新型抗肿瘤药物依曼替尼布

依曼替尼布是一种新型的 2 苯胺基嘧啶类酪氨酸激酶抑制药 ,用于α 干扰素治疗失败后的慢性髓样白血病 (CML)慢性期病人、加速期病人、急变期病人的治疗。临床研究表明该药对病人血液学缓解及主要细胞分化缓解显著     

半定量RT—PCR检测JWA基因在慢性粒细胞性白血病的表达

目的 探讨JWA基因表达与慢性粒细胞性白血病（CML）的相关意义。方法 应用半定量RT-PCR技术检测26例CML患者骨髓和/或外周血JWA基因的表达。结果 JWA基因表达在CML慢性期高达15/18例;而急变期（含加速期）为2/8例。结论 JWA基因的下调可能与CML急变的某个过程相关,具体机制仍有待进一步研究。     

Nilotinib

Nilotinib is an orally administered BCR-ABL tyrosine kinase inhibitor that has shown good clinical efficacy in imatinib-resistant or -intolerant, Philadelphia chromosome-positive, chronic myeloid leukaemia (CML) in a phase I/II trial. The phase I component of the trial established the dosage regimen used in the phase II part of the trial, which included several arms. Three of these arms, or phase II trials, evaluated nilotinib in each of the three phases of CML (chronic, accelerated or blast crisis).I n the phase II trial in patients with chronic-phase CML, major cytogenetic response (primary endpoint) was achieved in 48% of the 280 patients who received nilotinib and had a follow-up period of > or = 6 months. Major cytogenetic response rates did not differ between imatinib-resistant and -intolerant patients, and nilotinib was effective in patients with BCR-ABL mutations (except T315I). Haematologic response rate (primary endpoint) was 47% in the phase II trial with nilotinib in patients with accelerated-phase CML (n = 119). Complete haematologic response was achieved in 26% of patients and 21% had no evidence of leukaemia or returned to chronic-phase CML. Major cytogenetic response, an important secondary endpoint in the trial, occurred in 29% of patients. Data from the phase II trial in patients with CML in blast crisis (n = 135) also showed promising results, with 39% of patients achieving haematologic response with nilotinib. Adverse events reported with nilotinib have generally been of mild to moderate severity. Grade 3 or 4 neutropenia and thrombocytopenia were reported in 29% of patients each.     

应用实时定量PCR技术检测慢性粒细胞白血病患者bcr/ablP190融合基因转录本

目的研究bcr/ablP190融合基因转录本在慢性粒细胞白血病(CML)中表达水平及其临床相关性.方法应用实时定量聚合酶链反应(RQ-PCR)检测74例CML患者骨髓单个核细胞中的bcr/ablP190转录本.结果 bcr/ablP190转录本阳性54例(77.1%),中位含量2.60(1.08～8.58)×10-3,与性别、年龄、白细胞总数、血红蛋白含量、血小板计数、bcr/ablP210转录本类型和表达水平均不相关,但bcr/ablP190阳性患者的白细胞总数和血小板计数较阴性者明显降低.bcr/ablP190转录本水平在急变期与慢性期患者以及不同类型急变患者中都无差异,而细胞遗传学完全缓解患者的bcr/ablP190水平较慢性期患者、干扰素无效患者和急变期患者则明显下降.结论不同阶段CML患者体内大都存在着不同的bcr/abl剪切型转录本,不同剪切型的存在具有一定的血液学相关性.     

慢性粒细胞白血病骨髓磁共振成像表现及临床应用分析

目的探讨慢性粒细胞白血病(chronicmyeloid leukemia,CML)骨髓磁共振成像(MRI)表现及临床价值。方法收集成人CML50例,其中初诊慢性期患者16例,治疗后病情稳定于慢性期者18例,病情发展到加速期者7例,发生急性变者9例。所有患者均行骨盆及股骨中上段MRI检查。结果初诊慢性期及进展到加速和急变期的患者SE序列T1WI表现为髂骨及股骨骨髓弥漫性低信号或仅有在股骨头、大转子处残留斑片状高信号。治疗后维持在慢性期的患者SE序列T1WI表现为髂骨弥漫性低信号为主,夹杂点片状高信号,股骨主要表现为高低混杂信号。初诊慢性期组与治疗后组、治疗后组与加速急变组MRI表现差异有统计学意义(P<0.01);初诊慢性期组与加速急变期组差异无统计学意义(P>0.05)。结论CML患者骨髓MRI能反映其病程演变,与临床特点结合,有助于CML的诊断分期,对监测病情发展、提示加速和急变有重要价值。     

