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Gurnari C, Voso MT, Maciejewski JP, Visconte V. From Bench to Bedside and Beyond: Therapeutic Scenario in Acute Myeloid Leukemia. Cancers (Basel) 2020; 12:cancers12020357. [PMID: 32033196 PMCID: PMC7072629 DOI: 10.3390/cancers12020357] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 12/20/2022] Open
Abstract
Acute myeloid leukemia (AML) is a heterogeneous group of clonal disorders characterized by abnormal proliferation of undifferentiated myeloid progenitors, impaired hematopoiesis, and variable response to therapy. To date, only about 30% of adult patients with AML become long-term survivors and relapse and/or disease refractoriness are the major cause of treatment failure. Thus, this is an urgent unmet clinical need and new drugs are envisaged in order to ameliorate disease survival outcomes. Here, we review the latest therapeutic approaches (investigational and approved agents) for AML treatment. A specific focus will be given to molecularly targeted therapies for AML as a representation of possible agents for precision medicine. We will discuss experimental and preclinical data for FLT3, IDH1, BCL-2, Hedgehog pathway inhibitors, and epitherapy.
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Affiliation(s)
- Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (C.G.); (J.P.M.)
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy;
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy;
- Neuro-Oncohematology Unit, Fondazione Santa Lucia, Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S.), 00143 Rome, Italy
| | - Jaroslaw P. Maciejewski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (C.G.); (J.P.M.)
| | - Valeria Visconte
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (C.G.); (J.P.M.)
- Correspondence:
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Fiorentini A, Capelli D, Saraceni F, Menotti D, Poloni A, Olivieri A. The Time Has Come for Targeted Therapies for AML: Lights and Shadows. Oncol Ther 2020; 8:13-32. [PMID: 32700072 PMCID: PMC7359996 DOI: 10.1007/s40487-019-00108-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Indexed: 12/20/2022] Open
Abstract
Acute myeloid leukemia (AML) is a complex disease characterized by genetic and clinical heterogeneity and high mortality. After 40 years during which the standard of care for patients evolved very little, the therapeutic landscape has recently seen rapid changes, with the approval of eight new drugs by the Food and Drug Administration (FDA) within the last 2 years, providing new opportunities, as well as new challenges, for treating clinicians. These therapies include FLT3 inhibitors midostaurin and gilteritinib, CPX-351 (liposomal cytarabine and daunorubicin), gemtuzumab ozogamicin (GO, anti-CD33 monoclonal antibody conjugated with calicheamicin), IDH1/IDH2 inhibitors ivosidenib and enasidenib, Hedgehog inhibitor glasdegib, and BCL-2 inhibitor venetoclax. In this review, we summarize currently available data on these new drugs and discuss the rapidly evolving therapeutic armamentarium for AML, focusing on targeted therapies.
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Affiliation(s)
- Alessandro Fiorentini
- Hematology Department and Stem Cell Transplant Unit, Università Politecnica delle Marche, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Debora Capelli
- Hematology Department and Stem Cell Transplant Unit, Università Politecnica delle Marche, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Francesco Saraceni
- Hematology Department and Stem Cell Transplant Unit, Università Politecnica delle Marche, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Diego Menotti
- Hematology Department and Stem Cell Transplant Unit, Università Politecnica delle Marche, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Antonella Poloni
- Hematology Department and Stem Cell Transplant Unit, Università Politecnica delle Marche, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Attilio Olivieri
- Hematology Department and Stem Cell Transplant Unit, Università Politecnica delle Marche, Ospedali Riuniti di Ancona, Ancona, Italy.
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van Dijk AD, de Bont ESJM, Kornblau SM. Targeted therapy in acute myeloid leukemia: current status and new insights from a proteomic perspective. Expert Rev Proteomics 2020; 17:1-10. [PMID: 31945303 DOI: 10.1080/14789450.2020.1717951] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: The biological heterogeneity of acute myeloid leukemia (AML) complicates personalized medicine. Individual prognosis is typically based on the presence of chromosomal and genetic lesions. Nevertheless, these classifications often lack a priori information about response to therapy. Since the protein expression landscape reflects the functional activity state of cells, we hypothesize that analyzing this can be used for the identification of protein activity markers to provide better risk stratification as well as may provide targeted therapeutic guidance in AML.Areas covered: Herein, we review recently new adopted drugs in the treatment for AML and discuss how quantitative proteomic techniques may contribute to better therapeutic selection in AML.Expert commentary: The net functional state of the cell is defined by the activity of protein within all the pathways that are active in the cell. Recognition of the proteomic profile of the leukemic blast could, therefore, complement current classification systems by providing a better a priori description of what pathways are important within a cell as a guide to the selection of therapy for the patient.
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Affiliation(s)
- Anneke D van Dijk
- Division of Pediatric Oncology/Hematology, Department of Pediatrics, University Medical Center Groningen, Groningen, the Netherlands
| | - Eveline S J M de Bont
- Division of Pediatric Oncology/Hematology, Department of Pediatrics, University Medical Center Groningen, Groningen, the Netherlands
| | - Steven M Kornblau
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Wen J, Teske KA, Kyle Hadden M. Inhibition of hedgehog signaling by stereochemically defined des-triazole itraconazole analogues. Bioorg Med Chem Lett 2020; 30:126794. [PMID: 31761657 PMCID: PMC6942223 DOI: 10.1016/j.bmcl.2019.126794] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/28/2019] [Accepted: 10/30/2019] [Indexed: 01/28/2023]
Abstract
Dysregulation of the hedgehog (Hh) signaling pathway is associated with cancer occurrence and development in various malignancies. Previous structure-activity relationships (SAR) studies have provided potent Itraconazole (ITZ) analogues as Hh pathway antagonists. To further expand on our SAR for the ITZ scaffold, we synthesized and evaluated a series of compounds focused on replacing the triazole. Our results demonstrate that the triazole region is amenable to modification to a variety of different moieties; with a single methyl group representing the most favorable substituent. In addition, nonpolar substituents were more active than polar substituents. These SAR results provide valuable insight into the continued exploration of ITZ analogues as Hh pathway antagonists.
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Affiliation(s)
- Jiachen Wen
- Department of Pharmaceutical Sciences, University of Connecticut, 69 North Eagleville Rd, Unit 3092, Storrs, CT 06029-3092, United States
| | - Kelly A Teske
- Department of Pharmaceutical Sciences, University of Connecticut, 69 North Eagleville Rd, Unit 3092, Storrs, CT 06029-3092, United States
| | - M Kyle Hadden
- Department of Pharmaceutical Sciences, University of Connecticut, 69 North Eagleville Rd, Unit 3092, Storrs, CT 06029-3092, United States.
