201
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Engen C, Hellesøy M, Grob T, Al Hinai A, Brendehaug A, Wergeland L, Bedringaas SL, Hovland R, Valk PJM, Gjertsen BT. FLT3-ITD mutations in acute myeloid leukaemia - molecular characteristics, distribution and numerical variation. Mol Oncol 2021; 15:2300-2317. [PMID: 33817952 PMCID: PMC8410560 DOI: 10.1002/1878-0261.12961] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/02/2021] [Accepted: 04/01/2021] [Indexed: 11/07/2022] Open
Abstract
Recurrent somatic internal tandem duplications (ITD) in the FMS-like tyrosine kinase 3 (FLT3) gene characterise approximately one third of patients with acute myeloid leukaemia (AML), and FLT3-ITD mutation status guides risk-adapted treatment strategies. The aim of this work was to characterise FLT3-ITD variant distribution in relation to molecular and clinical features, and overall survival in adult AML patients. We performed two parallel retrospective cohort studies investigating FLT3-ITD length and expression by cDNA fragment analysis, followed by Sanger sequencing in a subset of samples. In the two cohorts, a total of 139 and 172 mutant alleles were identified in 111 and 123 patients, respectively, with 22% and 28% of patients presenting with more than one mutated allele. Further, 15% and 32% of samples had a FLT3-ITD total variant allele frequency (VAF) < 0.3, while 24% and 16% had a total VAF ≥ 0.7. Most of the assessed clinical features did not significantly correlate to FLT3-ITD numerical variation nor VAF. Low VAF was, however, associated with lower white blood cell count, while increasing VAF correlated with inferior overall survival in one of the cohorts. In the other cohort, ITD length above 50 bp was identified to correlate with inferior overall survival. Our report corroborates the poor prognostic association with high FLT3-ITD disease burden, as well as extensive inter- and intrapatient heterogeneity in the molecular features of FLT3-ITD. We suggest that future use of FLT3-targeted therapy could be accompanied with thorough molecular diagnostics and follow-up to better predict optimal therapy responders.
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Affiliation(s)
- Caroline Engen
- Department of Clinical Science, Centre for Cancer Biomarkers CCBIO, University of Bergen, Norway
| | - Monica Hellesøy
- Haematology Section, Department of Medicine, Haukeland University Hospital, Helse Bergen HF, Norway
| | - Tim Grob
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Adil Al Hinai
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Atle Brendehaug
- Department of Medical Genetics, Haukeland University Hospital, Helse Bergen HF, Norway
| | - Line Wergeland
- Department of Clinical Science, Centre for Cancer Biomarkers CCBIO, University of Bergen, Norway
| | - Siv Lise Bedringaas
- Department of Clinical Science, Centre for Cancer Biomarkers CCBIO, University of Bergen, Norway
| | - Randi Hovland
- Department of Medical Genetics, Haukeland University Hospital, Helse Bergen HF, Norway.,Department of Biosciences, University of Bergen, Norway
| | - Peter J M Valk
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Bjørn T Gjertsen
- Department of Clinical Science, Centre for Cancer Biomarkers CCBIO, University of Bergen, Norway.,Haematology Section, Department of Medicine, Haukeland University Hospital, Helse Bergen HF, Norway
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202
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Westermann J, Bullinger L. Precision medicine in myeloid malignancies. Semin Cancer Biol 2021; 84:153-169. [PMID: 33895273 DOI: 10.1016/j.semcancer.2021.03.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 03/28/2021] [Accepted: 03/29/2021] [Indexed: 12/13/2022]
Abstract
Myeloid malignancies have always been at the forefront of an improved understanding of the molecular pathogenesis of cancer. In accordance, over the last years, basic research focusing on the aberrations underlying malignant transformation of myeloid cells has provided the basis for precision medicine approaches and subsequently has led to the development of powerful therapeutic strategies. In this review article, we will recapitulate what has happened since in the 1980s the use of all-trans retinoic acid (ATRA), as a first targeted cancer therapy, has changed one of the deadliest leukemia subtypes, acute promyelocytic leukemia (APL), into one that can be cured without classical chemotherapy today. Similarly, imatinib, the first molecularly designed cancer therapy, has revolutionized the management of chronic myeloid leukemia (CML). Thus, targeted treatment approaches have become the paradigm for myeloid malignancy, but many questions still remain unanswered, especially how identical mutations can be associated with different phenotypes. This might be linked to the impact of the cell of origin, gene-gene interactions, or the tumor microenvironment including the immune system. Continuous research in the field of myeloid neoplasia has started to unravel the molecular pathways that are not only crucial for initial treatment response, but also resistance of leukemia cells under therapy. Ongoing studies focusing on leukemia cell vulnerabilities do already point to novel (targetable) "Achilles heels" that can further improve myeloid cancer therapy.
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Affiliation(s)
- Jörg Westermann
- Department of Hematology, Oncology and Tumor Immunology, Charité University Medicine Berlin, Campus Virchow Clinic, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Lars Bullinger
- Department of Hematology, Oncology and Tumor Immunology, Charité University Medicine Berlin, Campus Virchow Clinic, Augustenburger Platz 1, 13353 Berlin, Germany.
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203
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Loke J, Vyas H, Craddock C. Optimizing Transplant Approaches and Post-Transplant Strategies for Patients With Acute Myeloid Leukemia. Front Oncol 2021; 11:666091. [PMID: 33937080 PMCID: PMC8083129 DOI: 10.3389/fonc.2021.666091] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 03/23/2021] [Indexed: 11/13/2022] Open
Abstract
Acute Myeloid Leukemia (AML) is the commonest indication for allogeneic stem cell transplantation (allo-SCT) worldwide. The increasingly important role of allo-SCT in the management of AML has been underpinned by two important advances. Firstly, improvements in disease risk stratification utilizing genetic and Measurable Residual Disease (MRD) technologies permit ever more accurate identification of allo-mandatory patients who are at high risk of relapse if treated by chemotherapy alone. Secondly, increased donor availability coupled with the advent of reduced intensity conditioning (RIC) regimens has substantially expanded transplant access for patients with high risk AML In patients allografted for AML disease relapse continues to represent the commonest cause of transplant failure and the development of novel strategies with the potential to reduce disease recurrence represents a major unmet need.
