51
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Targeting IDH1 and IDH2 Mutations in Acute Myeloid Leukemia: Emerging Options and Pending Questions. Hemasphere 2021; 5:e583. [PMID: 34095766 PMCID: PMC8171378 DOI: 10.1097/hs9.0000000000000583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 04/17/2021] [Indexed: 11/26/2022] Open
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52
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Issa GC, DiNardo CD. Acute myeloid leukemia with IDH1 and IDH2 mutations: 2021 treatment algorithm. Blood Cancer J 2021; 11:107. [PMID: 34083508 PMCID: PMC8175383 DOI: 10.1038/s41408-021-00497-1] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/28/2021] [Accepted: 05/05/2021] [Indexed: 12/31/2022] Open
Abstract
Acute myeloid leukemia is a genetically heterogeneous hematologic malignancy; approximately 20% of AML harbors a mutation in the isocitrate dehydrogenase (IDH) genes, IDH1 or IDH2. These recurrent mutations in key metabolic enzymes lead to the production of the oncometabolite 2-hydroxyglutarate, which promotes leukemogenesis through a block in normal myeloid differentiation. Since this discovery, selective oral inhibitors of mutant IDH1 and IDH2 have subsequently been developed and are now approved as single agent therapy, based on clinical efficacy observed within the original first-in-human trials. The investigation of IDH inhibitors in combination with standard therapies such as azacytidine, with intensive chemotherapy, and with other small molecule targeted therapies in rational combinations are currently under evaluation to further improve upon clinical efficacy.
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Affiliation(s)
- Ghayas C Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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53
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Fathi AT, Stein EM, DiNardo CD, Levis MJ, Montesinos P, Botton S. Differentiation syndrome with lower-intensity treatments for acute myeloid leukemia. Am J Hematol 2021; 96:735-746. [PMID: 33625753 DOI: 10.1002/ajh.26142] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/16/2021] [Accepted: 02/23/2021] [Indexed: 12/19/2022]
Abstract
Differentiation Syndrome (DS) has been identified in a subset of patients undergoing treatment with novel classes of differentiating therapies for acute myeloid leukemia (AML) such as IDH and FLT3 inhibitors. While DS is a well-known treatment-related complication in acute promyelocytic leukemia (APL), efforts are still ongoing to standardize diagnostic and treatment parameters for DS in AML. Though the rates of incidence vary, many of the signs and symptoms of DS are common between APL and AML. So, DS can lead to fatal complications in AML, but prompt management is usually effective and rarely necessitates interruption or discontinuation of AML therapy.
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Affiliation(s)
- Amir T. Fathi
- Massachusetts General Hospital Cancer Center Boston Massachusetts USA
- Harvard Medical School Boston Massachusetts USA
| | - Eytan M. Stein
- Memorial Sloan Kettering Cancer Center New York New York USA
- Weill Cornell Medical College New York New York USA
| | | | - Mark J. Levis
- Sidney Kimmel Comprehensive Cancer Center Johns Hopkins University Baltimore Maryland USA
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54
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Lee E, Koh Y, Hong J, Eom HS, Yoon SS. Recent Clinical Update of Acute Myeloid Leukemia: Focus on Epigenetic Therapies. J Korean Med Sci 2021; 36:e85. [PMID: 33821592 PMCID: PMC8021975 DOI: 10.3346/jkms.2021.36.e85] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 01/20/2021] [Indexed: 01/05/2023] Open
Abstract
Acute myeloid leukemia (AML) is a complicated disease characterized by genetic heterogeneity and simultaneous alterations in multiple genes. For decades, its only curative method has been intensive induction chemotherapy with or without allogeneic hematopoietic stem cell transplantation, and this approach cannot be applied to elderly patients, who make up more than 50% of AML patients. Recent advances in genomics facilitated the elucidation of various mutations related to AML, and the most frequent mutations were discovered in epigenetic regulators. Alterations to epigenetic modifications that are essential for normal cell biology, including DNA methylation and histone acetylation, have been identified. As epigenetic dysregulation is an important carcinogenic mechanism and some epigenetic changes are reversible, these epigenetic alterations have become targets for novel drug development against AML. This review summarizes the recent advances in epigenetic therapies for AML and discusses future research directions.