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55
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Palmieri R, Paterno G, De Bellis E, Mercante L, Buzzatti E, Esposito F, Del Principe MI, Maurillo L, Buccisano F, Venditti A. Therapeutic Choice in Older Patients with Acute Myeloid Leukemia: A Matter of Fitness. Cancers (Basel) 2020; 12:cancers12010120. [PMID: 31906489 PMCID: PMC7016986 DOI: 10.3390/cancers12010120] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 12/19/2019] [Accepted: 12/31/2019] [Indexed: 01/17/2023] Open
Abstract
Acute myeloid leukemia (AML), with an incidence increasing with age, is the most common acute leukemia in adults. Concurrent comorbidities, mild to severe organ dysfunctions, and low performance status (PS) are frequently found in older patients at the onset, conditioning treatment choice and crucially influencing the outcome. Although anthracyclines plus cytarabine-based chemotherapy, also called “7 + 3” regimen, remains the standard of care in young adults, its use in patients older than 65 years should be reserved to selected cases because of higher incidence of toxicity. These adverse features of AML in the elderly underline the importance of a careful patient assessment at diagnosis as a critical tool in the decision-making process of treatment choice. In this review, we will describe selected recently approved drugs as well as examine prognostic algorithms that may be helpful to assign treatment in elderly patients properly.
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Affiliation(s)
- Raffaele Palmieri
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, 00133 Rome, Italy; (R.P.); (G.P.); (E.D.B.); (L.M.); (E.B.); (F.E.); (M.I.D.P.); (F.B.)
- Fondazione Policlinico Tor Vergata, 00133 Rome, Italy;
| | - Giovangiacinto Paterno
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, 00133 Rome, Italy; (R.P.); (G.P.); (E.D.B.); (L.M.); (E.B.); (F.E.); (M.I.D.P.); (F.B.)
- Fondazione Policlinico Tor Vergata, 00133 Rome, Italy;
| | - Eleonora De Bellis
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, 00133 Rome, Italy; (R.P.); (G.P.); (E.D.B.); (L.M.); (E.B.); (F.E.); (M.I.D.P.); (F.B.)
- Fondazione Policlinico Tor Vergata, 00133 Rome, Italy;
| | - Lisa Mercante
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, 00133 Rome, Italy; (R.P.); (G.P.); (E.D.B.); (L.M.); (E.B.); (F.E.); (M.I.D.P.); (F.B.)
- Fondazione Policlinico Tor Vergata, 00133 Rome, Italy;
| | - Elisa Buzzatti
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, 00133 Rome, Italy; (R.P.); (G.P.); (E.D.B.); (L.M.); (E.B.); (F.E.); (M.I.D.P.); (F.B.)
- Fondazione Policlinico Tor Vergata, 00133 Rome, Italy;
| | - Fabiana Esposito
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, 00133 Rome, Italy; (R.P.); (G.P.); (E.D.B.); (L.M.); (E.B.); (F.E.); (M.I.D.P.); (F.B.)
- Fondazione Policlinico Tor Vergata, 00133 Rome, Italy;
| | - Maria Ilaria Del Principe
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, 00133 Rome, Italy; (R.P.); (G.P.); (E.D.B.); (L.M.); (E.B.); (F.E.); (M.I.D.P.); (F.B.)
- Fondazione Policlinico Tor Vergata, 00133 Rome, Italy;
| | - Luca Maurillo
- Fondazione Policlinico Tor Vergata, 00133 Rome, Italy;
| | - Francesco Buccisano
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, 00133 Rome, Italy; (R.P.); (G.P.); (E.D.B.); (L.M.); (E.B.); (F.E.); (M.I.D.P.); (F.B.)
- Fondazione Policlinico Tor Vergata, 00133 Rome, Italy;
| | - Adriano Venditti
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, 00133 Rome, Italy; (R.P.); (G.P.); (E.D.B.); (L.M.); (E.B.); (F.E.); (M.I.D.P.); (F.B.)
- Fondazione Policlinico Tor Vergata, 00133 Rome, Italy;
- Correspondence: ; Tel.: +39-0620903226
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Dhakal P, Pyakuryal B, Pudasainee P, Rajasurya V, Gundabolu K, Bhatt VR. Treatment Strategies for Therapy-related Acute Myeloid Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 20:147-155. [PMID: 31953046 DOI: 10.1016/j.clml.2019.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 11/28/2019] [Accepted: 12/11/2019] [Indexed: 01/20/2023]
Abstract
Prospective evidence for management of therapy-related acute myeloid leukemia (t-AML) is limited, with evidence extrapolated from major AML trials. Optimal treatment is challenging and needs consideration of patient-specific, disease-specific, and therapy-specific factors. Clinical trials are recommended, especially for unfit patients or those with unfavorable cytogenetics or mutations. CPX-351 as an upfront intensive chemotherapy is preferred for fit patients; venetoclax with decitabine or azacitidine is an option for patients unfit for intensive chemotherapy. Hematopoietic cell transplant, the only curative option, should be offered to eligible patients with intermediate or unfavorable t-AML or patients with good-risk AML with minimal residual disease. Ongoing clinical trials focusing on treatment of t-AML, including targeted agents and immunotherapy, bode well for the future.
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Affiliation(s)
- Prajwal Dhakal
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE.
| | - Bimatshu Pyakuryal
- Department of Internal Medicine, Nepal Medical College, Kathmandu, Nepal
| | - Prasun Pudasainee
- Department of Internal Medicine, Nepal Medical College, Kathmandu, Nepal
| | | | - Krishna Gundabolu
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE
| | - Vijaya Raj Bhatt
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE
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57
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Lin S, Shaik N, Martinelli G, Wagner AJ, Cortes J, Ruiz‐Garcia A. Population Pharmacokinetics of Glasdegib in Patients With Advanced Hematologic Malignancies and Solid Tumors. J Clin Pharmacol 2019; 60:605-616. [PMID: 31769065 PMCID: PMC7187372 DOI: 10.1002/jcph.1556] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 10/22/2019] [Indexed: 01/08/2023]
Abstract
Glasdegib is an inhibitor of the Hedgehog pathway recently approved in the United States for the treatment of acute myeloid leukemia. A population pharmacokinetic analysis was conducted to characterize the kinetic behavior of glasdegib and its sources of variability (covariates) by utilizing data from 269 patients with cancer treated with oral glasdegib doses ranging from 5 to 640 mg/d. Nonlinear mixed-effects modeling was conducted using NONMEM (v.7.3) and Perl-speaks NONMEM (v.4.2.0). The estimated apparent total clearance, apparent central volume of distribution, and apparent peripheral volume of distribution were 6.27 L/h, 3.32 L, and 279.2 L, respectively. Age, sex, race, and hepatic function were not significant covariates on glasdegib pharmacokinetic parameters. Baseline body weight, percentage bone marrow blasts, creatinine clearance, and use of moderate or strong cytochrome P450 3A inhibitors were statistically significant covariates on apparent total clearance; however, the magnitude of the effects was not considered clinically meaningful.
