Discovering gene expression signatures responding to tyrosine kinase inhibitor treatment in chronic myeloid leukemia
© The Author(s). 2016
Published: 12 August 2016
Tyrosine kinase inhibitor (TKI)-based therapy is a recommended treatment for patients with chronic myeloid leukemia (CML). However, a considerable group of CML patients do not respond well to the TKI therapy. Challenging to overcome this problem, we tried to discover molecular signatures in gene expression profiles to discriminate the responders and non-responders of TKI therapy.
We collected three microarray datasets of CML patients having total 73 responders and 38 non-responders. Statistical analysis was performed to identify differentially expressed genes (DEGs) as gene signature candidates from integrated microarray datasets. The classification performance of these genes and further selected discriminator gene sets was tested by using random forest and iterative backward variable selection methods.
We identified a set of genes including CTBP2, NADK, AZU1, CTSH, FSTL1, and HDLBP showing the highest accuracy more than 69.44 % to classify TKI response in CML patients. Interestingly, four genes of them are on the signaling pathway of cell proliferation. This set of genes showed much higher performance than the average performance of other genes in downstream signaling of TKI target, BCR-ABL.
In this study, we could find a set of potential companion diagnostic markers for TKI treatment and, at the same time, the potential of gene expression analysis to enhance the coverage of companion diagnostics.
Chronic myeloid leukemia (CML) is a myeloproliferative disease with pluripotent hematopoietic cell and caused by a reciprocal translocation between chromosome nine and chromosome 22, which is specifically designated t(9;22)(q34;q11) . This translocation creates a novel fusion gene, BCR-ABL, which encodes a constitutively active isoform of ABL tyrosine kinase (TK) and leads to pathophysiology of CML [2–5]. Treatment with tyrosine kinase inhibitor (TKI) such as Imatinib, Dasatinib, and Nilotinib had been proved to be an effective therapy as inducing a complete cytogenetic response in more than half of with newly CML patients [6, 7]. However, a lot of patients failed to TK inhibitor treatment because of intrinsically resistant or developed resistance to drugs . In order to increase efficiency of treatment, it is necessary to predict the response to drugs which patients would benefit from treatment before clinical therapy.
DNA Microarray is one of the most powerful technology developed in recent years to profile gene expression, identifying the differentially expressed genes (DEGs), correlation of genes and their biological pathways [9–12]. DNA microarray and following data analysis solutions have become a new research tool for a disease diagnosis, prognosis, monitoring progress of a disease, and discovering gene signatures of various diseases [13, 14]. For example, based on multiple microarray data indicating drug response condition from RA patients, common DEGs were found in different dataset and one of them was selected as most believable biomarker by meta-analysis method . In the aspect of cancer, patient classifier was set up based on microarray data from Imatinib-naive CML patients and correctly predicted responders and non-responders . In addition, besides protein-encoding gene, long noncoding RNAs (lncRNAs) were found significantly changed between Dasatinib-resistance/sensitive patients, which indicated lncRNAs might be related to mechanisms of drug response . Although DEG sets were identified from each dataset, it is necessary to integrate them and to identify gene expression signatures to predict the drug response with a more reliability in inter-patient heterogeneity.
To this end, we compiled three microarray datasets from CML patients with the clinical outcome of TKI therapy. Therefore, we used statistical analysis to identify DEGs as gene signature candidates from three sets of microarray datasets covering 101 CML patients grouped by the response of TKI treatment. After statistical analysis on gene expression profiles, we selected the gene signatures to discriminate responder and non-responder patients treated with TKI agents using a random forest (RF) classifier. In addition, we performed functional annotation of these gene signatures to figure out the role of TKI related pathway in CML. We found that four genes were associated with cell proliferation of TKI resistance mechanisms in CML. This study provided to develop a robust gene expression signature-based classifier of the clinical outcome to TKI-based therapy. Moreover, our finding suggests biomarker candidates that could discriminate responder and non-responder patients treated with TKI. It would help to apply companion diagnostics by further experimental validation of putative biomarkers and to discover key targets of novel drugs for patients.