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Affiliation(s)
- Eunyoung Lee
- Department of Internal Medicine, Center for Hematologic Malignancy, National Cancer Center, Goyang, Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University Hospital, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Junshik Hong
- Department of Internal Medicine, Seoul National University Hospital, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeon Seok Eom
- Department of Internal Medicine, Center for Hematologic Malignancy, National Cancer Center, Goyang, Korea
| | - Sung Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea.
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55
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Cerchione C, Romano A, Daver N, DiNardo C, Jabbour EJ, Konopleva M, Ravandi-Kashani F, Kadia T, Martelli MP, Isidori A, Martinelli G, Kantarjian H. IDH1/IDH2 Inhibition in Acute Myeloid Leukemia. Front Oncol 2021; 11:639387. [PMID: 33898313 PMCID: PMC8063727 DOI: 10.3389/fonc.2021.639387] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/27/2021] [Indexed: 12/22/2022] Open
Abstract
Recently, the discovery of biological and clinical properties of mutated isoforms 1 and 2 mutations of isocitrate dehydrogenases (IDH) 1 and 2, affecting approximately 20% of patients with acute myeloid leukemia (AML), lead to the development of an individualized treatment strategy. Promoting differentiation and maturation of the malignant clone targeting IDH is an emerging strategy to promote clinical responses in AML. Phase I/II trials have shown evidence of safety, tolerability, and encouraging evidence of efficacy of two small molecule inhibitors targeting IDH2 and IDH1 gene mutations, respectively enasidenib and ivosidenib. In this review, the contribution of IDH1/IDH2 mutations in leukemogenesis and progress of targeted therapeutics in AML will be highlighted.
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Affiliation(s)
- Claudio Cerchione
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Alessandra Romano
- Dipartimento di Chirurgia e Specialità Medico-Chirurgiche, Sezione di Ematologia, Università degli Studi di Catania, Catania, Italy
| | - Naval Daver
- Hematology and Clinical Immunology, University of Perugia, Perugia, Italy
| | - Courtney DiNardo
- Hematology and Clinical Immunology, University of Perugia, Perugia, Italy
| | | | - Marina Konopleva
- Hematology and Clinical Immunology, University of Perugia, Perugia, Italy
| | | | - Tapan Kadia
- Hematology and Clinical Immunology, University of Perugia, Perugia, Italy
| | | | - Alessandro Isidori
- Leukemia Department, MD Anderson Cancer Center, Houston, TX, United States
| | - Giovanni Martinelli
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Hagop Kantarjian
- Hematology and Clinical Immunology, University of Perugia, Perugia, Italy
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56
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Abstract
The management of febrile neutropenia is a backbone of treating patients with hematologic malignancies and has evolved over the past decades. This article reviews my approach to the evaluation and treatment of febrile neutropenic patients. Key topics discussed include antibacterial and antifungal prophylaxis, the initial workup for fever, the choice of the empiric antibiotic regimen and its modifications, and criteria for discontinuation. For each of these questions, I review the literature and present my perspective.
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57
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Jasra S, Kazemi M, Shah N, Chen J, Fehn K, Wang Y, Mantzaris I, Kornblum N, Sica A, Bachier L, Goldfinger M, Gritsman K, Braunschweig I, Steidl U, Shastri A, Verma A. Case report of combination therapy with Azacytidine, Enasidenib and Venetoclax in primary refractory AML. Exp Hematol Oncol 2021; 10:1. [PMID: 33397455 PMCID: PMC7784272 DOI: 10.1186/s40164-020-00186-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/29/2020] [Indexed: 11/10/2022] Open
Abstract
Optimal treatment of acute myeloid leukemia (AML) arising in elderly patients remains a challenge. FDA approval of Ivosidenib and Enasidenib, small molecule inhibitors of isocitrate dehydrogenase enzymes (IDH1 and 2) have opened new avenues of treatment. We present a 60-year-old woman with refractory AML, achieving complete response to the combination therapy of hypomethylating agent, Azacytidine with the IDH2 inhibitor, Enasidenib, and BCL2 inhibitor, Venetoclax. To our knowledge, this is the first case report of a patient with IDH2 mutated refractory AML achieving complete response to combination therapy with azacytidine, enasidenib and venetoclax.