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Affiliation(s)
- Swan Lin
- Clinical PharmacologyGlobal Product DevelopmentPfizer IncSan DiegoCaliforniaUSA
| | - Naveed Shaik
- Clinical PharmacologyGlobal Product DevelopmentPfizer IncSan DiegoCaliforniaUSA
| | - Giovanni Martinelli
- Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST IRCCS)MeldolaItaly
| | | | - Jorge Cortes
- University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Ana Ruiz‐Garcia
- Clinical PharmacologyGlobal Product DevelopmentPfizer IncSan DiegoCaliforniaUSA
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58
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Cortes JE, Dombret H, Merchant A, Tauchi T, DiRienzo CG, Sleight B, Zhang X, Leip EP, Shaik N, Bell T, Chan G, Sekeres MA. Glasdegib plus intensive/nonintensive chemotherapy in untreated acute myeloid leukemia: BRIGHT AML 1019 Phase III trials. Future Oncol 2019; 15:3531-3545. [DOI: 10.2217/fon-2019-0373] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Glasdegib, an oral Hedgehog pathway inhibitor, has been associated with significantly improved survival when combined with low-dose cytarabine in patients with untreated acute myeloid leukemia (AML) who were unsuitable for intensive chemotherapy, when compared with low-dose cytarabine alone. BRIGHT AML 1019 (NCT03416179) comprises two independently powered Phase III, randomized (1:1), double-blind global trials evaluating oral glasdegib 100 mg once daily or placebo plus one of two standard chemotherapy regimens in adults with untreated AML. The intensive trial combines glasdegib/placebo with cytarabine and daunorubicin (7 + 3), while the nonintensive trial combines glasdegib/placebo with azacitidine. The primary end point of both studies is overall survival. Secondary end points include response, time to and duration of response, event-free survival, safety, patient-reported outcomes and pharmacokinetics. Trial registration number: ClinicalTrials.gov identifier: NCT03416179
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Affiliation(s)
- Jorge E Cortes
- Georgia Cancer Center, Augusta University, Augusta, GA 30912, USA
| | - Hervé Dombret
- Institut de Recherche Saint-Louis, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris Institut Universitaire d`Hematologie Hopital Saint Louis, Paris, France
| | - Akil Merchant
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Tetsuzo Tauchi
- Department of Hematology, Shin-Yurigaoka General Hospital, Kawasaki, Japan
| | | | | | - Xiaoxi Zhang
- Pfizer Oncology, Pfizer Inc., New York, NY 10017, USA
| | - Eric P Leip
- Pfizer Oncology, Pfizer Inc., New York, NY 10017, USA
| | - Naveed Shaik
- Pfizer Oncology, Pfizer Inc., New York, NY 10017, USA
| | - Timothy Bell
- Pfizer Oncology, Pfizer Inc., New York, NY 10017, USA
| | - Geoffrey Chan
- Pfizer Oncology, Pfizer Inc., New York, NY 10017, USA
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Wolska-Washer A, Robak T. Glasdegib in the treatment of acute myeloid leukemia. Future Oncol 2019; 15:3219-3232. [DOI: 10.2217/fon-2019-0171] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Pharmacologic inhibition of the Hedgehog pathway significantly enhanced the sensitivity of leukemic cells to cytotoxic drugs. Glasdegib (PF-04449913; DAURISMO™) is a potent and selective oral inhibitor of the Hedgehog signaling pathway with clinical activity in patients with acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS), particularly in combination with chemotherapy. The results of Phase Ib/II studies evaluating safety and efficacy of glasdegib combined with chemotherapy in previously untreated patients with AML or high-risk myelodysplastic syndrome have recently been published. In the BRIGHT AML 1003 study, glasdegib in combination with low-dose cytarabine (LDAC) was well tolerated and demonstrated a significant 54% reduction in mortality compared with LDAC for AML patients. In 2018, the US FDA approved glasdegib in combination with LDAC for the treatment of newly diagnosed patients with AML who are 75 years old or older or who have co-morbidities that preclude use of intensive induction chemotherapy.
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Affiliation(s)
- Anna Wolska-Washer
- Department of Hematology, Medical University of Lodz, ul. Ciolkowskiego 2, 93-510 Lodz, Poland
| | - Tadeusz Robak
- Department of Hematology, Medical University of Lodz, ul. Ciolkowskiego 2, 93-510 Lodz, Poland
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60
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Inaloo ID, Majnooni S. A Fe3
O4
@SiO2
/Schiff Base/Pd Complex as an Efficient Heterogeneous and Recyclable Nanocatalyst for One-Pot Domino Synthesis of Carbamates and Unsymmetrical Ureas. European J Org Chem 2019. [DOI: 10.1002/ejoc.201901140] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Iman Dindarloo Inaloo
- Chemistry Department; College of Sciences; Shiraz University; 84795 71946 Shiraz Iran
| | - Sahar Majnooni
- Chemistry Department; College of Sciences; University of Isfahan; 81746-73441 Isfahan Iran
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61
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Shallis RM, Bewersdorf JP, Boddu PC, Zeidan AM. Hedgehog pathway inhibition as a therapeutic target in acute myeloid leukemia. Expert Rev Anticancer Ther 2019; 19:717-729. [PMID: 31422721 DOI: 10.1080/14737140.2019.1652095] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: The Hedgehog (HH) pathway constitutes a collection of signaling molecules which critically influence embryogenesis. In adults, however, the HH pathway remains integral to the proliferation, maintenance, and apoptosis of adult stem cells including hematopoietic stem cells. Areas covered: We discuss the current understanding of the HH pathway as it relates to normal hematopoiesis, the pathology of acute myeloid leukemia (AML), the rationale for and data from combination therapies including HH pathway inhibitors, and ultimately the prospects that might offer promise in targeting this pathway in AML. Expert opinion: Efforts to target the HH pathway have been focused on impeding this disposition and restoring chemosensitivity to conventional myeloid neoplasm therapies. The year 2018 saw the first approval of a HH pathway inhibitor (glasdegib) for AML, though for an older population and in combination with an uncommonly-used therapy. Several other clinical trials with agents targeting modulators of HH signaling in AML and MDS are underway. Further study and understanding of the interplay between the numerous aspects of HH signaling and how it relates to the augmented survival of AML will provide a more reliable substrate for therapeutic strategies in patients with this poor-risk disease.
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Affiliation(s)
- Rory M Shallis
- Division of Hematology, Department of Medicine, Yale University School of Medicine , New Haven , CT , USA
| | - Jan Philipp Bewersdorf
- Division of Hematology, Department of Medicine, Yale University School of Medicine , New Haven , CT , USA
| | - Prajwal C Boddu
- Division of Hematology, Department of Medicine, Yale University School of Medicine , New Haven , CT , USA
| | - Amer M Zeidan
- Division of Hematology, Department of Medicine, Yale University School of Medicine , New Haven , CT , USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University , New Haven , CT , USA
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62
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Bhateja P, Cherian M, Majumder S, Ramaswamy B. The Hedgehog Signaling Pathway: A Viable Target in Breast Cancer? Cancers (Basel) 2019; 11:cancers11081126. [PMID: 31394751 PMCID: PMC6721501 DOI: 10.3390/cancers11081126] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 07/23/2019] [Accepted: 07/30/2019] [Indexed: 12/24/2022] Open
Abstract
The hedgehog (Hh) pathway plays a key role in embryonic development and stem cell programs. Deregulation of the Hh pathway is a key driver of basal cell carcinoma, and therapeutic targeting led to approval of Hh inhibitor, vismodegib, in the management of this cancer. The Hh pathway is implicated in other malignancies including hormone receptor (HR+) positive and triple negative breast cancer (TNBC). Hh signaling, which is activated in human mammary stem cells, results in activation of glioma-associated oncogene (GLI) transcription factors. High GLI1 expression correlates with worse outcomes in breast cancer. Non-canonical GLI1 activation is one mechanism by which estrogen exposure promotes breast cancer stem cell proliferation and epithelial–mesenchymal transition. Tamoxifen resistant cell lines show aberrant activation of Hh signaling, and knockdown of Hh pathway inhibited growth of tamoxifen resistant cells. As in other cancers Hh signaling is activated by the PI3K/AKT pathway in these endocrine resistant cell lines. Hh pathway activation has also been reported to mediate chemotherapy resistance in TNBC via various mechanisms including paracrine signaling to tumor micro-environment and selective proliferation of cancer stem cells. Co-activation of Hh and Wnt signaling pathways is a poor prognostic marker in TNBC. Early phase clinical trials are evaluating the combination of smoothened (SMO) inhibitors and chemotherapy in TNBC. In addition to SMO inhibitors like vismodegib and sonidegib, which are in clinical use for basal cell carcinoma, GLI1 inhibitors like GANT58 and GANT61 are in preclinical drug development and might be an effective mechanism to overcome drug resistance in breast cancer. Gene signatures predictive of Hh pathway activation could enrich for patients likely to respond to these agents.