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Affiliation(s)
- Justin Loke
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom.,Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Hrushikesh Vyas
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom.,Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Charles Craddock
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom.,Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
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204
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Piccini M, Pilerci S, Merlini M, Grieco P, Scappini B, Bencini S, Peruzzi B, Caporale R, Signori L, Pancani F, Vannucchi AM, Gianfaldoni G. Venetoclax-Based Regimens for Relapsed/Refractory Acute Myeloid Leukemia in a Real-Life Setting: A Retrospective Single-Center Experience. J Clin Med 2021; 10:jcm10081684. [PMID: 33919958 PMCID: PMC8070927 DOI: 10.3390/jcm10081684] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/31/2021] [Accepted: 04/08/2021] [Indexed: 11/16/2022] Open
Abstract
Relapsed/refractory (R/R) acute myeloid leukemia (AML) is a largely unmet medical need, owing to the lack of standardized, effective treatment approaches, resulting in an overall dismal outcome. The only curative option for R/R AML patients is allogeneic hematopoietic stem cell transplantation (HSCT) which is only applicable in a fraction of patients due to the scarce efficacy and high toxicity of salvage regimens. Recently, a number of targeted agents with relatively favorable toxicity profiles have been explored in clinical trials for R/R AML patients. The Bcl-2 inhibitor venetoclax, in combination with hypomethylating agents or low dose cytarabine, has produced impressive results for newly diagnosed AML, while its role in R/R disease is not well defined yet. We retrospectively analyzed the clinical outcomes of 47 R/R AML patients treated with venetoclax-based regimens between March 2018 and December 2020 at our institution. Overall, we report a composite complete response rate of 55% with an overall acceptable toxicity profile. Outcomes were particularly favorable for NPM1 mutated patients, unlike for FLT3-ITD positive patients irrespective of NPM1 status. For patients treated with intention to transplant, the procedure could be finally performed in 54%. These findings suggest a role for venetoclax-based regimens in R/R AML patients and support the design of prospective studies.
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Affiliation(s)
- Matteo Piccini
- SOD Ematologia, Università degli Studi di Firenze e Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (M.P.); (B.S.); (A.M.V.)
| | - Sofia Pilerci
- Scuola di Specializzazione in Ematologia, Università degli Studi di Firenze, 50139 Firenze, Italy; (S.P.); (M.M.)
| | - Marta Merlini
- Scuola di Specializzazione in Ematologia, Università degli Studi di Firenze, 50139 Firenze, Italy; (S.P.); (M.M.)
| | - Pietro Grieco
- SOD Ematologia, Ospedale San Donato, Azienda Usl Toscana Sud-Est, 20121 Milano, Italy;
| | - Barbara Scappini
- SOD Ematologia, Università degli Studi di Firenze e Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (M.P.); (B.S.); (A.M.V.)
| | - Sara Bencini
- SOD Centro Diagnostico di Citofluorimetria e Immunoterapia, Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (S.B.); (B.P.); (R.C.)
| | - Benedetta Peruzzi
- SOD Centro Diagnostico di Citofluorimetria e Immunoterapia, Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (S.B.); (B.P.); (R.C.)
| | - Roberto Caporale
- SOD Centro Diagnostico di Citofluorimetria e Immunoterapia, Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (S.B.); (B.P.); (R.C.)
| | - Leonardo Signori
- Centro di Ricerca e Innovazione per le Malattie Mieloproliferative (CRIMM), Università degli Studi e Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (L.S.); (F.P.)
| | - Fabiana Pancani
- Centro di Ricerca e Innovazione per le Malattie Mieloproliferative (CRIMM), Università degli Studi e Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (L.S.); (F.P.)
| | - Alessandro Maria Vannucchi
- SOD Ematologia, Università degli Studi di Firenze e Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (M.P.); (B.S.); (A.M.V.)
- Centro di Ricerca e Innovazione per le Malattie Mieloproliferative (CRIMM), Università degli Studi e Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (L.S.); (F.P.)
| | - Giacomo Gianfaldoni
- SOD Ematologia, Università degli Studi di Firenze e Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (M.P.); (B.S.); (A.M.V.)
- Correspondence:
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205
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Marconi G, Giannini MB, Bagnato G, Simonetti G, Cerchione C, Mosquera Orgueira A, Musuraca G, Martinelli G. The safety profile of FLT3 inhibitors in the treatment of newly diagnosed or relapsed/refractory acute myeloid leukemia. Expert Opin Drug Saf 2021; 20:791-799. [PMID: 33853481 DOI: 10.1080/14740338.2021.1913120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION FLT3 inhibitors are important drugs in the therapy of FLT3 positive acute myeloid leukemia (AML). Midostaurin was registered in combination with chemotherapy to treat newly diagnosed AML. Gilteritinib and quizartinib demonstrate effectiveness in a randomized trial in relapsed/refractory AML. Several promising FLT3 inhibitors are being evaluated in clinical research. AREAS COVERED This review will report the safety of FLT3 inhibitors that are registered for acute myeloid leukemia induction and rescue therapy. EXPERT OPINION In the near future, it is possible that all the FLT3 positive non M3-AML patients will receive a FLT3 inhibitor. Therapy adherence and strategies to mitigate adverse events must be pursued. The treatment with FLT3 inhibitors may be optimized in terms of toxicities with a rational evaluation of antifungal prophylaxis and concomitant therapy, cardiology monitoring, and keeping in mind rare adverse events. Future studies on unfit patients, special populations, and maintenance settings are warranted, together with post-market studies and real-life experiences. Whenever new FLT3 inhibitors will come to the clinic, we could face a scenario in which profound knowledge of effectiveness, toxicities, and off-target effects will be relevant to choose the best drug for each patient.