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Affiliation(s)
- Sakshi Jasra
- Department of Hematology/Oncology, University of Vermont, 89 Beaumont Avenue, Given E-214, Burlington, VT, 05405, USA.
| | - Mohammed Kazemi
- Albert Einstein College of Medicine, Department of Hematology/Oncology, Bronx, NY, USA
| | - Nishi Shah
- Albert Einstein College of Medicine, Department of Hematology/Oncology, Bronx, NY, USA
| | - Jiahao Chen
- Albert Einstein College of Medicine, Department of Hematology/Oncology, Bronx, NY, USA
| | - Karen Fehn
- Albert Einstein College of Medicine, Department of Hematology/Oncology, Bronx, NY, USA
| | - Yanhua Wang
- Albert Einstein College of Medicine, Department of Hematology/Oncology, Bronx, NY, USA
| | - Ioannis Mantzaris
- Albert Einstein College of Medicine, Department of Hematology/Oncology, Bronx, NY, USA
| | - Noah Kornblum
- Albert Einstein College of Medicine, Department of Hematology/Oncology, Bronx, NY, USA
| | - Alejandro Sica
- Albert Einstein College of Medicine, Department of Hematology/Oncology, Bronx, NY, USA
| | - LizaMarie Bachier
- Albert Einstein College of Medicine, Department of Hematology/Oncology, Bronx, NY, USA
| | - Mendel Goldfinger
- Albert Einstein College of Medicine, Department of Hematology/Oncology, Bronx, NY, USA
| | - Kira Gritsman
- Albert Einstein College of Medicine, Department of Hematology/Oncology, Bronx, NY, USA
| | - Ira Braunschweig
- Albert Einstein College of Medicine, Department of Hematology/Oncology, Bronx, NY, USA
| | - Ulrich Steidl
- Albert Einstein College of Medicine, Department of Hematology/Oncology, Bronx, NY, USA
| | - Aditi Shastri
- Albert Einstein College of Medicine, Department of Hematology/Oncology, Bronx, NY, USA
| | - Amit Verma
- Albert Einstein College of Medicine, Department of Hematology/Oncology, Bronx, NY, USA
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58
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Madan V, Koeffler HP. Differentiation therapy of myeloid leukemia: four decades of development. Haematologica 2021; 106:26-38. [PMID: 33054125 PMCID: PMC7776344 DOI: 10.3324/haematol.2020.262121] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/15/2020] [Indexed: 02/06/2023] Open
Abstract
Acute myeloid leukemia is characterized by arrested differentiation, and agents that overcome this block are therapeutically useful, as shown by the efficacy of all-trans retinoic acid in acute promyelocytic leukemia. However, the early promise of differentiation therapy did not translate into clinical benefit for other subtypes of acute myeloid leukemia, in which cytotoxic chemotherapeutic regimens remained the standard of care. Recent advances, including insights from sequencing of acute myeloid leukemia genomes, have led to the development of targeted therapies, comprising agents that induce differentiation of leukemic cells in preclinical models and clinical trials, thus rejuvenating interest in differentiation therapy. These agents act on various cellular processes including dysregulated metabolic programs, signaling pathways, epigenetic machinery and the cell cycle. In particular, inhibitors of mutant IDH1/2 and FLT3 have shown clinical benefit, leading to approval by regulatory bodies of their use. Besides the focus on recently approved differentiation therapies, this review also provides an overview of differentiation- inducing agents being tested in clinical trials or investigated in preclinical research. Combinatorial strategies are currently being tested for several agents (inhibitors of KDM1A, DOT1L, BET proteins, histone deacetylases), which were not effective in clinical studies as single agents, despite encouraging anti-leukemic activity observed in preclinical models. Overall, recently approved drugs and new investigational agents being developed highlight the merits of differentiation therapy; and ongoing studies promise further advances in the treatment of acute myeloid leukemia in the near future.