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Affiliation(s)
- Priyanka Bhateja
- Division of Medical Oncology, Department of Internal medicine, James Comprehensive Cancer Center, Ohio State University, Columbus, OH 43210, USA
| | - Mathew Cherian
- Division of Medical Oncology, Department of Internal medicine, James Comprehensive Cancer Center, Ohio State University, Columbus, OH 43210, USA
| | - Sarmila Majumder
- Division of Medical Oncology, Department of Internal medicine, James Comprehensive Cancer Center, Ohio State University, Columbus, OH 43210, USA
| | - Bhuvaneswari Ramaswamy
- Division of Medical Oncology, Department of Internal medicine, James Comprehensive Cancer Center, Ohio State University, Columbus, OH 43210, USA.
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63
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Winer ES, Stone RM. Novel therapy in Acute myeloid leukemia (AML): moving toward targeted approaches. Ther Adv Hematol 2019; 10:2040620719860645. [PMID: 31321011 PMCID: PMC6624910 DOI: 10.1177/2040620719860645] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/30/2019] [Indexed: 12/20/2022] Open
Abstract
Acute myeloid leukemia (AML) is a heterogenous and complex disease characterized by rapid cellular proliferation, an aggressive clinical course, and generally high mortality. While progress has been made in the understanding of the genetic and molecular biology of the disease, the standard of care for patients had only changed minimally over the past 40 years. Recently, rapid movement of potentially useful agents from bench to bedside has translated into new therapies either recently approved or in clinical trials. These therapies include improved chemotherapies, mutationally targeted inhibitors, pro-apoptotic agents, microenvironment targeting molecules, cell cycle checkpoint inhibitors, and epigenetic regulators. Furthermore, advances in immunotherapy employ monoclonal and bispecific antibodies, chimeric antigen receptor (CAR) T cells, checkpoint inhibitors, and vaccines provide an alternative pathway for AML treatment. In this review, we discuss the recent results of completed or ongoing clinical trials with these novel therapeutic agents in AML.
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Affiliation(s)
- Eric S. Winer
- Dana-Farber Cancer Institute, Leukemia Division,
Department of Medical Oncology, Boston, MA, USA
| | - Richard M. Stone
- Dana-Farber Cancer Institute, Leukemia Division,
Department of Medical Oncology, 450 Brookline Ave., Boston, MA 02115,
USA
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64
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Carpenter RL, Ray H. Safety and Tolerability of Sonic Hedgehog Pathway Inhibitors in Cancer. Drug Saf 2019; 42:263-279. [PMID: 30649745 DOI: 10.1007/s40264-018-0777-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The hedgehog pathway, for which sonic hedgehog (Shh) is the most prominent ligand, is highly conserved and is tightly associated with embryonic development in a number of species. This pathway is also tightly associated with the development of several types of cancer, including basal cell carcinoma (BCC) and acute promyelocytic leukemia, among many others. Inactivating mutations in Patched-1 (PTCH1), leading to ligand-independent pathway activation, are frequent in several cancer types, but most prominent in BCC. This has led to the development of several compounds targeting this pathway as a cancer therapeutic. These compounds target the inducers of this pathway in Smoothened (SMO) and the GLI transcription factors, although targeting SMO has had the most success. Despite the many attempts at targeting this pathway, only three US FDA-approved drugs for cancers affect the Shh pathway. Two of these compounds, vismodegib and sonidegib, target SMO to suppress signaling from either PTCH1 or SMO mutations that lead to upregulation of the pathway. The other approved compound is arsenic trioxide, which can suppress this pathway at the level of the GLI proteins, although current evidence suggests it also has other targets. This review focuses on the safety and tolerability of these clinically approved drugs targeting the Shh pathway, along with a discussion on other Shh pathway inhibitors being developed.
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Affiliation(s)
- Richard L Carpenter
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, 1001 E. 3rd St, Bloomington, IN, 47405, USA. .,Medical Sciences, Indiana University School of Medicine, 1001 E. 3rd St, Bloomington, IN, 47405, USA. .,Simon Cancer Center, Indiana University School of Medicine, 535 Barnhill Dr., Indianapolis, IN, 46202, USA.
| | - Haimanti Ray
- Medical Sciences, Indiana University School of Medicine, 1001 E. 3rd St, Bloomington, IN, 47405, USA
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65
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Pietrobono S, Gagliardi S, Stecca B. Non-canonical Hedgehog Signaling Pathway in Cancer: Activation of GLI Transcription Factors Beyond Smoothened. Front Genet 2019; 10:556. [PMID: 31244888 PMCID: PMC6581679 DOI: 10.3389/fgene.2019.00556] [Citation(s) in RCA: 184] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 05/24/2019] [Indexed: 12/16/2022] Open
Abstract
The Hedgehog-GLI (HH-GLI) pathway is a highly conserved signaling that plays a critical role in controlling cell specification, cell–cell interaction and tissue patterning during embryonic development. Canonical activation of HH-GLI signaling occurs through binding of HH ligands to the twelve-pass transmembrane receptor Patched 1 (PTCH1), which derepresses the seven-pass transmembrane G protein-coupled receptor Smoothened (SMO). Thus, active SMO initiates a complex intracellular cascade that leads to the activation of the three GLI transcription factors, the final effectors of the HH-GLI pathway. Aberrant activation of this signaling has been implicated in a wide variety of tumors, such as those of the brain, skin, breast, gastrointestinal, lung, pancreas, prostate and ovary. In several of these cases, activation of HH-GLI signaling is mediated by overproduction of HH ligands (e.g., prostate cancer), loss-of-function mutations in PTCH1 or gain-of-function mutations in SMO, which occur in the majority of basal cell carcinoma (BCC), SHH-subtype medulloblastoma and rhabdomyosarcoma. Besides the classical canonical ligand-PTCH1-SMO route, mounting evidence points toward additional, non-canonical ways of GLI activation in cancer. By non-canonical we refer to all those mechanisms of activation of the GLI transcription factors occurring independently of SMO. Often, in a given cancer type canonical and non-canonical activation of HH-GLI signaling co-exist, and in some cancer types, more than one mechanism of non-canonical activation may occur. Tumors harboring non-canonical HH-GLI signaling are less sensitive to SMO inhibition, posing a threat for therapeutic efficacy of these antagonists. Here we will review the most recent findings on the involvement of alternative signaling pathways in inducing GLI activity in cancer and stem cells. We will also discuss the rationale of targeting these oncogenic pathways in combination with HH-GLI inhibitors as a promising anti-cancer therapies.