Collection of microarray data
We searched microarray dataset to find available gene expression profiles that could predict treatment outcome of TKI therapy in CML patients. Microarray data were derived from the NCBI Gene Expression Omnibus (GEO) web site by KEY words such as “Imatinib”, “Dasatinib”, “Drug Response”, “Gene Expression”, and “Chronic Myeloid Leukemia” as dataset title and descriptions. We focused on the microarray data from blood samples with responder and non-responder patient treated with drugs targeting the same target because we were interested in collection of multiple microarray data to provide validated conclusion.
We selected three sets of gene expression datasets: GSE14671, GSE2535, and GSE33224. The GSE14671 dataset included 41 blood samples from responder patients and 18 samples from non-responder patients to Imatinib. This dataset was based on the Affymetrix Human Genome U133 Plus 2.0 Array . The GSE2535 dataset included 16 blood or bone marrow samples from responder patients and 12 samples from non-responder patients to Imatinib; this dataset was based on the Affymetrix Human Genome U95 Version 2 Array . The GSE33224 dataset included 12 peripheral blood samples from responder patients treated with Dasatinib, 16 samples from non-responder patients measured on Agilent-014850 Whole Human Genome Microarray 4x44K G4112F . SOFT formatted family files of three sets of microarray data were parsed by using the GEOquery R package . We collected the 101 samples including 73 responders and 38 non-responders from three gene expression datasets. The 101 samples were randomly selected 38 responders and 38 non-responders for avoiding overfitting. Next, 76 samples were divided into two-thirds training and one-third testing datasets for gene signature selection and performance test of them.
Microarray data preprocessing
With two-channel microarray dataset GSE33224, we firstly combined two dye swap technical replicates into one by take the average of them and transformed the expression values by inverting the log2-transformation. Then, we processed quantile normalization to each of the three microarray datasets using the limma R package . We converted the probe IDs into Entrez Gene IDs using platform information of each dataset to make the unique ID. We mapped to the Entrez Gene IDs from probe IDs in each set of microarray data and collapsed their expression values by averaging them to make each microarray dataset contain non-redundant set of genes.
Selection of gene signature candidates using statistical analysis
We analyzed each microarray dataset individually to identify gene signatures that are differentially expressed in two conditions of responder and non-responder patients treated with TKI. Student t-test analysis coupled with False Discovery Rate for multiple testing corrections were performed using the genefilter R package  to find out the DEGs between responders and non-responder groups.
We performed meta-analysis to combine the results of each microarray dataset and to extract more robust DEGs. We used MetaQC and MetaDE in R packages for quality controls and DEGs identification . MetaQC calculated six quantitative quality control (QC) measures: internal quality control for homogeneity of co-expression structure among studies (IQC), external quality control for consistency of co-expression pattern with pathway database (EQC), and accuracy and consistency quality control of differentially expressed gene detection (AQCg and CQCg) or enriched pathway identification (AQCp and CQCp). MetaDE contained 12 major meta-analysis method for DEG detection including three categories of combining P-value, combining effect size, and combining ranks. After QC measure process, the dataset with a poor IQC score excluded from meta-analysis which indicates that this dataset has a heterogeneous information with other datasets. We used the moderated-t statistics as an argument of function ind.method to calculate p-values of each gene in each microarray dataset. In addition, we conducted meta-analysis that identify DEGs from the results of each dataset using MetaDE with the three popular meta-analysis methods including Fisher method, maximum p-value (maxP) method, and adaptively weighted (AW) Fisher method of a type of combining p-values. The Fisher method summed up minus log-transformed p-values so that larger score reflected integrated differentially expressed evidence. The maxP method is taken as the maximum p-value among datasets. The AW Fisher method characterizes effective studies contributing to the meta-analysis for better biological interpretation.
Identification of gene signatures with random forest
To identify gene signatures for discriminating patients between responders and non-responders, we performed classification analysis either responders or non-responders using RF. The RF algorithm is a combinational classifier that selects one classifier model by constructing multiple classification trees. Each classification tree is constructed using bootstrap sample of two-thirds of datasets from total datasets. RF method has several properties that are less overfitting, feature selection, and robust performance by parameter choices. RF model was selected to find sets of gene signatures by Gini variable importance and was evaluated by out-of-bag (OOB) testing. This OOB estimate is as accurate as using validation test with a test set of the same size as the training set. To find a set of gene signatures from results of statistical analysis, RF was performed by using varSelRF  that can select the sets of gene signatures with high accuracy. The following arguments of varSelRF were used for selection of gene sets: ntree = 10000, ntreeIterat = 2000, mtryFactor = 1, and vars.drop.frac = 0.02. We finally selected and validated a set of gene expression signatures from testing datasets.