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Affiliation(s)
- Giovanni Marconi
- Istituto Romagnolo per Lo Studio Dei Tumori "Dino Amadori" - IRST, Meldola (FC), Italy
| | | | - Gianmarco Bagnato
- Istituto Romagnolo per Lo Studio Dei Tumori "Dino Amadori" - IRST, Meldola (FC), Italy
| | - Giorgia Simonetti
- Istituto Romagnolo per Lo Studio Dei Tumori "Dino Amadori" - IRST, Meldola (FC), Italy
| | - Claudio Cerchione
- Istituto Romagnolo per Lo Studio Dei Tumori "Dino Amadori" - IRST, Meldola (FC), Italy
| | - Adrián Mosquera Orgueira
- Health Research Institute of Santiago De Compostela (IDIS), Santiago De Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario De Santiago De Compostela (CHUS - SERGAS), Santiago De Compostela, Spain.,University of Santiago De Compostela, Santiago De Compostela, Spain
| | - Gerardo Musuraca
- Istituto Romagnolo per Lo Studio Dei Tumori "Dino Amadori" - IRST, Meldola (FC), Italy
| | - Giovanni Martinelli
- Istituto Romagnolo per Lo Studio Dei Tumori "Dino Amadori" - IRST, Meldola (FC), Italy
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206
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Miura K, Iriyama N, Hatta Y, Takei M. Personalized patient care with aggressive hematological malignancies in non-responders to first-line treatment. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2021. [DOI: 10.1080/23808993.2021.1903314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Katsuhiro Miura
- Tumor Center, Nihon University Itabashi Hospital, 173-8610, Itabashi city, Japan
- Department of Hematology and Rheumatology, Nihon University School of Medicine, 173-8610, Itabashi city, Tokyo, Japan
| | - Noriyoshi Iriyama
- Department of Hematology and Rheumatology, Nihon University School of Medicine, 173-8610, Itabashi city, Tokyo, Japan
| | - Yoshihiro Hatta
- Department of Hematology and Rheumatology, Nihon University School of Medicine, 173-8610, Itabashi city, Tokyo, Japan
| | - Masami Takei
- Department of Hematology and Rheumatology, Nihon University School of Medicine, 173-8610, Itabashi city, Tokyo, Japan
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207
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Zhang H, Wang P, Li Z, He Y, Gan W, Jiang H. Anti-CLL1 Chimeric Antigen Receptor T-Cell Therapy in Children with Relapsed/Refractory Acute Myeloid Leukemia. Clin Cancer Res 2021; 27:3549-3555. [PMID: 33832948 DOI: 10.1158/1078-0432.ccr-20-4543] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/20/2021] [Accepted: 04/06/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE The survival rate of children with refractory/relapsed acute myeloid leukemia (R/R-AML) by salvage chemotherapy is minimal. Treatment with chimeric antigen receptor T cells (CAR T) has emerged as a novel therapy to improve malignancies treatment. C-type lectin-like molecule 1 (CLL1) is highly expressed on AML stem cells, blast cells, and monocytes, but not on normal hematopoietic stem cells, indicating the therapeutic potential of anti-CLL1 CAR T in AML treatment. This study aimed to test the safety and efficacy of CAR T-cell therapy in R/R-AML. PATIENTS AND METHODS Four pediatric patients with R/R-AML were enrolled in the ongoing phase I/II anti-CLL1 CAR T-cell therapy trial. The CAR design was based on an apoptosis-inducing gene, FKBP-caspase 9, to establish a safer CAR (4SCAR) application. Anti-CLL1 CAR was transduced into peripheral blood mononuclear cells of the patients via lentivector 4SCAR, followed by infusion into the recipients after lymphodepletion chemotherapy. Cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, and other adverse events were documented. Treatment response was evaluated by morphology and flow cytometry-based minimal residual disease assays. RESULTS Three patients with R/R-AML achieved complete remission and minimal residual disease negativity, while the other patient remained alive for 5 months. All these patients experienced low-grade and manageable adverse events. CONCLUSIONS On the basis of our single-institution experience, autologous anti-CLL1 CAR T-cell therapy has the potential to be a safe and efficient alternative treatment for children with R/R-AML, and therefore requires further investigation.
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Affiliation(s)
- Hui Zhang
- Department of Hematology/Oncology, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, P.R. China.
| | - Pengfei Wang
- Department of Hematology/Oncology, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, P.R. China
| | - Zhuoyan Li
- Department of Hematology/Oncology, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, P.R. China
| | - Yingyi He
- Department of Hematology/Oncology, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, P.R. China
| | - Wenting Gan
- Department of Hematology/Oncology, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, P.R. China.
| | - Hua Jiang
- Department of Hematology/Oncology, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, P.R. China.
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208
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Synergistic targeting of FLT3 mutations in AML via combined menin-MLL and FLT3 inhibition. Blood 2021; 136:2442-2456. [PMID: 32589720 DOI: 10.1182/blood.2020005037] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 06/11/2020] [Indexed: 12/14/2022] Open
Abstract
The interaction of menin (MEN1) and MLL (MLL1, KMT2A) is a dependency and provides a potential opportunity for treatment of NPM1-mutant (NPM1mut) and MLL-rearranged (MLL-r) leukemias. Concomitant activating driver mutations in the gene encoding the tyrosine kinase FLT3 occur in both leukemias and are particularly common in the NPM1mut subtype. In this study, transcriptional profiling after pharmacological inhibition of the menin-MLL complex revealed specific changes in gene expression, with downregulation of the MEIS1 transcription factor and its transcriptional target gene FLT3 being the most pronounced. Combining menin-MLL inhibition with specific small-molecule kinase inhibitors of FLT3 phosphorylation resulted in a significantly superior reduction of phosphorylated FLT3 and transcriptional suppression of genes downstream of FLT3 signaling. The drug combination induced synergistic inhibition of proliferation, as well as enhanced apoptosis, compared with single-drug treatment in models of human and murine NPM1mut and MLL-r leukemias harboring an FLT3 mutation. Primary acute myeloid leukemia (AML) cells harvested from patients with NPM1mutFLT3mut AML showed significantly better responses to combined menin and FLT3 inhibition than to single-drug or vehicle control treatment, whereas AML cells with wild-type NPM1, MLL, and FLT3 were not affected by either of the 2 drugs. In vivo treatment of leukemic animals with MLL-r FLT3mut leukemia reduced leukemia burden significantly and prolonged survival compared with results in the single-drug and vehicle control groups. Our data suggest that combined menin-MLL and FLT3 inhibition represents a novel and promising therapeutic strategy for patients with NPM1mut or MLL-r leukemia and concurrent FLT3 mutation.
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209
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Dillon R, Potter N, Freeman S, Russell N. How we use molecular minimal residual disease (MRD) testing in acute myeloid leukaemia (AML). Br J Haematol 2021; 193:231-244. [PMID: 33058194 DOI: 10.1111/bjh.17185] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In recent years there have been major advances in the use of molecular diagnostic and monitoring techniques for patients with acute myeloid leukaemia (AML). Coupled with the simultaneous explosion of new therapeutic agents, this has sown the seeds for significant improvements to treatment algorithms. Here we show, using a selection of real-life examples, how molecular monitoring can be used to refine clinical decision-making and to personalise treatment in patients with AML with nucleophosmin (NPM1) mutations, core binding factor translocations and other fusion genes. For each case we review the established evidence base and provide practical recommendations where evidence is lacking or conflicting. Finally, we review important technical considerations that clinicians should be aware of in order to safely exploit these technologies as they undergo widespread implementation.