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Affiliation(s)
- Silvia Pietrobono
- Tumor Cell Biology Unit - Core Research Laboratory, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), Florence, Italy
| | - Sinforosa Gagliardi
- Tumor Cell Biology Unit - Core Research Laboratory, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), Florence, Italy
| | - Barbara Stecca
- Tumor Cell Biology Unit - Core Research Laboratory, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), Florence, Italy
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66
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Cortes JE, Gutzmer R, Kieran MW, Solomon JA. Hedgehog signaling inhibitors in solid and hematological cancers. Cancer Treat Rev 2019; 76:41-50. [PMID: 31125907 DOI: 10.1016/j.ctrv.2019.04.005] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 04/25/2019] [Accepted: 04/26/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND The hedgehog signaling pathway is normally tightly regulated. Mutations in hedgehog pathway components may lead to abnormal activation. Aberrantly activated hedgehog signaling plays a major role in the development of solid and hematological cancer. In recent years, inhibitors have been developed that attenuate hedgehog signaling; 2 have been approved for use in basal cell carcinoma (BCC), while others are under development or in clinical trials. The aim of this review is to provide an overview of known hedgehog inhibitors (HHIs) and their potential for the treatment of hematological cancers and solid tumors beyond BCC. DESIGN Published literature was searched to identify articles relating to HHIs in noncutaneous cancer. Both preclinical and clinical research articles were included. In addition, relevant clinical trial results were identified from www.clinicaltrials.gov. Information on the pharmacology of HHIs is also included. RESULTS HHIs show activity in a variety of solid and hematological cancers. In preclinical studies, HHIs demonstrated efficacy in pancreatic cancer, rhabdomyosarcoma, breast cancer, and acute myeloid leukemia (AML). In clinical studies, HHIs showed activity in medulloblastoma, as well as prostate, pancreatic, and hematological cancers. Current clinical trials testing the efficacy of HHIs are underway for prostate, pancreatic, and breast cancers, as well as multiple myeloma and AML. CONCLUSIONS As clinical trial results become available, it will be possible to discern which additional tumor types are suited to HHI mono- or combination therapy with other anticancer agents. The latter strategy may be useful for delaying or overcoming drug resistance.
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Affiliation(s)
- Jorge E Cortes
- Department of Leukemia, MD Anderson Cancer Center, 1515 Holcombe Blvd. #428, Houston, TX 77030, USA.
| | - Ralf Gutzmer
- Skin Cancer Center Hannover, Department of Dermatology, Hannover Medical School, Carl-Neuberg Str 1, D-30625 Hannover, Germany.
| | - Mark W Kieran
- Dana-Farber Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA.
| | - James A Solomon
- Ameriderm Research, 725 W Granada Blvd Ste 44, Ormond Beach, FL 32174, USA; University of Central Florida, Orlando, FL, USA.
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67
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Bhatt VR. Personalizing therapy for older adults with acute myeloid leukemia: Role of geriatric assessment and genetic profiling. Cancer Treat Rev 2019; 75:52-61. [PMID: 31003190 PMCID: PMC6481658 DOI: 10.1016/j.ctrv.2019.04.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 04/07/2019] [Indexed: 01/16/2023]
Abstract
Acute myeloid leukemia (AML) presents therapeutic challenges in older adults because of high-risk leukemia biology conferring chemoresistance, and poor functional status resulting in increased therapy-related toxicities. Recent FDA approval of 8 new drugs for AML has increased therapeutic armamentarium and also provides effective low-intensity treatment options. Rational therapy selection strategies that consider individual's risk of therapy-related toxicities and probability of disease control can maximize benefits of available treatments. Studies have demonstrated that fitness level, measured by geriatric assessment can predict therapy-related toxicities, whereas cytogenetic and mutation results correlate with the probability of responses to standard chemotherapy. We are approaching an era when we move from "one size fits all" approach to personalized therapy selection based on geriatric assessment, genetic and molecular profiling.
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Affiliation(s)
- Vijaya Raj Bhatt
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE, United States; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, United States.
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Xie H, Paradise BD, Ma WW, Fernandez-Zapico ME. Recent Advances in the Clinical Targeting of Hedgehog/GLI Signaling in Cancer. Cells 2019; 8:E394. [PMID: 31035664 PMCID: PMC6562674 DOI: 10.3390/cells8050394] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 04/24/2019] [Accepted: 04/25/2019] [Indexed: 12/11/2022] Open
Abstract
The Hedgehog/GLI signaling pathway plays an important role in normal embryonic tissue development and has been implicated in the pathogenesis of various human cancers. In this review article, we summarize pre-clinical evidence supporting the suitability of targeting this signaling pathway in cancers. We review agents blocking both the ligand-dependent and ligand-independent cascades, and discuss the clinical evidence, which has led to the FDA approval of Hedgehog receptor Smoothened inhibitors, vismodegib, and sonidegib, in different malignancies. Finally, we provide an overview of published and ongoing clinical trial data on single agent or combination therapeutic strategies, targeting Hedgehog/GLI signaling pathway, in both advanced solid tumors and hematologic malignancies.
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Affiliation(s)
- Hao Xie
- Division of Medical Oncology, Mayo Clinic, Rochester, MN 55905, USA.
| | - Brooke D Paradise
- Schulze Center for Novel Therapeutics, Division of Oncology Research, Mayo Clinic, Rochester, MN 55905, USA..
| | - Wen Wee Ma
- Division of Medical Oncology, Mayo Clinic, Rochester, MN 55905, USA.
| | - Martin E Fernandez-Zapico
- Schulze Center for Novel Therapeutics, Division of Oncology Research, Mayo Clinic, Rochester, MN 55905, USA..
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69
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Bohl SR, Bullinger L, Rücker FG. New Targeted Agents in Acute Myeloid Leukemia: New Hope on the Rise. Int J Mol Sci 2019; 20:E1983. [PMID: 31018543 PMCID: PMC6515298 DOI: 10.3390/ijms20081983] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 04/17/2019] [Accepted: 04/19/2019] [Indexed: 02/07/2023] Open
Abstract
The therapeutic approach for acute myeloid leukemia (AML) remains challenging, since over the last four decades a stagnation in standard cytotoxic treatment has been observed. But within recent years, remarkable advances in the understanding of the molecular heterogeneity and complexity of this disease have led to the identification of novel therapeutic targets. In the last two years, seven new targeted agents (midostaurin, gilteritinib, enasidenib, ivosidenib, glasdegib, venetoclax and gemtuzumab ozogamicin) have received US Food and Drug Administration (FDA) approval for the treatment of AML. These drugs did not just prove to have a clinical benefit as single agents but have especially improved AML patient outcomes if they are combined with conventional therapy. In this review, we will focus on currently approved and promising upcoming agents and we will discuss controversial aspects and limitations of targeted treatment strategies.
