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Acute Leukemias

Azacitidine fails to eradicate leukemic stem/progenitor cell populations in patients with acute myeloid leukemia and myelodysplasia

Leukemia volume 27, pages 1028–1036 (2013)Cite this article

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Abstract

Epigenetic therapies demonstrate significant clinical activity in acute myeloid leukemia (AML) and myelodysplasia (MDS) and constitute an important new class of therapeutic agents. However hematological responses are not durable and disease relapse appears inevitable. Experimentally, leukemic stem/progenitor cells (LSC) propagate disease in animal models of AML and it has been postulated that their relative chemo-resistance contributes to disease relapse. We serially measured LSC numbers in patients with high-risk AML and MDS treated with 5'-azacitidine and sodium valproate (VAL–AZA). Fifteen out of seventy-nine patients achieved a complete remission (CR) or complete remission with incomplete blood count recovery (CRi) with VAL–AZA therapy. There was no significant reduction in the size of the LSC-containing population in non-responders. While the LSC-containing population was substantially reduced in all patients achieving a CR/CRi it was never eradicated and expansion of this population antedated morphological relapse. Similar studies were performed in seven patients with newly diagnosed AML treated with induction chemotherapy. Eradication of the LSC-containing population was observed in three patients all of whom achieved a durable CR in contrast to patients with resistant disease where LSC persistence was observed. LSC quantitation provides a novel biomarker of disease response and relapse in patients with AML treated with epigenetic therapies. New drugs that target this cellular population in vivo are required.

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References

  1. Burnett A, Wetzler M, Lowenberg B . Therapeutic advances in acute myeloid leukemia. J Clin Oncol 2011; 29: 487–494.

    Article  Google Scholar 

  2. Garcia-Manero G, Kantarjian HM, Sanchez-Gonzalez B, Yang H, Rosner G, Verstovsek S et al. Phase 1/2 study of the combination of 5-aza-2'-deoxycytidine with valproic acid in patients with leukemia. Blood 2006; 108: 3271–3279.

    Article  CAS  Google Scholar 

  3. Soriano AO, Yang H, Faderl S, Estrov Z, Giles F, Ravandi F et al. Safety and clinical activity of the combination of 5-azacytidine, valproic acid, and all-trans retinoic acid in acute myeloid leukemia and myelodysplastic syndrome. Blood 2007; 110: 2302–2308.

    Article  CAS  Google Scholar 

  4. Garcia-Manero G, Yang H, Bueso-Ramos C, Ferrajoli A, Cortes J, Wierda WG et al. Phase 1 study of the histone deacetylase inhibitor vorinostat (suberoylanilide hydroxamic acid [SAHA]) in patients with advanced leukemias and myelodysplastic syndromes. Blood 2008; 111: 1060–1066.

    Article  CAS  Google Scholar 

  5. Fenaux P, Mufti GJ, Hellstrom-Lindberg E, Santini V, Finelli G, Giagounidis A et al. Efficacy of azacitidine compared with that of conventional care regimens in the treatment of higher-risk myelodysplastic syndromes: a randomised, open-label, phase III study. Lancet Oncol 2009; 10: 223–232.

    Article  CAS  Google Scholar 

  6. Fenaux P, Mufti GJ, Hellstrom-Lindberg E, Santini V, Gattermann N, Germing U et al. Azacitidine prolongs overall survival compared with conventional care regimens in elderly patients with low bone marrow blast count acute myeloid leukemia. J Clin Oncol 2010; 28: 562–569.

    Article  CAS  Google Scholar 

  7. Raffoux E, Cras A, Recher C, Boelle PY, de Labarthe A, Turlure P et al. Phase 2 clinical trial of 5-azacitidine, valproic acid, and all-trans retinoic acid in patients with high-risk acute myeloid leukemia or myelodysplastic syndrome. Oncotarget 2010; 1: 34–42.

    PubMed  PubMed Central  Google Scholar 

  8. Bonnet D, Dick JE . Human acute myeloid leukemia is organized as a hierarchy that originates from a primitive hematopoietic cell. Nat Med 1997; 3: 730–737.

    Article  CAS  Google Scholar 

  9. Taussig DC, Miraki-Moud F, Anjos-Afonso F, Perace DJ, Allen K, Ridler C et al. Anti-CD38 antibody-mediated clearance of human repopulating cells masks the heterogeneity of leukemia-initiating cells. Blood 2008; 112: 568–575.