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Affiliation(s)
- Richard Dillon
- Cancer Genetics Laboratory, Department of Medical and Molecular Genetics, King's College, London, UK
- Department of Haematology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Nicola Potter
- Cancer Genetics Laboratory, Department of Medical and Molecular Genetics, King's College, London, UK
| | - Sylvie Freeman
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Nigel Russell
- Department of Haematology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
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210
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Cortes JE, Mehta P. Determination of fitness and therapeutic options in older patients with acute myeloid leukemia. Am J Hematol 2021; 96:493-507. [PMID: 33368536 PMCID: PMC7986910 DOI: 10.1002/ajh.26079] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 12/15/2020] [Accepted: 12/20/2020] [Indexed: 12/11/2022]
Abstract
Treatment of older patients with AML remains challenging. Although age, performance status, and comorbidities are commonly employed to determine fitness for intensive treatment, several studies have demonstrated improved outcomes with treatment in older and classically unfit patients, highlighting the importance of other disease-related and patient-related factors that have prognostic value for treatment outcome in AML. However, consistent and objective assessments for fitness are lacking. Multi-parameter geriatric assessment tools offer more comprehensive evaluation, but are limited by the required resources and lack of standardization and consensus regarding prognostic value. These assessments are particularly important considering the emerging new AML therapies that represent a spectrum of intensities. Patients should therefore be evaluated holistically for fitness to receive a specific treatment, with the aim of providing individualized care, and such definitions of fitness should also consistently be applied to clinical trials. This review will examine evolving criteria for the determination of fitness among AML patients and discuss treatment options for older and/or unfit patients with AML.
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Affiliation(s)
- Jorge E. Cortes
- Georgia Cancer Center Augusta University Augusta Georgia USA
| | - Priyanka Mehta
- Department of Haematology University Hospitals Bristol, NHS Foundation Trust Bristol UK
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211
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Almatani MF, Ali A, Onyemaechi S, Zhao Y, Gutierrez L, Vaikari VP, Alachkar H. Strategies targeting FLT3 beyond the kinase inhibitors. Pharmacol Ther 2021; 225:107844. [PMID: 33811956 DOI: 10.1016/j.pharmthera.2021.107844] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/24/2021] [Accepted: 03/29/2021] [Indexed: 12/20/2022]
Abstract
Acute myeloid leukemia (AML) is a hematological malignancy characterized by clonal expansion and differentiation arrest of the myeloid progenitor cells, which leads to the accumulation of immature cells called blasts in the bone marrow and peripheral blood. Mutations in the receptor tyrosine kinase FLT3 occur in 30% of normal karyotype patients with AML and are associated with a higher incidence of relapse and worse survival. Targeted therapies against FLT3 mutations using small-molecule FLT3 tyrosine kinase inhibitors (TKIs) have long been investigated, with some showing favorable clinical outcomes. However, major setbacks such as limited clinical efficacy and the high risk of acquired resistance remain unresolved. FLT3 signaling, mutations, and FLT3 inhibitors are topics that have been extensively reviewed in recent years. Strategies to target FLT3 beyond the small molecule kinase inhibitors are expanding, nevertheless they are not receiving enough attention. These modalities include antibody-based FLT3 targeted therapies, immune cells mediated targeting strategies, and approaches targeting downstream signaling pathways and FLT3 translation. Here, we review the most recent advances and the challenges associated with the development of therapeutic modalities targeting FLT3 beyond the kinase inhibitors.
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Affiliation(s)
- Mohammed F Almatani
- Department of Pharmacology and Pharmaceutical Sciences, School of Pharmacy, University of Southern California, Los Angeles, CA 90089, United States
| | - Atham Ali
- Department of Clinical Pharmacy, School of Pharmacy, University of Southern California, Los Angeles, CA 90089, United States
| | - Sandra Onyemaechi
- Department of Pharmacology and Pharmaceutical Sciences, School of Pharmacy, University of Southern California, Los Angeles, CA 90089, United States
| | - Yang Zhao
- Department of Pharmacology and Pharmaceutical Sciences, School of Pharmacy, University of Southern California, Los Angeles, CA 90089, United States
| | - Lucas Gutierrez
- Department of Clinical Pharmacy, School of Pharmacy, University of Southern California, Los Angeles, CA 90089, United States
| | - Vijaya Pooja Vaikari
- Department of Clinical Pharmacy, School of Pharmacy, University of Southern California, Los Angeles, CA 90089, United States
| | - Houda Alachkar
- Department of Clinical Pharmacy, School of Pharmacy, University of Southern California, Los Angeles, CA 90089, United States; USC Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA 90089, United States.
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212
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Perl AE. Which novel agents will have a clinically meaningful impact in AML at diagnosis? Best Pract Res Clin Haematol 2021; 34:101257. [PMID: 33762111 DOI: 10.1016/j.beha.2021.101257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
New drug approvals now afford AML physicians a wider choice of initial treatment options than ever before. Although chemotherapy for AML is by no means ready to be replaced entirely by novel agents, the role of traditional cytotoxics in AML therapy is rapidly changing. In particular, biologically targeted agents such as the BCL2 inhibitor venetoclax and inhibitors of FLT3 and IDH mutations stand out as drugs likely to take AML therapy in important new directions. Maximum response and survival benefits likely require combinations of novel agents and chemotherapy or multiple novel agents together. The recently-published phase 3 VIALE-A study demonstrates a very successful example of a new combination approach, which led to venetoclax plus azacitidine establishing itself as the new standard of care for patients unfit for intensive chemotherapy. One could reasonably expect other subsets of AML to benefit from this regimen or other applications of venetoclax combinations. Building on this experience, venetoclax-based regimens also have the potential to replace standard intensive cytarabine/anthracycline "7&3" induction approach for some if not many patients who are fit for induction. This review will describe novel agents with the greatest potential for impactful frontline applications that will change the AML treatment paradigm.
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Affiliation(s)
- Alexander E Perl
- Perelman School of Medicine at the University of Pennsylvania, Division of Hematology-Oncology, Abramson Cancer Center, Leukemia Program, Phiadelphia, PA, USA.