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Affiliation(s)
- Vikas Madan
- Cancer Science Institute of Singapore, National University of Singapore.
| | - H Phillip Koeffler
- Cancer Science Institute of Singapore, National University of Singapore; Cedars-Sinai Medical Center, Division of Hematology/Oncology, UCLA School of Medicine, Los Angeles, CA, USA; Department of Hematology-Oncology, National University Cancer Institute of Singapore (NCIS), National University Hospital.
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59
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Wang ES, Baron J. Management of toxicities associated with targeted therapies for acute myeloid leukemia: when to push through and when to stop. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:57-66. [PMID: 33275692 PMCID: PMC7727512 DOI: 10.1182/hematology.2020000089] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
The recent advent of myriad targeted therapies for acute myeloid leukemia (AML) has led to new hope for our patients but has also introduced new challenges in managing the disease. For clinicians, the ability to treat AML in the outpatient setting with novel agents of equal or greater efficacy than 7+3 has been transformative. Despite the enthusiasm, however, the reality is that many patients are still frail and remain at risk for treatment-related complications. Translating the results of clinical trials into improved outcomes for these individuals requires an understanding of how best to manage the adverse effects of these agents. Which patients benefit most and what to watch for? When to stop therapy? Using illustrative case presentations, this review details the unique toxicities associated with each of the approved mutation-specific and nonspecific targeted drugs for AML. The goal of this review is to help clinicians determine the risk:benefit ratio in decision making for individual patients with AML.
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Affiliation(s)
| | - Jeffrey Baron
- Department of Pharmacy, Roswell Park Comprehensive Cancer Center, Buffalo, NY
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60
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Gasparovic L, Weiler S, Higi L, Burden AM. Incidence of Differentiation Syndrome Associated with Treatment Regimens in Acute Myeloid Leukemia: A Systematic Review of the Literature. J Clin Med 2020; 9:E3342. [PMID: 33081000 PMCID: PMC7603213 DOI: 10.3390/jcm9103342] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 12/30/2022] Open
Abstract
Differentiation syndrome (DS) is a potentially fatal adverse drug reaction caused by the so-called differentiating agents such as all-trans retinoic acid (ATRA) and arsenic trioxide (ATO), used for remission induction in the treatment of the M3 subtype of acute myeloid leukemia (AML), acute promyelocytic leukemia (APL). However, recent DS reports in trials of isocitrate dehydrogenase (IDH)-inhibitor drugs in patients with IDH-mutated AML have raised concerns. Given the limited knowledge of the incidence of DS with differentiating agents, we conducted a systematic literature review of clinical trials with reports of DS to provide a comprehensive overview of the medications associated with DS. In particular, we focused on the incidence of DS reported among the IDH-inhibitors, compared to existing ATRA and ATO therapies. We identified 44 published articles, encompassing 39 clinical trials, including 6949 patients. Overall, the cumulative incidence of DS across all treatment regimens was 17.7%. Incidence of DS was notably lower in trials with IDH-inhibitors (10.4%) compared to other regimens, including ATRA and/or ATO (15.4-20.6%). Compared to other therapies, the median time to onset was four times longer with IDH-inhibitors (48 vs. 11 days). Treating oncologists should be mindful of this potentially fatal adverse drug reaction, as we expect the current trials represent an underestimation of the actual incidence.
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Affiliation(s)
- Lucia Gasparovic
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, 8093 Zurich, Switzerland; (L.G.); (S.W.); (L.H.)
| | - Stefan Weiler
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, 8093 Zurich, Switzerland; (L.G.); (S.W.); (L.H.)