The functional meaning and related pathway information of the each list of DEGs that was identified by individual analysis and meta-analysis was interpreted using functional enrichment analysis. This analysis was based on a one-sided Fisher’s exact test using Gene Ontology (GO), KEGG pathway, BIOCARTA pathway, Panther pathways, and Reactome pathway in The Database for Annotation, Visualization and Integrated Discovery (DAVID) . The p-values were adjusted by multiple testing corrections using Benjamini correction method.
Characteristics of analyzed dataset
Studies included in analysis
The number of samples
McWeeney et al., 2010 
Crossman et al., 2005 
White cell/Blood, BM
Silveira et al., 2013 
Since previous studies were performed individually accompanying with clinical and experimental variations, as well as being analyzed by different statistical analysis methods, no overlapped DEGs were found between them. Even though, two studies set up models of drug response classifiers based on DEGs from single dataset, and one of them correctly predicted ≥80 % of responder and non-responder . Another studies evaluated DEGs/lncRNAs functional relevance by using Ingenuity Pathway Analysis (IPA) tools. Interestingly, most of DEGs were identified within “Cell-to-Cell Signaling and Interaction” category and differently expressed lncRNAs were in “Cell Death” category .
Selection of gene signature candidates
To further investigate the role of DEGs, we performed functional enrichment to DEGs in each dataset by DAVID. Raw p-value threshold was set to 0.05 and significantly enriched annotation terms were shown in Additional file 2: Table S2. 205 annotation terms were found in GSE14671 and the most significant term, “defense response”, contains 54 genes. 21 annotation terms were found in GSE2535 and the most significant term “immune response” contains 16 genes. 212 annotation terms were found in GSE33224 and the most significant term, “response to organic substance” contains 55 genes. Duplicate analysis showed 3 overlapped annotation terms including “defense response”, “immune response” and “response to organic substance” were found among all datasets. 57 overlapped annotation terms including “immune response”, “defense response”, “response to organic substance” and “homeostatic process” were found between GSE14671 and GSE33224. 12 overlapped annotation terms including “immune response”, “defense response”, “response to organic substance” and “actin cytoskeleton organization” were found between GSE2535 and GSE33224. Eventually, three overlapped annotation terms “immune response”, “defense response” and “response to organic substance” were shared by all datasets (Fig. 1b). Considering the fact that only a few number of common DEGs and functional terms found in all datasets, we guessed individual analysis for dataset separately provide insufficient statistic power and the result is variously dependent on experimental or sample bias, limiting to find the common features from different datasets.
The number of differentially expressed genes by meta-analysis methods
P < 0.01
P < 0.05
Identification of gene signatures
Error rates of sets of gene signatures
Number of genes
After identifying six genes signatures, we then interested in these genes function and how they participate in CML development or TKI-resistance mechanism in patients. We surveyed canonical pathways of CML signaling and TKI signaling from literatures, IPA software and public biological databases. First of all, to find relationships between six gene signatures and known CML-associated genes, we collected 258 CML-associated genes from five available disease-associated databases including OMIM (Online Mendelian Inheritance in Man) , Genetic Association Database , PharmGKB , KEGG DISEASE , and Cancer gene census . None of the six genes mapped with CML-associated genes. We then used our comprehensive protein-protein interaction database, ComBiCom  to discover interaction between six gene signatures and CML-associated genes. As a result, two genes, CTBP2 and FSTL1, directly interact with three proteins (BCL3, MDM2, and MDS1) and one protein (TGFB1), respectively.