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213
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Abstract
Until recently, acute myeloid leukemia (AML) patients used to have limited treatment options, depending solely on cytarabine + anthracycline (7 + 3) intensive chemotherapy and hypomethylating agents. Allogeneic stem cell transplantation (Allo-SCT) played an important role to improve the survival of eligible AML patients in the past several decades. The exploration of the genomic and molecular landscape of AML, identification of mutations associated with the pathogenesis of AML, and the understanding of the mechanisms of resistance to treatment from excellent translational research helped to expand the treatment options of AML quickly in the past few years, resulting in noteworthy breakthroughs and FDA approvals of new therapeutic treatments in AML patients. Targeted therapies and combinations of different classes of therapeutic agents to overcome treatment resistance further expanded the treatment options and improved survival. Immunotherapy, including antibody-based treatment, inhibition of immune negative regulators, and possible CAR T cells might further expand the therapeutic armamentarium for AML. This review is intended to summarize the recent developments in the treatment of AML.
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Affiliation(s)
- Hongtao Liu
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago Medical Center, 5841 S. Maryland Ave, MC 2115, Chicago, IL, 60637-1470, USA.
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Wang Z, Cai J, Cheng J, Yang W, Zhu Y, Li H, Lu T, Chen Y, Lu S. FLT3 Inhibitors in Acute Myeloid Leukemia: Challenges and Recent Developments in Overcoming Resistance. J Med Chem 2021; 64:2878-2900. [PMID: 33719439 DOI: 10.1021/acs.jmedchem.0c01851] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Mutations in the FMS-like tyrosine kinase 3 (FLT3) gene are often present in newly diagnosed acute myeloid leukemia (AML) patients with an incidence rate of approximately 30%. Recently, many FLT3 inhibitors have been developed and exhibit positive preclinical and clinical effects against AML. However, patients develop resistance soon after undergoing FLT3 inhibitor treatment, resulting in short durable responses and poor clinical effects. This review will discuss the main mechanisms of resistance to clinical FLT3 inhibitors and summarize the emerging strategies that are utilized to overcome drug resistance. Basically, medicinal chemistry efforts to develop new small-molecule FLT3 inhibitors offer a direct solution to this problem. Other potential strategies include the combination of FLT3 inhibitors with other therapies and the development of multitarget inhibitors. It is hoped that this review will provide inspiring insights into the discovery of new AML therapies that can eventually overcome the resistance to current FLT3 inhibitors.
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Affiliation(s)
- Zhijie Wang
- School of Science, China Pharmaceutical University, Nanjing 211198, P.R. China
| | - Jiongheng Cai
- School of Science, China Pharmaceutical University, Nanjing 211198, P.R. China
| | - Jie Cheng
- School of Science, China Pharmaceutical University, Nanjing 211198, P.R. China
| | - Wenqianzi Yang
- School of Science, China Pharmaceutical University, Nanjing 211198, P.R. China
| | - Yifan Zhu
- School of Pharmacy, China Pharmaceutical University, Nanjing 210009, P.R. China
| | - Hongmei Li
- School of Science, China Pharmaceutical University, Nanjing 211198, P.R. China
| | - Tao Lu
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing 210009, P.R. China
| | - Yadong Chen
- Laboratory of Molecular Design and Drug Discovery, China Pharmaceutical University, Nanjing, 211198, P.R. China
| | - Shuai Lu
- School of Science, China Pharmaceutical University, Nanjing 211198, P.R. China
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215
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Burchert A. Maintenance therapy for FLT3-ITD-mutated acute myeloid leukemia. Haematologica 2021; 106:664-670. [PMID: 33472354 PMCID: PMC7927878 DOI: 10.3324/haematol.2019.240747] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Indexed: 12/15/2022] Open
Abstract
FLT3-ITD is a constitutively activated variant of the FLT3 tyrosine kinase receptor. Its expression in acute myeloid leukemia (AML) is associated with a poor prognosis. Due to this, the development of tyrosine kinase inhibitors (TKI) blocking FLT3-ITD became a rational therapeutic concept. This review describes key milestones in the clinical development of different FLT3-specific TKI with a particular focus on FLT3-TKI maintenance therapy in remission after allogeneic hematopoietic stem cell transplantation (HCT). Recent evidence from randomized trials using sorafenib in FLT3-ITD mutated AML provided a proof of concept that targeted post-HCT maintenance therapy could become a new treatment paradigm in AML.
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Affiliation(s)
- Andreas Burchert
- Department of Internal Medicine, Hematology, Oncology and Immunology, Philipps University Marburg and University Hospital Giessen and Marburg, Campus Marburg, Marburg.
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216
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Abstract
Aberrant FLT3 receptor signaling is common in acute myeloid leukemia (AML) and has important implications for the biology and clinical management of the disease. Patients with FLT3-mutated AML frequently present with critical illness, are more likely to relapse after treatment, and have worse clinical outcomes than their FLT3 wild type counterparts. The clinical management of FLT3-mutated AML has been transformed by the development of FLT3 inhibitors, which are now in use in the frontline and relapsed/refractory settings. However, many questions regarding the optimal approach to the treatment of these patients remain. In this paper, we will review the rationale for targeting the FLT3 receptor in AML, the impact of FLT3 mutation on patient prognosis, the current standard of care approaches to FLT3-mutated AML management, and the diverse array of FLT3 inhibitors in use and under investigation. We will also explore new opportunities and strategies for targeting the FLT3 receptor. These include targeting the receptor in patients with non-canonical FLT3 mutations or wild type FLT3, pairing FLT3 inhibitors with other novel therapies, using minimal residual disease (MRD) testing to guide the targeting of FLT3, and novel immunotherapeutic approaches.
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Affiliation(s)
- Alexander J Ambinder
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mark Levis
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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217
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Shallis RM, Podoltsev NA. Maintenance therapy for acute myeloid leukemia: sustaining the pursuit for sustained remission. Curr Opin Hematol 2021; 28:110-121. [PMID: 33394722 DOI: 10.1097/moh.0000000000000637] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Maintenance therapy for acute myeloid leukemia (AML) has been studied for decades with mixed results. However, the application of modern agents has renewed interest and the recent data from randomized trials has provided evidence for the use of maintenance therapy in certain populations of AML patients. RECENT FINDINGS Unselected patients are unlikely to benefit from maintenance therapy as has been previously and consistently demonstrated. The increasing availability of newer and targeted agents like oral hypomethylating agents, protein modifiers, as well as FLT3, IDH1/2 BCL-2 and immune checkpoint inhibitors have restoked interest in maintenance therapy for which randomized, placebo-controlled trials have recently demonstrated benefits, including in the post-transplant setting. Patients with high-risk disease, suboptimal consolidation or remission associated with measurable residual disease (MRD) appear to be beneficiaries of this strategy. The influence of MRD status and the platform by which it is measured are important factors in the current understanding of when maintenance therapy works and how future studies should be designed. SUMMARY The recent positive findings in support of maintenance therapy for certain AML patient populations are practice changing and bolster the need for properly designed, randomized studies using unified and standardized MRD techniques.