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Affiliation(s)
- Stephan R Bohl
- Department of Internal Medicine III, University Hospital Ulm, 89081 Ulm, Germany.
| | - Lars Bullinger
- Department of Hematology, Oncology and Tumorimmunology, Charité University Medicine, 13353 Berlin, Germany.
| | - Frank G Rücker
- Department of Internal Medicine III, University Hospital Ulm, 89081 Ulm, Germany.
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70
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Peer E, Tesanovic S, Aberger F. Next-Generation Hedgehog/GLI Pathway Inhibitors for Cancer Therapy. Cancers (Basel) 2019; 11:cancers11040538. [PMID: 30991683 PMCID: PMC6520835 DOI: 10.3390/cancers11040538] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 04/04/2019] [Accepted: 04/09/2019] [Indexed: 12/26/2022] Open
Abstract
The Hedgehog/Glioma-associated oncogene homolog (HH/GLI) signaling pathway regulates self-renewal of rare and highly malignant cancer stem cells (CSC), which have been shown to account for the initiation and maintenance of tumor growth as well as for drug resistance, metastatic spread and relapse. Efficacious therapeutic approaches targeting CSC pathways, such as HH/GLI signaling in combination with chemo, radiation or immunotherapy are, therefore, of high medical need. Pharmacological inhibition of HH/GLI pathway activity represents a promising approach to eliminate malignant CSC. Clinically approved HH/GLI pathway inhibitors target the essential pathway effector Smoothened (SMO) with striking therapeutic efficacy in skin and brain cancer patients. However, multiple genetic and molecular mechanisms resulting in de novo and acquired resistance to SMO inhibitors pose major limitations to anti-HH/GLI therapies and, thus, the eradication of CSC. In this review, we summarize reasons for clinical failure of SMO inhibitors, including mechanisms caused by genetic alterations in HH pathway effectors or triggered by additional oncogenic signals activating GLI transcription factors in a noncanonical manner. We then discuss emerging novel and rationale-based approaches to overcome SMO-inhibitor resistance, focusing on pharmacological perturbations of enzymatic modifiers of GLI activity and on compounds either directly targeting oncogenic GLI factors or interfering with synergistic crosstalk signals known to boost the oncogenicity of HH/GLI signaling.
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Affiliation(s)
- Elisabeth Peer
- Department of Biosciences, Paris-Lodron University of Salzburg, Cancer Cluster Salzburg, Hellbrunner Strasse 34, 5020 Salzburg, Austria.
| | - Suzana Tesanovic
- Department of Biosciences, Paris-Lodron University of Salzburg, Cancer Cluster Salzburg, Hellbrunner Strasse 34, 5020 Salzburg, Austria.
| | - Fritz Aberger
- Department of Biosciences, Paris-Lodron University of Salzburg, Cancer Cluster Salzburg, Hellbrunner Strasse 34, 5020 Salzburg, Austria.
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71
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Terao T, Minami Y. Targeting Hedgehog (Hh) Pathway for the Acute Myeloid Leukemia Treatment. Cells 2019; 8:cells8040312. [PMID: 30987263 PMCID: PMC6523210 DOI: 10.3390/cells8040312] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 03/25/2019] [Accepted: 03/28/2019] [Indexed: 02/06/2023] Open
Abstract
The Hedgehog (Hh) pathway, containing the Patched (PTCH) and Smoothened (SMO) multitransmembrane proteins, is the main regulator of vertebrate embryonic development. A non-canonical Hh pathway was recently observed in numerous types of solid cancers and hematological malignancies. Although acute myeloid leukemia (AML) is a common and lethal myeloid malignancy, the chemotherapy for AML has not changed in the last three decades. The Hh pathway and other intracellular signaling pathways are important for the tumor cells’ cycle or therapeutic resistance of AML cells. In this article, we will review the current trends in Hh pathway inhibitors for treating AML.
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Affiliation(s)
- Toshiki Terao
- Department of Hematology, National Cancer Center Hospital East, Kashiwa 277-8577, Japan.
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa 296-8602, Japan.
| | - Yosuke Minami
- Department of Hematology, National Cancer Center Hospital East, Kashiwa 277-8577, Japan.
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72
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LeBlanc TW, Erba HP. Shifting paradigms in the treatment of older adults with AML. Semin Hematol 2019; 56:110-117. [DOI: 10.1053/j.seminhematol.2019.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 02/22/2019] [Indexed: 12/31/2022]
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73
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Canaani J. Management of AML Beyond "3 + 7" in 2019. Clin Hematol Int 2019; 1:10-18. [PMID: 34595406 PMCID: PMC8432380 DOI: 10.2991/chi.d.190316.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 03/06/2019] [Indexed: 12/25/2022] Open
Abstract
The therapeutic paradigm for treatment of acute myeloid leukemia (AML) is rapidly changing with the advent of a new generation of drugs targeting diverse aspects of leukemogenesis. Whereas standard treatment for AML until recently consisted of a classic chemotherapy backbone, the incorporation of novel agents targeting pathogenic mutations, myeloid surface markers, and apoptosis-related proteins may become a reality in the next few years. In this review, we outline the therapeutic landscape of recently approved novel agents for AML, including FLT3 inhibitors, isocitrate dehydrogenase 1/2 (IDH1/2) inhibitors, Bcl-2 antagonists, hedgehog signaling inhibitors, and immunotherapy-based approaches. Some of the future challenges in the field would be to delineate which specific patient subsets derive the most clinical benefit from a given novel agent and, furthermore, which drug combinations will yield the maximal antileukemia effect without increased toxicity. To this end, it is expected that advances in genomic and epigenomic classification of AML will facilitate a rational and optimal choice of these novel agents for AML patients.
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Affiliation(s)
- Jonathan Canaani
- Hematology Division, Chaim Sheba Medical Center, Tel Hashomer, Israel
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74
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Girardi D, Barrichello A, Fernandes G, Pereira A. Targeting the Hedgehog Pathway in Cancer: Current Evidence and Future Perspectives. Cells 2019; 8:cells8020153. [PMID: 30759860 PMCID: PMC6406365 DOI: 10.3390/cells8020153] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/10/2019] [Accepted: 02/11/2019] [Indexed: 01/05/2023] Open
Abstract
The Hedgehog pathway (HhP) plays an important role in normal embryonic development and its abnormal function has been linked to a variety of neoplasms. Recently, the complex mechanisms involved in this pathway have been deciphered and the cross talks with other important pathways involved in carcinogenesis have been characterized. This knowledge has led to the development of targeted therapies against key components of HhP, which culminated in the approval of vismodegib for the treatment of advanced basal cell carcinoma in 2012. Since then, other compounds have been developed and evaluated in preclinical and clinical studies with interesting results. Today, several medications against components of the HhP have demonstrated clinical activity as monotherapies and in combination with cytotoxic treatment or other targeted therapies against mitogenic pathways that are linked to the HhP. This review aims to clarify the mechanism of the HhP and the complex crosstalk with others pathways involved in carcinogenesis and to discuss both the evidence associated with the growing number of medications and combined therapies addressing this pathway and future perspectives.