    Article  CAS  Google Scholar 

  10. Taussig DC, Vargaftig J, Mirak-Moud F, Greissinger E, Sharrock K, Luke T et al. Leukemia-initiating cells from some acute myeloid leukemia patients with mutated nucleophosmin reside in the CD34(-) fraction. Blood 2010; 115: 1976–1984.

    Article  CAS  Google Scholar 

  11. Sarry JE, Murphy K, Perry R, Sanchez PV, Secreto A, Keefer C et al. Human acute myelogenous leukemia stem cells are rare and heterogeneous when assayed in NOD/SCID/IL2Rgammac-deficient mice. J Clin Invest 2011; 121: 384–395.

    Article  CAS  Google Scholar 

  12. Eppert K, Takenaka K, Lechman ER, Walsron L, Nilsson B, van Galen P et al. Stem cell gene expression programs influence clinical outcome in human leukemia. Nat Med 2011; 17: 1086–1093.

    Article  CAS  Google Scholar 

  13. Goardon N, Marchi E, Atzberger A, Quek L, Shuh A, Soneji S et al. Coexistence of LMPP-like and GMP-like leukemia stem cells in acute myeloid leukemia. Cancer Cell 2011; 19: 138–152.

    Article  CAS  Google Scholar 

  14. Ishikawa F, Yoshida S, Saito Y, Hijikata A, Katamura H, Tanaka S et al. Chemotherapy-resistant human AML stem cells home to and engraft within the bone-marrow endosteal region. Nat Biotechnol 2007; 25: 1315–1321.

    Article  CAS  Google Scholar 

  15. van Rhenen A, Moshaver B, Kelder A, Feller N, Nieuwint AW, Zweegman S et al. Aberrant marker expression patterns on the CD34+CD38- stem cell compartment in acute myeloid leukemia allows to distinguish the malignant from the normal stem cell compartment both at diagnosis and in remission. Leukemia 2007; 21: 1700–1707.

    Article  CAS  Google Scholar 

  16. Ran D, Schubert M, Pietsch L, Taubert I, Wuchter P, Eckstein V et al. Aldehyde dehydrogenase activity among primary leukemia cells is associated with stem cell features and correlates with adverse clinical outcomes. Exp Hematol 2009; 37: 1423–1434.

    Article  CAS  Google Scholar 

  17. Gerber JM, Smith BD, Ngwang B, Zhang H, Vala MS, Mosberger L et al. A clinically relevant population of leukemic CD34+CD38- cells in acute myeloid leukemia. Blood 2012; 119: 3571–3577.

    Article  CAS  Google Scholar 

  18. Cheson BD, Bennet JM, Kopecky KJ, Buchner T, Willman CL, Estey EH et al. Revised recommendations of the international working group for diagnosis, standardization of response criteria, treatment outcomes, and reporting standards for therapeutic trials in acute myeloid leukemia. J Clin Oncol 2003; 21: 4642–4649.

    Article  Google Scholar 

  19. Peto R, Pike MC, Armitage P, Breslow NE, Cox DR, Howard SV et al. Design and analysis of randomized clinical trials requiring prolonged observation of each patient. II. analysis and examples. Br J Cancer 1977; 35: 1–39.

    Article  CAS  Google Scholar 

  20. Cox DR . Regression models and life tables. J R Stat Soc. Series B (Methodological) 1972; 34: 187–220.

    Article  Google Scholar 

  21. Ley TJ, Ding L, Walter MJ, McLellan MD, Lamprecht T, Larson DE et al. DNMT3A mutations in acute myeloid leukemia. N Engl J Med 2010; 363: 2424–2433.

    Article  CAS  Google Scholar 

  22. Walter MJ, Ding L, Shen D, Shao J, Grillot M, McLellan M et al. Recurrent DNMT3A mutations in patients with myelodysplastic syndromes. Leukemia 2011; 25: 1153–1158.

    Article  CAS  Google Scholar 

  23. Mardis ER, Ding L, Dooling DJ, Larson DE, McLellan MD, Chen K et al. Recurring mutations found by sequencing an acute myeloid leukemia genome. N Engl J Med 2009; 361: 1058–1066.

    Article  CAS  Google Scholar 

  24. Gross S, Cairns RA, Minden MD, Driggers EM, Bittinger MA, Jang HG et al. Cancer-associated metabolite 2-hydroxyglutarate accumulates in acute myelogenous leukemia with isocitrate dehydrogenase 1 and 2 mutations. J Exp Med 2010; 207: 339–344.