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Affiliation(s)
- Rory M Shallis
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, Connecticut, USA
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218
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Yilmaz M, Alfayez M, DiNardo CD, Borthakur G, Kadia TM, Konopleva MY, Loghavi S, Kanagal-Shamanna R, Patel KP, Jabbour EJ, Garcia-Manero G, Pemmaraju N, Pierce SA, Ghayas I, Short NJ, Montalban-Bravo G, Takahashi K, Assi R, Alotaibi AS, Ohanian M, Andreeff M, Cortes JE, Kantarjian HM, Ravandi F, Daver NG. Correction to: Outcomes with sequential FLT3-inhibitor-based therapies in patients with AML. J Hematol Oncol 2021; 14:34. [PMID: 33618754 PMCID: PMC7901199 DOI: 10.1186/s13045-020-01023-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Mansour Alfayez
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Marina Y Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rashmi Kanagal-Shamanna
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keyur P Patel
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias J Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Sherry A Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Issa Ghayas
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Guillermo Montalban-Bravo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Koichi Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Rita Assi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Ahmad S Alotaibi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Maro Ohanian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Michael Andreeff
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Jorge E Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA.
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219
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Brown PA, Kairalla JA, Hilden JM, Dreyer ZE, Carroll AJ, Heerema NA, Wang C, Devidas M, Gore L, Salzer WL, Winick NJ, Carroll WL, Raetz EA, Borowitz MJ, Small D, Loh ML, Hunger SP. FLT3 inhibitor lestaurtinib plus chemotherapy for newly diagnosed KMT2A-rearranged infant acute lymphoblastic leukemia: Children's Oncology Group trial AALL0631. Leukemia 2021; 35:1279-1290. [PMID: 33623141 DOI: 10.1038/s41375-021-01177-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/11/2021] [Accepted: 01/29/2021] [Indexed: 12/12/2022]
Abstract
Infants with KMT2A-rearranged acute lymphoblastic leukemia (KMT2A-r ALL) have a poor prognosis. KMT2A-r ALL overexpresses FLT3, and the FLT3 inhibitor (FLT3i) lestaurtinib potentiates chemotherapy-induced cytotoxicity in preclinical models. Children's Oncology Group (COG) AALL0631 tested whether adding lestaurtinib to post-induction chemotherapy improved event-free survival (EFS). After chemotherapy induction, KMT2A-r infants received either chemotherapy only or chemotherapy plus lestaurtinib. Correlative assays included FLT3i plasma pharmacodynamics (PD), which categorized patients as inhibited or uninhibited, and FLT3i ex vivo sensitivity (EVS), which categorized leukemic blasts as sensitive or resistant. There was no difference in 3-year EFS between patients treated with chemotherapy plus lestaurtinib (n = 67, 36 ± 6%) vs. chemotherapy only (n = 54, 39 ± 7%, p = 0.67). However, for the lestaurtinib-treated patients, FLT3i PD and FLT3i EVS significantly correlated with EFS. For FLT3i PD, EFS for inhibited/uninhibited was 59 ± 10%/28 ± 7% (p = 0.009) and for FLTi EVS, EFS for sensitive/resistant was 52 ± 8%/5 ± 5% (p < 0.001). Seventeen patients were both inhibited and sensitive, with an EFS of 88 ± 8%. Adding lestaurtinib did not improve EFS overall, but patients achieving potent FLT3 inhibition and those whose leukemia blasts were sensitive FLT3-inhibition ex vivo did benefit from the addition of lestaurtinib. Patient selection and PD-guided dose escalation may enhance the efficacy of FLT3 inhibition for KMT2A-r infant ALL.
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Affiliation(s)
- Patrick A Brown
- Division of Pediatric Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA.
| | - John A Kairalla
- Department of Biostatistics, Colleges of Medicine, Public Health & Health Professions, University of Florida, Gainesville, FL, USA
| | - Joanne M Hilden
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, CO, USA
| | | | - Andrew J Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nyla A Heerema
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Cindy Wang
- Department of Biostatistics, Colleges of Medicine, Public Health & Health Professions, University of Florida, Gainesville, FL, USA
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Lia Gore
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, CO, USA
| | - Wanda L Salzer
- U.S. Army Medical Research and Materiel Command, Fort Detrick, MD, USA
| | - Naomi J Winick
- Division of Pediatric Hematology/Oncology, University of Texas Southwestern School of Medicine, Dallas, TX, USA
| | - William L Carroll
- Department of Pediatrics and Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Elizabeth A Raetz
- Department of Pediatrics and Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Michael J Borowitz
- Departments of Pathology and Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - Donald Small
- Division of Pediatric Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Mignon L Loh
- Department of Pediatrics, Benioff Children's Hospital and the Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - Stephen P Hunger
- Department of Pediatrics and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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220
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Mosquera Orgueira A, Peleteiro Raíndo A, Cid López M, Antelo Rodríguez B, Díaz Arias JÁ, Ferreiro Ferro R, Alonso Vence N, Bendaña López Á, Abuín Blanco A, Bao Pérez L, Melero Valentín P, González Pérez MS, Cerchione C, Martinelli G, Montesinos Fernández P, Pérez Encinas MM, Bello López JL. Gene expression profiling identifies FLT3 mutation-like cases in wild-type FLT3 acute myeloid leukemia. PLoS One 2021; 16:e0247093. [PMID: 33592069 PMCID: PMC7886212 DOI: 10.1371/journal.pone.0247093] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 02/01/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND FLT3 mutation is present in 25-30% of all acute myeloid leukemias (AML), and it is associated with adverse outcome. FLT3 inhibitors have shown improved survival results in AML both as upfront treatment and in relapsed/refractory disease. Curiously, a variable proportion of wild-type FLT3 patients also responded to these drugs. METHODS We analyzed 6 different transcriptomic datasets of AML cases. Differential expression between mutated and wild-type FLT3 AMLs was performed with the Wilcoxon-rank sum test. Hierarchical clustering was used to identify FLT3-mutation like AMLs. Finally, enrichment in recurrent mutations was performed with the Fisher's test. RESULTS A FLT3 mutation-like gene expression pattern was identified among wild-type FLT3 AMLs. This pattern was highly enriched in NPM1 and DNMT3A mutants, and particularly in combined NPM1/DNMT3A mutants. CONCLUSIONS We identified a FLT3 mutation-like gene expression pattern in AML which was highly enriched in NPM1 and DNMT3A mutations. Future analysis about the predictive role of this biomarker among wild-type FLT3 patients treated with FLT3 inhibitors is envisaged.