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Affiliation(s)
- Daniel Girardi
- Division of Medical Oncology, Hospital Sírio-Libanês, Brasilia, 70200-730, Brazil.
| | - Adriana Barrichello
- Division of Medical Oncology, Hospital Sírio-Libanês, Brasilia, 70200-730, Brazil.
| | - Gustavo Fernandes
- Division of Medical Oncology, Hospital Sírio-Libanês, Brasilia, 70200-730, Brazil.
| | - Allan Pereira
- Division of Medical Oncology, Hospital Sírio-Libanês, Brasilia, 70200-730, Brazil.
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75
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76
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Bewersdorf JP, Stahl M, Zeidan AM. Are we witnessing the start of a therapeutic revolution in acute myeloid leukemia? Leuk Lymphoma 2019; 60:1354-1369. [DOI: 10.1080/10428194.2018.1546854] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Jan Philipp Bewersdorf
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Maximilian Stahl
- Division of Hematologic Malignancies, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amer M. Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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77
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Leukemia Stem Cells in the Pathogenesis, Progression, and Treatment of Acute Myeloid Leukemia. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1143:95-128. [DOI: 10.1007/978-981-13-7342-8_5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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78
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Pession A, Lonetti A, Bertuccio S, Locatelli F, Masetti R. Targeting Hedgehog pathway in pediatric acute myeloid leukemia: challenges and opportunities. Expert Opin Ther Targets 2018; 23:87-91. [PMID: 30556755 DOI: 10.1080/14728222.2019.1559822] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Andrea Pession
- a Department of Pediatrics, "Lalla Seràgnoli", Hematology-Oncology Unit , University of Bologna , Bologna , Italy
| | - Annalisa Lonetti
- a Department of Pediatrics, "Lalla Seràgnoli", Hematology-Oncology Unit , University of Bologna , Bologna , Italy
| | - Salvatore Bertuccio
- a Department of Pediatrics, "Lalla Seràgnoli", Hematology-Oncology Unit , University of Bologna , Bologna , Italy
| | - Franco Locatelli
- b Department of Pediatric Hematology-Oncology and Cell and Gene Therapy, IRCCS Ospedale Pediatrico Bambino Gesù , Sapienza University , Rome , Italy
| | - Riccardo Masetti
- a Department of Pediatrics, "Lalla Seràgnoli", Hematology-Oncology Unit , University of Bologna , Bologna , Italy
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79
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Cortes JE, Heidel FH, Hellmann A, Fiedler W, Smith BD, Robak T, Montesinos P, Pollyea DA, DesJardins P, Ottmann O, Ma WW, Shaik MN, Laird AD, Zeremski M, O'Connell A, Chan G, Heuser M. Randomized comparison of low dose cytarabine with or without glasdegib in patients with newly diagnosed acute myeloid leukemia or high-risk myelodysplastic syndrome. Leukemia 2018; 33:379-389. [PMID: 30555165 PMCID: PMC6365492 DOI: 10.1038/s41375-018-0312-9] [Citation(s) in RCA: 350] [Impact Index Per Article: 58.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 11/02/2018] [Indexed: 01/19/2023]
Abstract
Glasdegib is a Hedgehog pathway inhibitor. This phase II, randomized, open-label, multicenter study (ClinicalTrials.gov, NCT01546038) evaluated the efficacy of glasdegib plus low-dose cytarabine (LDAC) in patients with acute myeloid leukemia (AML) or high-risk myelodysplastic syndrome unsuitable for intensive chemotherapy. Glasdegib 100 mg (oral, QD) was administered continuously in 28-day cycles; LDAC 20 mg (subcutaneous, BID) was administered for 10 per 28 days. Patients (stratified by cytogenetic risk) were randomized (2:1) to receive glasdegib/LDAC or LDAC. The primary endpoint was overall survival. Eighty-eight and 44 patients were randomized to glasdegib/LDAC and LDAC, respectively. Median (80% confidence interval [CI]) overall survival was 8.8 (6.9–9.9) months with glasdegib/LDAC and 4.9 (3.5–6.0) months with LDAC (hazard ratio, 0.51; 80% CI, 0.39–0.67, P = 0.0004). Fifteen (17.0%) and 1 (2.3%) patients in the glasdegib/LDAC and LDAC arms, respectively, achieved complete remission (P < 0.05). Nonhematologic grade 3/4 all-causality adverse events included pneumonia (16.7%) and fatigue (14.3%) with glasdegib/LDAC and pneumonia (14.6%) with LDAC. Clinical efficacy was evident across patients with diverse mutational profiles. Glasdegib plus LDAC has a favorable benefit–risk profile and may be a promising option for AML patients unsuitable for intensive chemotherapy.
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Affiliation(s)
- Jorge E Cortes
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
| | - Florian H Heidel
- Otto-von-Guericke University Medical Center, Magdeburg, Germany.,Internal Medicine II, University Hospital Jena, Jena, Germany
| | - Andrzej Hellmann
- Department of Haematology and Transplantology, Medical University of Gdańsk, Gdańsk, Poland
| | - Walter Fiedler
- Department of Hematology and Oncology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - B Douglas Smith
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Lodz, Poland
| | - Pau Montesinos
- Hospital Universitari i Politècnic La Fe, Valencia, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Daniel A Pollyea
- Division of Hematology, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Oliver Ottmann
- Division of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff, UK
| | | | | | | | | | | | | | - Michael Heuser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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80
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Pietrobono S, Stecca B. Targeting the Oncoprotein Smoothened by Small Molecules: Focus on Novel Acylguanidine Derivatives as Potent Smoothened Inhibitors. Cells 2018; 7:cells7120272. [PMID: 30558232 PMCID: PMC6316656 DOI: 10.3390/cells7120272] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 11/30/2018] [Accepted: 12/10/2018] [Indexed: 12/13/2022] Open
Abstract
Hedgehog-GLI (HH) signaling was originally identified as a critical morphogenetic pathway in embryonic development. Since its discovery, a multitude of studies have reported that HH signaling also plays key roles in a variety of cancer types and in maintaining tumor-initiating cells. Smoothened (SMO) is the main transducer of HH signaling, and in the last few years, it has emerged as a promising therapeutic target for anticancer therapy. Although vismodegib and sonidegib have demonstrated effectiveness for the treatment of basal cell carcinoma (BCC), their clinical use has been hampered by severe side effects, low selectivity against cancer stem cells, and the onset of mutation-driven drug resistance. Moreover, SMO antagonists are not effective in cancers where HH activation is due to mutations of pathway components downstream of SMO, or in the case of noncanonical, SMO-independent activation of the GLI transcription factors, the final mediators of HH signaling. Here, we review the current and rapidly expanding field of SMO small-molecule inhibitors in experimental and clinical settings, focusing on a class of acylguanidine derivatives. We also discuss various aspects of SMO, including mechanisms of resistance to SMO antagonists.
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Affiliation(s)
- Silvia Pietrobono
- Tumor Cell Biology Unit⁻Core Research Laboratory, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), 50139 Florence, Italy.
| | - Barbara Stecca
- Tumor Cell Biology Unit⁻Core Research Laboratory, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), 50139 Florence, Italy.