Current treatment concepts of CML

The elucidation of the triggering molecular mechanism of chronic myeloid leukemia gave rise to the development of imatinib, a tyrosine kinase inhibitor and a prototype of target-oriented drugs. Imatinib led to impressing response and survival rates and now represents the standard therapy of CML. However, a significant proportion of patients do not tolerate or fail to respond to imatinib treatment. Alternative therapies can be offered to those patients. The particular challenge of CML patient management is to recognize an impending imatinib failure by adequate surveillance and to know about therapeutic options to prevent progression of the disease to accelerated phase or blast crisis since these are more difficult to control. Targeted therapy with second-generation tyrosine kinase inhibitors should be used in synopsis with mutational analysis and the patients' history. In this review we present current knowledge of diagnosis, monitoring and therapy strategies of patients with CML.     

IgH/TCR基因重排与EB病毒原位杂交联合分析在淋巴瘤诊断中的应用

目的：探讨免疫球蛋白重链/T细胞受体（IgH/TCR）基因重排检测联合EB病毒（EBV）原位杂交在淋巴瘤诊断中的应用,分析EBV＋-B细胞淋巴瘤的细胞学及基因组学特征、鉴别诊断要点,以缩短诊断时间,减少误诊。方法采用IgH/TCR基因重排与EB原位杂交联合分析诊断EBV＋-B细胞淋巴瘤1例,分析其免疫组化特征、EBV原位杂交、基因重排结果。结果 EBV＋-B细胞淋巴瘤临床上主要表现为淋巴结增大,常伴骨髓和外周血浸润。淋巴结活检显示其结构破坏,淋巴滤泡减少,淋巴结高度增生性病变,可见轻至中度异型淋巴细胞,淋巴窦扩张,组织细胞增生。免疫组化证实EBV感染的细胞毒性B细胞构成病变主体;EBV原位杂交显示部分淋巴细胞核阳性;基因重排提示IgH、免疫球蛋白轻链（Igκ）基因发生克隆性重排,TCRγ无克隆性重排。结论 EBV＋-B细胞淋巴瘤从形态学上难以与伯基特淋巴瘤、慢性淋巴细胞白血病等淋巴瘤区分,早期诊断困难。联合应用IgH/TCR基因重排与EBV原位杂交技术对EBV＋-B细胞淋巴瘤的诊断有较高准确性。     

伊马替尼治疗Ph染色体阳性慢性粒细胞白血病的临床观察

目的:评价酪氨酸激酶抑制剂伊马替尼治疗Ph染色体阳性慢性粒细胞白血病的有效性及安全性。方法:90例慢性粒细胞白血病患者,其中慢性期67例,非慢性期23例(加速期14例,急变期9例),每天应用剂量分别为400,600mg。每周复查血常规,每3个月进行骨髓象及细胞遗传学检查,根据血象和骨髓象调整剂量。结果:观察截止时,84例(93.3%)获得血液学完全缓解;68例可评价遗传学效应,35例(51.5%)发生主要遗传学效应(慢性期30例,加速期3例,急变期2例),其中31例(88.6%)为遗传学完全缓解(慢性期27例,加速期2例,急变期2例)。11例(12.2%)患者发生严重白细胞和/或血小板减少,但可通过调整剂量控制。严重非血液学不良反应发生较少。结论:伊马替尼治疗Ph染色体阳性慢性粒细胞白血病患者疗效较好,可获得较高的完全血液学缓解率和主要细胞遗传学缓解率,起效迅速,且不良反应较少,可耐受或自行消失。     

Imatinib.