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Affiliation(s)
- Adrián Mosquera Orgueira
- Health Research Institute of Santiago de Compostela (IDIS), Santiago, Spain
- Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), SERGAS, Santiago, Spain
- University of Santiago de Compostela, Santiago, Spain
- * E-mail:
| | - Andrés Peleteiro Raíndo
- Health Research Institute of Santiago de Compostela (IDIS), Santiago, Spain
- Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), SERGAS, Santiago, Spain
- University of Santiago de Compostela, Santiago, Spain
| | - Miguel Cid López
- Health Research Institute of Santiago de Compostela (IDIS), Santiago, Spain
- Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), SERGAS, Santiago, Spain
- University of Santiago de Compostela, Santiago, Spain
| | - Beatriz Antelo Rodríguez
- Health Research Institute of Santiago de Compostela (IDIS), Santiago, Spain
- Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), SERGAS, Santiago, Spain
- University of Santiago de Compostela, Santiago, Spain
| | - José Ángel Díaz Arias
- Health Research Institute of Santiago de Compostela (IDIS), Santiago, Spain
- Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), SERGAS, Santiago, Spain
| | - Roi Ferreiro Ferro
- Health Research Institute of Santiago de Compostela (IDIS), Santiago, Spain
- Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), SERGAS, Santiago, Spain
| | - Natalia Alonso Vence
- Health Research Institute of Santiago de Compostela (IDIS), Santiago, Spain
- Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), SERGAS, Santiago, Spain
| | - Ángeles Bendaña López
- Health Research Institute of Santiago de Compostela (IDIS), Santiago, Spain
- Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), SERGAS, Santiago, Spain
| | - Aitor Abuín Blanco
- Health Research Institute of Santiago de Compostela (IDIS), Santiago, Spain
- Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), SERGAS, Santiago, Spain
| | - Laura Bao Pérez
- Health Research Institute of Santiago de Compostela (IDIS), Santiago, Spain
- Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), SERGAS, Santiago, Spain
| | | | - Marta Sonia González Pérez
- Health Research Institute of Santiago de Compostela (IDIS), Santiago, Spain
- Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), SERGAS, Santiago, Spain
| | | | - Giovanni Martinelli
- Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, Meldola, Italy
| | | | - Manuel Mateo Pérez Encinas
- Health Research Institute of Santiago de Compostela (IDIS), Santiago, Spain
- Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), SERGAS, Santiago, Spain
- University of Santiago de Compostela, Santiago, Spain
| | - José Luis Bello López
- Health Research Institute of Santiago de Compostela (IDIS), Santiago, Spain
- Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), SERGAS, Santiago, Spain
- University of Santiago de Compostela, Santiago, Spain
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221
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Fodil S, Raffoux E, Dumas PY, Desbrosses Y, Larosa F, Chantepie S, Larcher MV, Mear JB, Peterlin P, Hunault-Berger M, Hospital MA, Morel V, Lucas N, Vidal V, Salanoubat C, Michel J, Mediavilla C, Ojeda-Uribe M, Alexis M, Frayfer J, Carré M, Maillard N, Redjoul R, Banos A, Detrait M, Cluzeau T, Wickenhauser S, Chaoui D, Elassy M, Pigneux A, Dombret H, Récher C, Bertoli S. Data from French named patient program of quizartinib in relapsed/refractory acute myeloid leukemia. Leuk Lymphoma 2021; 62:1756-1760. [PMID: 33596765 DOI: 10.1080/10428194.2021.1881505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- S Fodil
- Service d'Hématologie adulte, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
| | - E Raffoux
- Service d'Hématologie adulte, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
| | - P Y Dumas
- Service d'Hématologie, CHU Bordeaux, F-33000, Bordeaux, France
| | - Y Desbrosses
- Service d'Hématologie, CHRU Jean Minjoz, Besançon, France
| | - F Larosa
- Service d'Hématologie, CHU de Dijon, Dijon, France
| | - S Chantepie
- Service d'Hématologie, Institut d'Hématologie de Basse-Normandie CHU de Caen, Caen, France
| | - M V Larcher
- Service d'Hématologie, Hospices civils de Lyon, CHU de Lyon, Lyon, France
| | - J B Mear
- Service d'Hématologie, CHU de Rennes - Hôpital Pontchaillou, Rennes, France
| | - P Peterlin
- Service d'Hématologie, CHU de Nantes, Nantes, France
| | - M Hunault-Berger
- Service des Maladies du Sang, Centre Hospitalier Universitaire, FHU GOAL, CRCINA, INSERM, Angers, France
| | - M A Hospital
- Service d'Hématologie, Institut Paoli-Calmettes, Marseille, France
| | - V Morel
- Service d'Hématologie, Hôpital Pitié-Salpêtrière AP-HP, Paris, France
| | - N Lucas
- Service d'Hématologie, Institut Gustave Roussy, Villejuif, France
| | - V Vidal
- Service d'Hématologie, Hôpital Avicenne AP-HP, Bobigny, France
| | - C Salanoubat
- Service d'Hématologie, C.H. Sud Francilien, Corbeil-Essonnes, France
| | - J Michel
- Service d'Hématologie, C.H.R. - Hôpital Félix Maréchal, Metz-Thionville, France
| | - C Mediavilla
- Service d'Hématologie, Hôpital Saint-Antoine AP-HP, Paris, France
| | - M Ojeda-Uribe
- Service d'Hématologie, Groupe Hospitalier Régional Mulhouse Sud-Alsace, Mulhouse, France
| | - M Alexis
- Service d'Hématologie, CHR Orléans, Orléans, France
| | - J Frayfer
- Service d'Hématologie, Grand Hôpital de l'Est Francilien - Site de Meaux, Meaux, France
| | - M Carré
- Service d'Hématologie, CHU Grenoble Alpes, La Tronche, France
| | - N Maillard
- Service d'Hématologie, CHU de Poitiers, Poitiers, France
| | - R Redjoul
- Service d'Hématologie, CHU Henri Mondor, AP-HP et UPEC, Créteil, France
| | - A Banos
- Service d'Hématologie, Centre hospitalier de la côte basque, Bayonne, France
| | - M Detrait
- Service d'Hématologie, CHRU de Nancy, Nancy, France
| | - T Cluzeau
- Département d'Hématologie, Université Cote d'Azur, CHU de Nice, Nice, France
| | | | - D Chaoui
- Service d'Hématologie, CH d'Argenteuil, Argenteuil, France
| | - M Elassy
- Service d'Hématologie, CH d'Auxerre, Auxerre, France
| | - A Pigneux
- Service d'Hématologie, CHU Bordeaux, F-33000, Bordeaux, France
| | - H Dombret