On the other aspect, we investigated relationship between six gene signatures and TKI-resistance mechanisms in CML. We filtered out 22 molecules form “Imatinib-resistant CML disease” in IPA and manually added another 26 TKI-resistance related molecules which mentioned in literatures but not contained in IPA. The added genes were listed as follows: 1) 16 genes related to alternative signaling pathways, 2) four genes related drug transporter regulation, 3) two genes related to DNA repair pathway, and 4) four genes related to epigenetic modification [30, 31]. After input of six gene signatures, we expanded connections between each molecules and overlaid “disease & function” and “canonical pathway” layer to all genes. As a result, CTBP2 was found to interact and decrease activity of HDACs as well as increase activity of PI3K. In addition, CTBP2 located in the downstream of TGF-beta signal pathway in CML, mediating cell growth inhibition. PP1 was found as intermediate between AZU1 and AKT/MAPK/SRC signaling pathways. PP1 inhibits AZU1 release and reduces activation of PI3K, SRC, BCR-xL, Ras and AKT. HDLBP inhibits mRNA of CSF1R which activates PI3K, AKT, and STAT and also interacts with HDACs. In summary, three of the total six genes (CTBP2, AZU1 and HDLBP) were found to be related with TKI-resistance mechanisms.
We performed combined analysis with statistical analysis and classification analysis on gene expression data to identify gene expression signatures for classification of CML patients to the drug response of TKI-based therapy. Based on our results, there was a few overlapped DEGs among microarray datasets by individual analysis. It could be caused by a diverse of variables in each dataset such as characteristics of patients, platforms of microarray, analysis methods, and a type of drugs. To diminish the bias, we compared three sets of microarray data by three different method of meta-analysis and discovered 99 non-redundant DEGs by Fisher method, maxP method, and AW method with p-value <0.01. Among them, a set of six DEGs including CTBP2, NADK, AZU1, CTSH, FSTL1, and HDLBP with the highest accuracy of 69.44 % was identified. Moreover, we found that CTBP2, NADK, AZU1, and HDLBP were related to BCR-ABL inhibitor resistance mechanisms in BCR-ABL downstream signaling pathways.
We performed both statistical and classification analysis to identify gene expression signatures to discriminate patients between responder and non-responder groups from integrated gene expression profiles. In our analysis, we used three gene expression profiles which were different in terms of platforms, sample sources, drugs, and clinical criteria between drug responders and non-responders. So, the biological and technical biases were controlled by the following ways. 1) The systematic integration of gene expression profiles from multiple sources, meta-analysis, were used to analyze three datasets for reducing platform-caused batch effects. 2) All of samples from three datasets belongs to blood-related mononuclear cells, which are key cells lesion in CML disease. 3) Both of selected drugs, Imatinib and Dasatinib, directly bind BCR-ABL kinase and inhibit the function of BCR-ABL in CML therapy, which reduced drugs-caused bias. 4) All datasets used CR as major clinical criteria to decide drug response vs. non-response groups. The slightly difference in each dataset is that GSE2535 defined drug-response patient when they achieved CR within 9 months whereas GSE14671 defined them when they achieved CR within 12 months. This approach could reduce the heterogeneity of various datasets having a similar purpose and make them comparable to each other. To our knowledge, there is no other study that used the meta-analysis and classification analysis on gene expression dataset to identify a set of gene signatures and their biological functions for the response of TKI-based therapy in CML patients. Our study suggests potential drug-response biomarkers from gene expression profiles and provides a leading view to understand more precise control mechanisms of drugs.
Publication of this article has been funded by the Bio-Synergy Research Project (NRF-2012M3A9C4048759) of the Ministry of Science, ICT and Future Planning through the National Research Foundation and by the National Research Foundation of Korea(NRF) grant funded by the Korea government (MSIP) (No. 2010-0028631). This article has been published as part of BMC Medical Genomics Volume 9 Supplement 1, 2016. Selected articles from the 5th Translational Bioinformatics Conference (TBC 2015): medical genomics. The full contents of the supplement are available online https://bmcmedgenomics.biomedcentral.com/articles/supplements/volume-9-supplement-1.
Availability of data and materials
The datasets supporting the conclusion of this article are available in the Gene Expression Omnibus repository (GEO accession number GSE14671; http://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc=GSE14671, GSE2535; http://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc=GSE2535, GSE33224; http://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc=GSE33224) and included within the article and its additional files.