Imatinib inhibits the BCR-ABL tyrosine kinase created by the Philadelphia chromosome (Ph+) in chronic myeloid leukaemia (CML). Complete haematological responses were achieved in 88% of patients and major cytogenetic responses were detected in 49% of patients with chronic phase CML treated with oral imatinib 400 mg/day in a multicentre noncomparative study of 532 patients. Administration of oral imatinib 400 or 600 mg/day to 235 patients with accelerated phase CML in a multicentre noncomparative study resulted in haematological responses in 63% of patients and major cytogenetic responses in 21% of patients. 26% of the 260 patients with blast crisis CML receiving imatinib 400 or 600 mg/day in a multicentre noncomparative trial sustained a haematological response and 13.5% of patients had a major cytogenetic response. Imatinib 400 or 600 mg/day orally achieved ahaematological response in 19 of 32 patients with Ph+ acute lymphoblastic leukaemia in a pilot study. Clinical improvement was demonstrated in 89% of 36 patients with gastrointestinal stromal tumours unresponsive to standard chemotherapy during treatment with 400 or 600 mg/day oral imatinib in a noncomparative phase II trial. Adverse events were frequent in clinical trials of imatinib but most events were mild or moderate in severity. Serious adverse events reported include severe fluid retention, cytopenias and hepatotoxicity.     

Imatinib activity in vitro in tumor cells from patients with chronic myeloid leukemia in chronic phase and blast crisis

The aims of this study were to evaluate the feasibility of using the non-clonogenic fluorometric microculture cytotoxicity assay in drug sensitivity testing of tumor cells from patients with chronic myeloid leukemia. In nine samples (six chronic phase, three blast crisis), the drug sensitivities in tumor cells from blood versus from bone marrow and fresh tumor cells versus cryopreserved were compared. In 26 samples obtained in chronic phase (pretreatment), in six samples from patients in blast crisis and in the K 562 cell line, the activity of imatinib alone and in combination with cytarabine, vincristine, daunorubicin, interferon, arsenic trioxide and homoharringtonine was evaluated. All chronic myeloid leukemia chronic phase samples were sensitive to imatinib, with a mean IC50 at 10.3 mumol/l. The chronic myeloid leukemia samples from blast crisis (n=6) were significantly more sensitive to imatinib than the samples from chronic phase (n=26) (P<0.05), with an IC50 mean at 0.4 mumol/l. In blast crisis samples, significant positive interaction effects were observed between imatinib and all other tested drugs except for interferon. In chronic phase samples, interferon, daunorubicin and arsenic trioxide were the drugs with the highest frequency of positive interactions with imatinib (P<0.05). We conclude that the fluorometric microculture cytotoxicity assay may be a useful method for drug sensitivity testing in chronic myeloid leukemia patient samples from both chronic phase and blast crisis, and that testing primary tumor cells may have advantages over cell line studies. Imatinib shows a higher in vitro activity and more positive drug interactions in cells from blast crisis than chronic phase chronic myeloid leukemia patients. Combinations between imatinib and interferon, daunorubicin and arsenic trioxide may be interesting for future clinical trials in patients with chronic myeloid leukemia chronic phase.     

Imatinib: new preparation. For Chronic myeloid leukaemia: further assessment required

(1) Chronic myeloid leukaemia goes through three clinical phases: a chronic phase, an acceleration phase, and a terminal blast crisis. In the chronic phase, interferon alfa-2 is more effective than cytotoxic chemotherapies but it also has more adverse effects. (2) Imatinib inhibits tyrosine kinase, an enzyme encoded by the pathological gene BCR-ABL, which is created during a reverse translocation between chromosomes 9 and 22 (characteristic of chronic myeloid leukaemia). This translocation almost always creates the pathological chromosome Philadelphia in blood cell lines. (3) 1 027 patients were recruited to three non comparative trials of imatinib, each focusing on a different phase of chronic myeloid leukaemia. Efficacy was evaluated largely on the basis of blood cell count and clearance of cells harbouring the Philadelphia chromosome. (4) During the chronic phase, in patients in whom interferon alfa-2 had failed or been poorly tolerated, a major cytogenetic response, lasting at least one month, occurred in 35% of patients on imatinib, compared to 20% of patients on interferon alfa-2 + cytarabine (historical comparison). It is not known whether this translated into longer survival. (5) Preliminary results from a randomised but unblinded trial comparing imatinib with interferon + cytarabine seem to favour imatinib. Some patients developed relapses resistant to imatinib, owing to mutations in the BCR-ABL gene. (6) In patients going through the acceleration phase or blast crisis, imatinib did not improve survival compared with standard treatments. (7) The main adverse effects so far described with imatinib are gastrointestinal problems, oedema and fluid retention, and muscle and joint pain, which prompted patients to stop treatment in no more than 5% of cases. (8) Imatinib has a strong potential to interact with other drugs, including paracetamol, but few specific studies have been done. (9) In practice imatinib may be a useful option during the chronic phase, after interferon alfa-2 has failed or been stopped because of adverse effects, provided that its benefits, so far shown only in surrogate endpoints, translate into longer survival. During the acceleration phase and blast crisis imatinib may cause fewer side effects than existing treatments.     