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81
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Cladribine in the remission induction of adult acute myeloid leukemia: where do we stand? Ann Hematol 2018; 98:561-579. [DOI: 10.1007/s00277-018-3562-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 11/16/2018] [Indexed: 01/22/2023]
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82
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Cortes JE, Douglas Smith B, Wang ES, Merchant A, Oehler VG, Arellano M, DeAngelo DJ, Pollyea DA, Sekeres MA, Robak T, Ma WW, Zeremski M, Naveed Shaik M, Douglas Laird A, O'Connell A, Chan G, Schroeder MA. Glasdegib in combination with cytarabine and daunorubicin in patients with AML or high-risk MDS: Phase 2 study results. Am J Hematol 2018; 93:1301-1310. [PMID: 30074259 PMCID: PMC6221102 DOI: 10.1002/ajh.25238] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 07/25/2018] [Accepted: 07/27/2018] [Indexed: 12/21/2022]
Abstract
Glasdegib is a Hedgehog pathway inhibitor. This ongoing, open‐label, phase 2 study (NCT01546038) evaluated glasdegib plus cytarabine/daunorubicin in patients with untreated acute myeloid leukemia (AML) or high‐risk myelodysplastic syndromes (MDS). Patients received glasdegib 100 mg orally, once daily in continuous 28‐day cycles from day −3, with intravenous cytarabine 100 mg/m2 on days 1‐7 and daunorubicin 60 mg/m2 on days 1‐3. Patients in remission then received consolidation therapy (2‐4 cycles of cytarabine 1 g/m2 twice daily on days 1, 3, 5 of each cycle), followed by maintenance glasdegib (maximum 6 cycles). Primary endpoint was complete remission (CR) in patients aged ≥55 years. Secondary endpoints included overall survival (OS), safety and outcome by mutational status. Patients had a median (range) age of 64.0 (27‐75) years, 60.0% were male, and 84.5% were white. In 69 evaluable patients, 46.4% (80% confidence interval [CI]: 38.7‐54.1) achieved investigator‐reported CR. Among patients ≥55 years old (n = 60), 40.0% (80% CI 31.9‐48.1) achieved CR. Among all 69 patients, median OS was 14.9 (80% CI 13.4‐19.3) months, with 12‐month survival probability 66.6% (80% CI 58.5‐73.4). The most common treatment‐related adverse events (≥50% patients) were diarrhea and nausea. There were no significant associations between mutational status (12 genes) and clinical response, suggesting potential benefit across diverse molecular profiles. Glasdegib plus cytarabine/daunorubicin was well tolerated and associated with clinical activity in patients with untreated AML or high‐risk MDS. A randomized phase 3 trial of glasdegib in combination with chemotherapy (7 + 3 schedule) is ongoing.
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Affiliation(s)
- Jorge E. Cortes
- Department of Leukemia; University of Texas, MD Anderson Cancer Center; Houston Texas
| | - B. Douglas Smith
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center; Baltimore Maryland
| | - Eunice S. Wang
- Leukemia Service, Department of Medicine; Roswell Park Comprehensive Cancer Center; Buffalo New York
| | - Akil Merchant
- Department of Medicine, Keck School of Medicine; University of Southern California; Los Angeles California
| | | | - Martha Arellano
- Department of Hematology and Medical Oncology; Emory University School of Medicine; Atlanta Georgia
| | - Daniel J. DeAngelo
- Dana-Farber Cancer Institute and Harvard Medical School; Boston Massachusetts
| | - Daniel A. Pollyea
- Division of Hematology; University of Colorado School of Medicine; Aurora Colorado
| | | | - Tadeusz Robak
- Department of Hematology; Medical University of Lodz; Lodz Poland
| | | | | | | | | | | | | | - Mark A. Schroeder
- Division of Oncology; Washington University School of Medicine; St Louis Missouri
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A phase 1 trial of vadastuximab talirine combined with hypomethylating agents in patients with CD33-positive AML. Blood 2018; 132:1125-1133. [PMID: 30045838 DOI: 10.1182/blood-2018-03-841171] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 07/11/2018] [Indexed: 01/05/2023] Open
Abstract
Treatment of acute myeloid leukemia (AML) among the elderly is challenging because of intolerance of intensive therapy and therapy-resistant biology. Hypomethylating agents (HMAs) are commonly used, with suboptimal outcomes. Vadastuximab talirine is a CD33-directed antibody conjugated to pyrrolobenzodiazepine (PBD) dimers. Preclinically, HMAs followed by vadastuximab talirine produced upregulated CD33 expression, increased DNA incorporation by PBD, and enhanced cytotoxicity. A combination cohort in a phase 1 study (NCT01902329) assessed safety, tolerability, and activity of vadastuximab talirine with HMAs. Those eligible had Eastern Cooperative Oncology Group status 0 to 1 and previously untreated CD33-positive AML, and declined intensive therapy. Vadastuximab talirine was administered intravenously at 10 μg/kg on last day of HMA (azacitidine or decitabine) infusion in 4-week cycles. Among 53 patients treated, the median age was 75 years. Patients had adverse (38%) or intermediate (62%) cytogenetic risk. Median treatment duration was 19.3 weeks. No dose-limiting toxicities were reported. The majority of adverse events were a result of myelosuppression, with some causing therapy delays. Thirty- and 60-day mortality rates were 2% and 8%, respectively. The composite remission rate (complete remission [CR] and CR with incomplete blood count recovery) was 70%. Fifty-one percent of remissions were minimal residual disease-negative by flow cytometry. Similarly high remission rates were observed in patients with secondary AML, aged at least 75 years, and with adverse cytogenetic risk. Median relapse-free survival and overall survival were 7.7 and 11.3 months, respectively. Compared with historical data for HMA monotherapy, the combination of vadastuximab talirine with HMAs produced a high remission rate, but was accompanied by increased hematologic toxicity.
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Kubasch AS, Platzbecker U. Beyond the Edge of Hypomethylating Agents: Novel Combination Strategies for Older Adults with Advanced MDS and AML. Cancers (Basel) 2018; 10:E158. [PMID: 29795051 PMCID: PMC6025349 DOI: 10.3390/cancers10060158] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 05/19/2018] [Accepted: 05/21/2018] [Indexed: 12/14/2022] Open
Abstract
Higher-risk myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) of the elderly exhibit several commonalities, including first line treatment with hypomethylating agents (HMA) like azacitidine (AZA) or decitabine (DAC). Until today, response to treatment occurs in less than 50 percent of patients, and is often short-lived. Moreover, patients failing HMA have a dismal prognosis. Current developments include combinations of HMA with novel drugs targeting epigenetic or immunomodulatory pathways. Other efforts focus on the prevention of resistance to HMA using checkpoint inhibitors to enhance immune attack. This review focuses on recent advances in the field of HMA-based front-line therapies in elderly patients with myeloid diseases.
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Affiliation(s)
- Anne Sophie Kubasch
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany.
| | - Uwe Platzbecker
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany.
- National Center for Tumor Diseases (NCT), University Hospital Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany.
- German Cancer Consortium (DKTK), 01307 Dresden, Germany.
- German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany.
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