    Article  CAS  Google Scholar 

  25. Figueroa ME, Abdel-Waheb O, Lu C, Ward PS, Patel J, Shih A et al. Leukemic IDH1 and IDH2 mutations result in a hypermethylation phenotype, disrupt TET2 function, and impair hematopoietic differentiation. Cancer Cell 2010; 18: 553–567.

    Article  CAS  Google Scholar 

  26. van Rhenen A, van Dongen GA, Kelder A, Rombouts EJ, feller N, Moshaver B et al. The novel AML stem cell associated antigen CLL-1 aids in 483 discrimination between normal and leukemic stem cells. Blood 2007; 110: 2659–2666.

    Article  CAS  Google Scholar 

Download references

Acknowledgements

Celgene Company provided AZA and an unrestricted educational grant for data management support. We thank patients and clinical teams; Naomi Robertson and Yvonne Morgan for sample processing; Susanna Akiki, Lindsey Bradley and Hayley Newell for CEBPA, NPM1, DNMT3A, IDH1, IDH2 and FISH analysis. CC was supported by CRUK ECMC Funding. NG was supported by an EMBO long-term fellowship and MRC funding. PV acknowledges funding from the Medical Research Council (MRC) Molecular Hematology Unit, MRC Disease Team Award, the Leukemia Lymphoma Research Specialist Program Grant 08030, CRUK Program Grant C7893/A12796 and the National Institute for Health Research (NIHR) Oxford Biomedical Research Center based at Oxford University Hospitals Trust, Oxford. HN was funded by Cure Leukemia (UK registered charity 1100154). NPM1 mutant monitoring studies conducted by AI and DG supported by Leukemia and Lymphoma Research (Grant Ref 07069). SF, RKH, AKB and DG were funded by National Institute for Heath Research Program Grant for assessment of minimal residual disease in the AML17 trial. RM and IL were supported by CIRM Disease Team Grant DR1–01485.

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Author notes

  1. L Quek and N Goardon: These authors contributed equally to this work.

Authors and Affiliations

  1. Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK

    C Craddock, S Freeman, S Siddique, M Raghavan, T McSkeane & J Arrazi

  2. Cancer Research UK Clinical Trials Unit, School of Cancer Sciences, University of Birmingham, Birmingham, UK

    C Craddock, S Siddique, M Raghavan, T McSkeane & C Brookes

  3. MRC Molecular Haematology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK

    L Quek, N Goardon, A Aztberger & P Vyas

  4. Department of Haematology, Radcliffe Hospitals NHS Trust, Oxford, UK

    L Quek, A Schuh & P Vyas

  5. Department of Immunology, Queen Elizabeth Hospital, University of Birmingham, Birmingham, UK

    S Freeman

  6. Department of Medical & Molecular Genetics, King’s College London School of Medicine, London, UK

    D Grimwade & A Ivey

  7. Department of Haematology, Guy’s & St Thomas’ NHS Foundation Trust, London, UK

    D Grimwade & A Ivey

  8. Department of Immunology, North Bristol NHS Trust, Bristol, UK

    P Virgo

  9. Department of Haematology, Cardiff University, Cardiff, UK

    R Hills, S Knapper & A Burnett

  10. Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences Nuffield NIHR Biomedical Research Unit, Oxford, UK

    B Davies & A Price

  11. West Midlands Regional Genetics Laboratory, Birmingham, UK

    K Wall & M Griffiths

  12. Department of Haematology, Barts and the London School of Medicine, London, UK

    J Cavenagh

  13. Department of Internal Medicine, Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Palo Alto, CA, USA

    R Majeti & I Weissman

Authors
  1. C Craddock
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  2. L Quek
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  3. N Goardon
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  7. A Aztberger
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  8. A Schuh
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  9. D Grimwade
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  14. J Arrazi
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  16. C Brookes
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  17. B Davies
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  18. A Price
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  19. K Wall
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  20. M Griffiths
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  22. R Majeti
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  23. I Weissman
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  24. A Burnett
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  25. P Vyas
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Corresponding author

Correspondence to C Craddock.

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Craddock, C., Quek, L., Goardon, N. et al. Azacitidine fails to eradicate leukemic stem/progenitor cell populations in patients with acute myeloid leukemia and myelodysplasia. Leukemia 27, 1028–1036 (2013). https://doi.org/10.1038/leu.2012.312

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