慢性粒细胞白血病bcr-abl融合基因克隆与真核细胞表达的研究

目的 为研究慢性粒细胞白血病(CML)的肿瘤基因疫苗，克隆和表达CML的bcr—abl融合基因片段。方法 根据bcr—abl(b3a2)融合基因序列自行设计一对寡核苷酸引物，以CML K562细胞株的总RNA为模板，通过RT—PCR扩增包含bcr-abl融合位点周围450bp的基因片段，并将其克隆进pGEM—T easy载体。经序列测定证实其阅读框架正确后，将bcr—abl融合基因片段正向插入真核细胞表达载体pcDNA3．1。以脂质体介导重组质粒pcDNAbcr—abl转染中国仓鼠卵巢(CHO)细胞，用间接免疫荧光法(IFA)检测基因表达情况。结果 成功构建了包含融合位点基因片段的bcr—abl融合基因真核细胞表达载体pcDNAbcr—abl，pcDNAbcr—abl转染的CHO细胞的免疫荧光强度高于K562阳性对照细胞。结论 bcr—abl融合基因片段在真核细胞中能高效表达，pcDNAbcr—abl真核细胞表达载体的构建为进一步研究bcr—abl融合基因在CML防治中的作用奠定了基础。     

慢性粒细胞白血病bcr/abl基因检测在造血干细胞移植过程中的临床意义

目的探讨慢性粒细胞白血病（CML）bcr/abl基因检测的临床意义,以及移植后治疗效果及预后监测等方面的价值。了解慢性粒细胞白血病融合基因表达、染色体改变及细胞学的改变与临床诊断和治疗的关系。方法采用实时定量逆转录-聚合酶链反应（RT-PCR）检测15例CML患者移植前、后bcr/abl融合基因的表达;染色体制备采用骨髓短期培养法,G显带,分析核型。结果对照组bcr/abl基因表达、Ph染色体均为阴性;15例患者移植前：bcr/abl基因表达阳性率为100%（15/15）,表达量范围4.7×104～3.2×108copies/L;Ph染色体分析结果中,13例为Ph（＋）/bcr（＋）,2例为Ph（-）/bcr（＋）。细胞学分析结果 ：呈CML的细胞学改变。移植后1个月bcr/abl融合基因转阴率为80%,2个月转阴率达93%,3个月转阴率达100%。Ph染色体均为阴性。另外,0.5～3年内有13%（2/15）的患者bcr/abl基因表达呈阳性,6%（1/15）的患者Ph（＋）,有复发的阳性指标。结论 bcr/abl基因表达水平的定量检测及动态观察,对CML的临床诊断、移植后疗效判断及预后的监测具有重要意义.     

髓系白血病患者骨髓单个核细胞β-连环蛋白mRNA的表达

目的观察急慢性髓系白血病患者骨髓单个核细胞β-连环蛋白的表达及其意义。方法 41例髓系白血病患者,其中25例急性髓系白血病（AML）,16例慢性髓系白血病（CML）。同时选择18例非恶性血液病患者作为对照。肝素抗凝骨髓2 ml,Ficoll液分离骨髓单个核细胞,荧光定量逆转录聚合酶链反应法检测β-连环蛋白的表达。结果β-连环蛋白在AML组表达量明显高于CML组及对照组（P〈0.01）;CML组表达量高于对照组表达量,差异有统计学意义（P〈0.05）;CML组4例急变患者的β-连环蛋白表达量也较高。β-连环蛋白表达量与患者年龄、性别无关;与骨髓原始细胞含量有关,含量≥30%的患者β-连环蛋白表达量较高。结论β-连环蛋白在AML和CML急变的患者骨髓单个核细胞中异常高表达,Wnt/β-连环蛋白通路在AML和CML急变病例中异常激活可能与白血病细胞的异常增殖有关。     

Molecular pathogenesis of Philadelphia-positive chronic myeloid leukemia - is it all BCR-ABL?