- National Poisons Information Centre, Tox Info Suisse, Associated Institute of the University of Zurich, 8032 Zurich, Switzerland
| | - Lukas Higi
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, 8093 Zurich, Switzerland; (L.G.); (S.W.); (L.H.)
| | - Andrea M. Burden
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, 8093 Zurich, Switzerland; (L.G.); (S.W.); (L.H.)
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61
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Martelli MP, Martino G, Cardinali V, Falini B, Martinelli G, Cerchione C. Enasidenib and ivosidenib in AML. Minerva Med 2020; 111:411-426. [PMID: 32955829 DOI: 10.23736/s0026-4806.20.07024-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The isocitrate dehydrogenases enzymes, IDH1 and IDH2, catalyze the conversion of isocitrate to α-ketoglutarate (αKG) in the cell cytoplasm and mitochondria, respectively, and contribute to generating the dihydronicotinamide-adenine dinucleotide phosphate (NADPH) as reductive potential in different cellular processes. Mutations in IDH1 and IDH2 genes are found collectively in about 20-25% of acute myeloid leukemia (AML) patients. Mutant IDH enzymes have neomorphic activity and convert αKG to the oncometabolite R-2-hydroxyglutarate (R-2-HG) which accumulates at high levels in the cell and hampers the function of αKG-dependent enzymes, including epigenetic regulators, thus leading to altered gene expression and block of differentiation and contributing to leukemia development. Inhibition of the neomorphic mutants induces marked decrease in R-2-HG levels and restores myeloid differentiation. Enasidenib and ivosidenib are potent and selective inhibitors of mutant IDH2 and IDH1, respectively, act as differentiating agents and showed clinical activity in relapsed/refractory (R/R) AML harboring the specific mutation. As single agents, both drugs have been approved by the Food and Drug Administration (FDA) for the treatment of R/R AML. The relevance of IDH targeting within either single agent approach or, most importantly, combinatorial treatments in AML will be discussed.
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Affiliation(s)
- Maria Paola Martelli
- Section of Hematology and Clinical Immunology, Department of Medicine, University of Perugia, Perugia, Italy -
| | - Giovanni Martino
- Section of Hematology and Clinical Immunology, Department of Medicine, University of Perugia, Perugia, Italy
| | - Valeria Cardinali
- Section of Hematology and Clinical Immunology, Department of Medicine, University of Perugia, Perugia, Italy
| | - Brunangelo Falini
- Section of Hematology and Clinical Immunology, Department of Medicine, University of Perugia, Perugia, Italy
| | - Giovanni Martinelli
- IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy
| | - Claudio Cerchione
- Unit of Hematology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy
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62
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Donker ML, Ossenkoppele GJ. Evaluating ivosidenib for the treatment of acute myeloid leukemia. Expert Opin Pharmacother 2020; 21:2205-2213. [DOI: 10.1080/14656566.2020.1806822] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- M. L. Donker
- Department of Haematology, Amsterdam UMC, Vrije Universiteit University Medical Center, Amsterdam, The Netherlands
| | - G. J. Ossenkoppele
- Department of Haematology, Amsterdam UMC, Vrije Universiteit University Medical Center, Amsterdam, The Netherlands
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63
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Zeidner JF. Differentiating the Differentiation Syndrome Associated with IDH Inhibitors in AML. Clin Cancer Res 2020; 26:4174-4176. [PMID: 32554513 DOI: 10.1158/1078-0432.ccr-20-1820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/01/2020] [Accepted: 06/16/2020] [Indexed: 11/16/2022]
Abstract
Isocitrate dehydrogenase (IDH) inhibitors have clinical activity in acute myeloid leukemia, in part, by differentiating blasts to mature myeloid cells. In the largest systematic analysis to date, differentiation syndrome was seen in 19% of patients treated with IDH inhibitors. Early recognition with uniform diagnostic criteria, as utilized in acute promyelocytic leukemia, may reduce subsequent complications.See related article by Norsworthy et al., p. 4280.
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Affiliation(s)
- Joshua F Zeidner
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina.
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