, Blakesley RE et al (2012) Nilotinib is effective in imatinib-resistant or intolerant patients with chronic myeloid leukemia in blastic phase. Leukemia 26:959–962
Cortes JE, Hochhaus A, le Coutre PD, Rosti G, Pinilla-Ibarz J, Jabbour E et al (2011) Minimal cross-intolerance with nilotinib in patients with chronic myeloid leukemia in chronic or accelerated phase who are intolerant to imatinib. Blood 117:5600–5606
Kim TD, Rea D, Schwarz M, Grille P, Nicolini FE, Rosti G et al (2013) Peripheral artery occlusive disease in chronic phase chronic myeloid leukemia patients treated with nilotinib or imatinib. Leukemia 27:1316–1321
Giles FJ, Mauro MJ, Hong F, Ortmann CE, McNeill C, Woodman RC et al (2013) Rates of peripheral arterial occlusive disease in patients with chronic myeloid leukemia in the chronic phase treated with imatinib, nilotinib, or non-tyrosine kinase therapy: a retrospective cohort analysis. Leukemia 27:1310–1315
Redaelli S, Piazza R, Rostagno R, Magistroni V, Perini P, Marega M et al (2009) Activity of bosutinib, dasatinib, and nilotinib against 18 imatinib-resistant BCR/ABL mutants. J Clin Oncol 27:469–471
Cortes JE, Kantarjian HM, Brümmendorf TH, Kim DW, Turkina AG, Shen ZX et al (2011) Safety and efficacy of bosutinib (SKI-606) in chronic phase Philadelphia chromosome positive chronic myeloid leukemia patients with resistance or intolerance to imatinib. Blood 118:4567–4576
Khoury HJ, Cortes JE, Kantarjian HM, Gambacorti-Passerini C, Baccarani M, Kim DW et al (2012) Bosutinib is active in chronic phase chronic myeloid leukemia after imatinib and dasatinib and/or nilotinib therapy failure. Blood 119:3403–3412
Kantarjian HM, Cortes JE, Kim DW, Khoury HJ, Brümmendorf TH, Porkka K et al (2014) Bosutinib safety and management of toxicity in leukemia patients with resistance or intolerance to imatinib and other tyrosine kinase inhibitors. Blood 123:1309–1318
Hanaizi Z, Unkrig C, Enzmann H, Camarero J, Sancho-Lopez A, Salmonson T et al (2014) The European medicines agency review of bosutinib for the treatment of adult patients with chronic myelogenous leukemia: summary of the scientific assessment of the committee for medicinal products for human use. Oncologist 19:421–425
Zhou T, Commodore L, Huang WS, Wang Y, Thomas M, Keats J et al (2011) Structural mechanism of the Pan-BCR-ABL inhibitor ponatinib (AP24534): lessons for overcoming kinase inhibitor resistance. Chem Biol Drug Des 77:1–11
Cortes JE, Kim DW, Pinilla-Ibarz J, le Coutre P, Paquette R, Chuah C et al (2013) A phase 2 trial of ponatinib in Philadelphia chromosome-positive leukemias. N Engl J Med 369:1783–1796
Ernst T, La Rosée P, Müller MC, Hochhaus A (2011) BCR-ABL mutations in chronic myeloid leukemia. Hematol Oncol Clin N Am 25:997–1008
Hughes T, Saglio G, Branford S, Soverini S, Kim DW, Müller MC et al (2009) Impact of baseline BCR-ABL mutations on response to nilotinib in patients with chronic myeloid leukemia in chronic phase. J Clin Oncol 27:4204–4210
Müller MC, Cortes JE, Kim DW, Druker BJ, Erben P, Pasquini R et al (2009) Dasatinib treatment of chronic-phase chronic myeloid leukemia: analysis of responses according to preexisting BCR-ABL mutations. Blood 114:4944–4953
Hochhaus A (2011) Educational session: managing chronic myeloid leukemia as a chronic disease. Hematology Am Soc Hematol Educ Program 2011:128–135
Kantarjian HM, Cortes J, La Rosée P, Hochhaus A (2010) Optimizing therapy for patients with chronic myelogenous leukemia in chronic phase. Cancer 116:1419–1430
Jabbour E, Hochhaus A, Cortes J, La Rosée P, Kantarjian HM (2010) Choosing the best treatment strategy for chronic myeloid leukemia patients resistant to imatinib: weighing the efficacy and safety of individual drugs with BCR-ABL mutations and patient history. Leukemia 24:6–12
Quintás-Cardama A, Kantarjian H, O’Brien S, Borthakur G, Bruzzi J, Munden R, Cortes J (2007) Pleural effusion in patients with chronic myelogenous leukemia treated with dasatinib after imatinib failure. J Clin Oncol 25:3908–3914
Montani D, Bergot E, Günther S, Savale L, Bergeron A, Bourdin A et al (2012) Pulmonary arterial hypertension in patients treated by dasatinib. Circulation 125:2128–2137