CML is characterized by the presence of the Philadelphia chromosome, which is the product of a reciprocal translocation between chromosomes 9 and 22 that results in the formation of BCR-ABL1. Apart from its diagnostic importance in CML patients BCR-ABL1 it is a potent oncogene. The natural evolution of CML is to progress into accelerated phase and blast crisis after a rather indolent chronic phase. Clinical experience shows that long term remissions can be achieved at a high rate at least in chronic phase by specific inhibition of BCR-ABL1. This underlines the importance of BCR-ABL1 at this stage of the disease. However, in accelerated phase and blast crisis the effect of these substances is of inferior importance as relapses are the rule rather than the exception. Treatment failure in advanced disease is frequent in patients without detectable resistance mechanisms such as BCR-ABL1-mutations, which suggests that the previously BCR-ABL1 dependent pathways probably become autonomous. Such pathways include signal transduction as well as DNA damage surveillance and repair. Especially the latter appear to be crucial for disease progression by causing genetic instability, accumulation of mutations and additional chromosomal alterations leading to the loss of tumor suppressors. How is BCR-ABL1 organized on the genetic level, is there a genetic precursor lesion as discussed for Philadelphia-negative myeloproliferative diseases, what is its role in pathogenesis and progression of CML and what is its role in the CML-stem cell? These questions will be discussed in this review.     

Cardiac tamponade in the blastic crisis of chronic myelogenous leukemia.

A 36-year-old man with Philadelphia chromosome-positive chronic myelogenous leukemia (CML) developed hemorrhagic pericarditis with tamponade as a terminal manifestation of the blastic crisis. Cardiac tamponade should be kept in mind as an uncommon cause of death of CML patients. Based on a literature review, symptomatic pericarditis in patients with CML blast crisis suggests imminent death. This is in contrast to long-term survival for patients in the chronic phase.     

Ph~+急性淋巴细胞白血病与慢性粒细胞白血病急淋变的比较研究

目的探讨Ph染色体阳性急性淋巴细胞白血病(Ph+ALL)与慢性粒细胞白血病急淋变的临床特点。方法对21例Ph+ALL患者及31例慢粒急淋变患者的临床资料进行回顾性对比分析。结果 Ph+ALL与慢粒急淋变有以下区别:①慢粒急淋变肝脾肿大发生率(80.65%)比Ph+ALL(14.28%)高(P<0.05);②起病时慢粒急淋变外周血白细胞数比Ph+ALL高(P<0.05);③Ph+ALL完全缓解率(76.19%)比慢粒急淋变(48.39%)高(P<0.05)。Ph+ALL的中位生存期为(10.76±6.91)个月,而慢粒急淋变的中位生存期为(7.06±6.03)个月,差异有统计学意义(P<0.05)。慢粒急淋变者完全缓解后Ph染色体持续存在,Ph+ALL患者完全缓解后Ph染色体消失。两组患者年龄、性别、骨髓中原始加幼稚细胞数差异均无统计学意义(P>0.05)。结论 Ph+ALL与慢粒急淋变具有不同的临床特点及治疗反应。     

Evolutionary Dynamics of Chronic Myeloid Leukemia Progression: the Progression-Inhibitory Effect of Imatinib

The t(9;22) translocation that causes chronic myeloid leukemia (CML) drives both transformation and the progression process that eventually results in the disease changing to acute leukemia. Constitutively activated Bcr-Abl signaling in CML creates high levels of reactive oxygen species (ROS) that produce 8-oxo-guanine in DNA; this is mutagenic and causes chronic phase (CP) progression to blast phase (BP). We modeled three types of mutations involved in this progression: mutations that result in myeloid progenitor cells proliferating independently of external growth factors; mutations causing failure of myeloid progenitor cells to differentiate; and mutations that enable these cells to survive independently of attachment to marrow stroma. We further modeled tyrosine kinase inhibitors (TKI) as restoring myeloid cell apoptosis and preventing ROS-driven mutagenesis, and mutations that cause TKI resistance. We suggest that the unusually low rate of resistance to TKI arises because these drugs deplete ROS, which in turn decrease mutation rates.     