KC carried out the analysis of microarray datasets, functional analysis, and drafted the manuscript. YL carried out the preprocessing of microarray dataset and functional analysis. GSY conceived of the study, participated in its design and coordination, and reviewed the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Rowley JD. Letter: a new consistent chromosomal abnormality in chronic myelogenous leukaemia identified by quinacrine fluorescence and giemsa staining. Nature. 1973;243(5405):290–3.View ArticlePubMedGoogle Scholar
- Konopka JB, Watanabe SM, Witte ON. An alteration of the human c-abl protein in K562 leukemia cells unmasks associated tyrosine kinase activity. Cell. 1984;37(3):1035–42.View ArticlePubMedGoogle Scholar
- Heisterkamp N, Stam K, Groffen J, de Klein A, Grosveld G. Structural organization of the bcr gene and its role in the Ph’ translocation. Nature. 1985;315(6022):758–61.View ArticlePubMedGoogle Scholar
- Shtivelman E, Lifshitz B, Gale RP, Canaani E. Fused transcript of abl and bcr genes in chronic myelogenous leukaemia. Nature. 1985;315(6020):550–4.View ArticlePubMedGoogle Scholar
- Druker BJ, Guilhot F, O’Brien SG, Gathmann I, Kantarjian H, Gattermann N, Deininger MW, Silver RT, Goldman JM, Stone RM, et al. Five-year follow-up of patients receiving imatinib for chronic myeloid leukemia. N Engl J Med. 2006;355(23):2408–17.View ArticlePubMedGoogle Scholar
- Crossman LC, Mori M, Hsieh YC, Lange T, Paschka P, Harrington CA, Krohn K, Niederwieser DW, Hehlmann R, Hochhaus A, et al. In chronic myeloid leukemia white cells from cytogenetic responders and non-responders to imatinib have very similar gene expression signatures. Haematologica. 2005;90(4):459–64.PubMedGoogle Scholar
- Miura M. Therapeutic drug monitoring of imatinib, nilotinib, and dasatinib for patients with chronic myeloid leukemia. Biol Pharm Bull. 2015;38(5):645–54.View ArticlePubMedGoogle Scholar
- de Lavallade H, Apperley JF, Khorashad JS, Milojkovic D, Reid AG, Bua M, Szydlo R, Olavarria E, Kaeda J, Goldman JM, et al. Imatinib for newly diagnosed patients with chronic myeloid leukemia: incidence of sustained responses in an intention-to-treat analysis. J Clin Oncol. 2008;26(20):3358–63.View ArticlePubMedGoogle Scholar
- Haupl T, Stuhlmuller B, Grutzkau A, Radbruch A, Burmester GR. Does gene expression analysis inform us in rheumatoid arthritis? Ann Rheum Dis. 2010;69 Suppl 1:i37–42.View ArticlePubMedGoogle Scholar
- Hwang T, Sun CH, Yun T, Yi GS. FiGS: a filter-based gene selection workbench for microarray data. BMC Bioinf. 2010;11:50.View ArticleGoogle Scholar
- Yun T, Hwang T, Cha K, Yi GS. CLIC: clustering analysis of large microarray datasets with individual dimension-based clustering. Nucleic Acids Res. 2010;38(Web Server issue):W246–253.View ArticlePubMedPubMed CentralGoogle Scholar
- Yun T, Yi GS. Biclustering for the comprehensive search of correlated gene expression patterns using clustered seed expansion. BMC Genomics. 2013;14:144.View ArticlePubMedPubMed CentralGoogle Scholar
- D’Angelo G, Di Rienzo T, Ojetti V. Microarray analysis in gastric cancer: a review. World J Gastroenterol. 2014;20(34):11972–6.View ArticlePubMed CentralGoogle Scholar
- Kim TH, Choi SJ, Lee YH, Song GG, Ji JD. Gene expression profile predicting the response to anti-TNF treatment in patients with rheumatoid arthritis; analysis of GEO datasets. Joint Bone Spine. 2014;81(4):325–30.View ArticlePubMedGoogle Scholar
- McWeeney SK, Pemberton LC, Loriaux MM, Vartanian K, Willis SG, Yochum G, Wilmot B, Turpaz Y, Pillai R, Druker BJ, et al. A gene expression signature of CD34+ cells to predict major cytogenetic response in chronic-phase chronic myeloid leukemia patients treated with imatinib. Blood. 2010;115(2):315–25.View ArticlePubMedPubMed CentralGoogle Scholar