Sano M, Saotome M, Urushida T, Katoh H, Satoh H, Ohnishi K, Hayashi H (2012) Pulmonary arterial hypertension caused by treatment with dasatinib for chronic myeloid leukemia -critical alert-. Intern Med 51:2337–2340
Dumitrescu D, Seck C, ten Freyhaus H, Gerhardt F, Erdmann E, Rosenkranz S (2011) Fully reversible pulmonary arterial hypertension associated with dasatinib treatment for chronic myeloid leukaemia. Eur Respir J 38:218–220
Tasigna (nilotinib) capsules [prescribing information]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2014
Porkka K, Khoury HJ, Paquette RL, Matloub Y, Sinha R, Cortes JE (2010) Dasatinib 100 mg once daily minimizes the occurrence of pleural effusion in patients with chronic myeloid leukemia in chronic phase and efficacy in unaffected in patients who develop pleural effusion. Cancer 116:377–386
Wang X, Roy A, Hochhaus A, Kantarjian HM, Chen TT, Shah NP (2013) Differential effects of dosing regimen on the safety and efficacy of dasatinib: retrospective exposure-response analysis of a Phase III study. Clin Pharmacol 5:85–97
Hehlmann R, Lauseker M, Jung-Munkwitz S, Leitner A, Müller MC, Pletsch N et al (2011) Tolerability-adapted imatinib 800 mg/d versus 400 mg/d versus 400 mg/d plus interferon-α in newly diagnosed chronic myeloid leukemia. J Clin Oncol 29:1634–1642
Deininger MW, Kopecky KJ, Radich JP, Kamel-Reid S, Stock W, Paietta E et al (2014) Imatinib 800 mg daily induces deeper molecular responses than imatinib 400 mg daily: results of SWOG S0325, an intergroup randomized PHASE II trial in newly diagnosed chronic phase chronic myeloid leukaemia. Br J Haematol 164:223–232
Hochhaus A (2014) Optimizing tolerability of TKI therapy in CML. Blood 123:1284–1285
La Rosée P, Martiat P, Leitner A, Klag T, Müller MC, Erben P et al (2013) Improved tolerability by a modified intermittent treatment schedule of dasatinib for patients with chronic myeloid leukemia resistant or intolerant to imatinib. Ann Hematol 92:1345–1350
Rousselot P, Mollica L, Etienne G, Bouchet S, Guerci A, Nicolini FE et al (2012) Pharmacologic monitoring of dasatinib as first line therapy in newly diagnosed chronic phase chronic myelogenous leukemia (CP-CML) identifies patients at higher risk of pleural effusion: a sub-analysis of the OPTIM-dasatinib trial. [abstract]. Blood 120:abstract 3770
Zabriskie MS, Eide CA, Tantravahi SK, Vellore NA, Estrada J, Nicolini FE et al (2014) BCR-ABL1 compound mutations combining key kinase domain positions confer clinical resistance to ponatinib in Ph chromosome-positive leukemia. Cancer Cell 26:428–442
Milojkovic D, Nicholson E, Apperley JF, Holyoake TL, Shepherd P, Drummond MW et al (2010) Early prediction of success or failure of treatment with second-generation tyrosine kinase inhibitors in patients with chronic myeloid leukemia. Haematologica 95:224–231
Stein AM, Martinelli G, Hughes TP, Müller MC, Beppu L, Gottardi E et al (2013) Rapid initial decline in BCR-ABL1 is associated with superior responses to second-line nilotinib in patients with chronic-phase chronic myeloid leukemia. BMC Cancer 13:173
Branford S, Kim DW, Soverini S, Haque A, Shou Y, Woodman RC et al (2012) Initial molecular response at 3 months may predict both response and event-free survival at 24 months in imatinib-resistant or intolerant patients with Philadelphia chromosome-positive chronic myeloid leukemia in chronic phase treated with nilotinib. J Clin Oncol 30:4323–4329
Jabbour E, le Coutre PD, Cortes J, Giles F, Bhalla KN, Pinilla-Ibarz J et al (2013) Prediction of outcomes in patients with Ph+ chronic myeloid leukemia in chronic phase treated with nilotinib after imatinib resistance/intolerance. Leukemia 27:907–913
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AH received research support from Novartis, BMS, Ariad, Pfizer and MSD.
All other authors do not declare any conflict of interest.
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Hochhaus, A., Ernst, T., Eigendorff, E. et al. Causes of resistance and treatment choices of second- and third-line treatment in chronic myelogenous leukemia patients. Ann Hematol 94 (Suppl 2), 133–140 (2015). https://doi.org/10.1007/s00277-015-2323-1
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DOI: https://doi.org/10.1007/s00277-015-2323-1