Tyrosine kinase inhibitor as a therapeutic drug for chronic myelogenous leukemia and gastrointestinal stromal tumor

The Philadelphia chromosome found in leukemia cells of chronic myelogenous leukemia (CML) patients is produced by translocation between chromosomes 9 and 22, resulting in expression of a chimera protein of Bcr and Abl kinase in the cytoplasm. Bcr-Abl kinase attracted oncology researchers as a molecular target for CML therapy, and a variety of small Abl kinase inhibitors were synthesized. STI571 (imatinib mesylate) was produced by modification of 2-phenylaminopyrimidine, a core structure of protein kinase C inhibitor, to improve selectivity, stability, solubility, and bioavailability. STI571 competitively binds to the ATP binding site of Bcr-Abl kinase and inhibits Abl tyrosine kinase activity. STI571 showed significant efficacy in the clinical study with CML patients at all stages: chronic phase, accelerated phase, and blast crisis. More than 90% of the patients showed good hematologic response to STI571. STI571 is also a potent inhibitor of a receptor-type c-Kit tyrosine kinase. Therefore, STI571 was examined for therapeutic efficacy against malignant Gastro-Intestinal Stromal Tumors (GIST), which are mainly caused by aberrant expression of a mutated c-Kit that is constitutively active without binding of a ligand, stem cell factor (SCF). More than a half of the metastatic GIST patients enrolled in the clinical study responded to STI571. Thus, STI571 is now used as a therapeutic drug for both CML and GIST in more than 80 countries worldwide. Certain point mutations in the ATP binding site were found to be a cause of resistance to STI571 in both Bcr-Abl and c-Kit kinases. Therefore, it would be better to make a precise therapeutic strategy with STI571 based on the gene analysis data. It is also expected that it will be possible to design an inhibitor to overcome such resistance by using the structural information on the mutants.     

Dasatinib: an anti-tumour agent via Src inhibition

Dasatinib (BMS-354825, Sprycel?) is an oral, multitargeted inhibitor of receptor tyrosine kinases (RTKs), including BCR-ABL fusion protein, stem cell factor receptor (c-KIT), platelet-derived growth factor receptor (PDGFR), and Src family kinases (SFKs). Several early- and late-phase clinical trials for chronic myelogeneous leukaemia (CML) have demonstrated the direct inhibition of BCR-ABL fusion protein and SFKs, which led to dasatinib approval by the Food and Drug Administration (FDA) and the European Union for the treatment of imatinib-resistant or -intolerant CML, and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL). Phase III dose-optimization study was performed to compare different regimens, stating that dasatinib 100 mg once daily is now the recommended schedule for patients with chronic CML, and 140 mg once daily for patients with accelerated phase or myeloid or lymphoid blast phase CML, and for patients with Ph+ ALL until progression. Because of the myriad of critical roles of SFKs in biological processes, SFKs inhibition could induce numerous biological responses. Ongoing clinical trials evaluate dasatinib in the treatment of several solid tumours, including gastrointestinal stromal tumours (GIST), prostate cancer, malignant pleural mesothelioma, sarcomas, NSCLC, colorectal cancer, glioblastoma and other haematologic malignancies as multiple myeloma. Ongoing pre-clinical studies assess the therapeutic potential of dasatinib in other solid tumours, including melanoma, head and neck cancer, breast cancer and ovarian cancer. Dasatinib is generally well tolerated. Myelosuppression is the common adverse event which is, however, reversible by dose reduction, discontinuation, or interruption. Thrombocytopenia is more significant than neutropenia and associated to gastrointestinal bleeding and CNS haemorrhage. The most common non-haematologic adverse events include gastrointestinal symptoms (diarrhoea, nausea, vomiting, abdominal pain and anorexia), headache, peripheral edema, and pleural effusion. In respect of these encouraging studies investigating dasatinib in the treatment of patients with GIST, prostate cancer, multiple myeloma and sarcomas, ongoing phase III clinical trials warrant the drug evaluation as recommended agent for the treatment of these diseases, also in association with chemotherapy or other targeted therapies.