- Silveira RA, Fachel AA, Moreira YB, De Souza CA, Costa FF, Verjovski-Almeida S, Pagnano KB. Protein-coding genes and long noncoding RNAs are differentially expressed in dasatinib-treated chronic myeloid leukemia patients with resistance to imatinib. Hematology. 2014;19(1):31–41.View ArticlePubMedGoogle Scholar
- Davis S, Meltzer PS. GEOquery: a bridge between the Gene Expression Omnibus (GEO) and BioConductor. Bioinf (Oxford, England). 2007;23(14):1846–7.View ArticleGoogle Scholar
- Ritchie ME, Phipson B, Wu D, Hu Y, Law CW, Shi W, Smyth GK. limma powers differential expression analyses for RNA-sequencing and microarray studies. Nucleic Acids Res. 2015;43(7):e47.Google Scholar
- Gentleman R, Carey V, Huber W, Hahne F. genefilter: methods for filtering genes from high-throughput experiments. R package version 1.52.1. 2015.Google Scholar
- Wang X, Kang DD, Shen K, Song C, Lu S, Chang LC, Liao SG, Huo Z, Tang S, Ding Y, et al. An R package suite for microarray meta-analysis in quality control, differentially expressed gene analysis and pathway enrichment detection. Bioinf (Oxford, England). 2012;28(19):2534–6.View ArticleGoogle Scholar
- Diaz-Uriarte R. GeneSrF and varSelRF: a web-based tool and R package for gene selection and classification using random forest. BMC Bioinf. 2007;8:328.View ArticleGoogle Scholar
- da Huang W, Sherman BT, Lempicki RA. Systematic and integrative analysis of large gene lists using DAVID bioinformatics resources. Nat Protoc. 2009;4(1):44–57.View ArticleGoogle Scholar
- Kolch W, Pitt A. Functional proteomics to dissect tyrosine kinase signalling pathways in cancer. Nat Rev Cancer. 2010;10(9):618–29.View ArticlePubMedGoogle Scholar
- Hamosh A, Scott AF, Amberger JS, Bocchini CA, McKusick VA. Online Mendelian Inheritance in Man (OMIM), a knowledgebase of human genes and genetic disorders. Nucleic Acids Res. 2005;33(Database issue):D514–517.View ArticlePubMedGoogle Scholar
- Becker KG, Barnes KC, Bright TJ, Wang SA. The genetic association database. Nat Genet. 2004;36(5):431–2.View ArticlePubMedGoogle Scholar
- Whirl-Carrillo M, McDonagh EM, Hebert JM, Gong L, Sangkuhl K, Thorn CF, Altman RB, Klein TE. Pharmacogenomics knowledge for personalized medicine. Clin Pharmacol Ther. 2012;92(4):414–7.View ArticlePubMedPubMed CentralGoogle Scholar
- Kanehisa M, Goto S, Furumichi M, Tanabe M, Hirakawa M. KEGG for representation and analysis of molecular networks involving diseases and drugs. Nucleic Acids Res. 2010;38(Database issue):D355–360.View ArticlePubMedGoogle Scholar
- Futreal PA, Coin L, Marshall M, Down T, Hubbard T, Wooster R, Rahman N, Stratton MR. A census of human cancer genes. Nat Rev Cancer. 2004;4(3):177–83.View ArticlePubMedGoogle Scholar
- Youngwoong H, Choong-Hyun S, Min-Sung K, Gwan-Su Y. Combined database system for binary protein interaction and Co-complex association. In: Computer science and information technology - spring conference, 2009 IACSITSC ’09 international association of: 17–20 april 2009 2009. 2009. p. 538–42.Google Scholar
- Bixby D, Talpaz M. Mechanisms of resistance to tyrosine kinase inhibitors in chronic myeloid leukemia and recent therapeutic strategies to overcome resistance, Hematology/the education program of the american society of hematology american society of hematology education program. 2009. p. 461–76.Google Scholar
- Yang K, Fu LW. Mechanisms of resistance to BCR-ABL TKIs and the therapeutic strategies: a review. Crit Rev Oncol Hematol. 2015;93(3):277–92.View ArticlePubMedGoogle Scholar
- Balabanov S, Braig M, Brummendorf TH. Current aspects in resistance against tyrosine kinase inhibitors in chronic myelogenous leukemia. Drug Discov Today Technol. 2014;11:89–99.View ArticlePubMedGoogle Scholar