- Service d'Hématologie adulte, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
| | - C Récher
- Service d'Hématologie, CHU de Toulouse, Centre de Recherches en Cancérologie de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Université de Toulouse 3 Paul Sabatier, Toulouse, France
| | - S Bertoli
- Service d'Hématologie, CHU de Toulouse, Centre de Recherches en Cancérologie de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Université de Toulouse 3 Paul Sabatier, Toulouse, France
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Tabata R, Chi S, Yuda J, Minami Y. Emerging Immunotherapy for Acute Myeloid Leukemia. Int J Mol Sci 2021; 22:1944. [PMID: 33669431 PMCID: PMC7920435 DOI: 10.3390/ijms22041944] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 12/12/2022] Open
Abstract
Several immune checkpoint molecules and immune targets in leukemic cells have been investigated. Recent studies have suggested the potential clinical benefits of immuno-oncology (IO) therapy against acute myeloid leukemia (AML), especially targeting CD33, CD123, and CLL-1, as well as immune checkpoint inhibitors (e.g., anti-PD (programmed cell death)-1 and anti-CTLA4 (cytotoxic T-lymphocyte-associated protein 4) antibodies) with or without conventional chemotherapy. Early-phase clinical trials of chimeric antigen receptor (CAR)-T or natural killer (NK) cells for relapsed/refractory AML showed complete remission (CR) or marked reduction of marrow blasts in a few enrolled patients. Bi-/tri-specific antibodies (e.g., bispecific T-cell engager (BiTE) and dual-affinity retargeting (DART)) exhibited 11-67% CR rates with 13-78% risk of cytokine-releasing syndrome (CRS). Conventional chemotherapy in combination with anti-PD-1/anti-CTLA4 antibody for relapsed/refractory AML showed 10-36% CR rates with 7-24 month-long median survival. The current advantages of IO therapy in the field of AML are summarized herein. However, although cancer vaccination should be included in the concept of IO therapy, it is not mentioned in this review because of the paucity of relevant evidence.
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Affiliation(s)
- Rikako Tabata
- Department of Hematology, National Cancer Center Hospital East, Kashiwa 277-8577, Japan; (R.T.); (S.C.); (J.Y.)
- Department of Hematology, Kameda Medical Center, Kamogawa 296-8602, Japan
| | - SungGi Chi
- Department of Hematology, National Cancer Center Hospital East, Kashiwa 277-8577, Japan; (R.T.); (S.C.); (J.Y.)
| | - Junichiro Yuda
- Department of Hematology, National Cancer Center Hospital East, Kashiwa 277-8577, Japan; (R.T.); (S.C.); (J.Y.)
| | - Yosuke Minami
- Department of Hematology, National Cancer Center Hospital East, Kashiwa 277-8577, Japan; (R.T.); (S.C.); (J.Y.)
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Rimando JC, Christopher MJ, Rettig MP, DiPersio JF. Biology of Disease Relapse in Myeloid Disease: Implication for Strategies to Prevent and Treat Disease Relapse After Stem-Cell Transplantation. J Clin Oncol 2021; 39:386-396. [PMID: 33434062 PMCID: PMC8462627 DOI: 10.1200/jco.20.01587] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 10/05/2020] [Accepted: 10/13/2020] [Indexed: 12/15/2022] Open
Affiliation(s)
- Joseph C. Rimando
- Division of Oncology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Matthew J. Christopher
- Division of Oncology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Michael P. Rettig
- Division of Oncology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - John F. DiPersio
- Division of Oncology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO
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224
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Waksal JA, Tallman MS. Incorporation of Novel therapies for the treatment of acute myeloid leukemia: a perspective. Leuk Lymphoma 2021; 62:779-790. [PMID: 33541192 DOI: 10.1080/10428194.2020.1842403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Acute myeloid leukemia (AML) is a heterogeneous group of diseases that poses an array of therapeutic challenges. For decades two chemotherapeutic agents, cytarabine and daunorubicin, remained the backbone of AML therapy protocols. However, since 2017 nine novel therapies have been approved for the management of AML. With the rapid expansion of therapeutic options, hematologists must adapt their practice to optimize the benefits of these novel therapy options and minimize treatment toxicity. Here, we discuss the novel therapies that have changed the standard of care in management of patients with AML. We summarize the pivotal clinical trials that lead to the approval of these agents, and ongoing trials evaluating additional potential indications. We discuss several promising therapy candidates and their corresponding clinical trials. We discuss therapeutic strategies to incorporate these therapies into practice and pose unanswered questions that have arisen along with the expansion of treatment options.
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225
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Tang H, Jia S, Bi L, Jia W, Gao G. Treatment options for older unfit patients with acute myeloid leukemia. Future Oncol 2021; 17:837-851. [PMID: 33522289 DOI: 10.2217/fon-2020-0615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Older acute myeloid leukemia patients usually experience a bleak outcome, especially those in the unfit group. For this unfit category, intensive chemotherapy and allogeneic stem cell transplantation are usually accompanied by higher early mortality, which results from higher risk genetic profiles and worse psychological and physiological conditions. The significant improvement in genetic technology recently has driven the appearance of several mutation-targeted therapies, such as FLT3, Bcl-2, IDH and Hedgehog pathway inhibitors and an anti-CD33 antibody-drug conjugate, which have changed enormously the therapeutic landscape of acute myeloid leukemia. This review describes the treatment dilemma of the unfit group and discusses the objective clinical data of each targeted drug and mechanisms of resistance, with a focus on combination strategies with fewer toxicities and abrogation of drug resistance.
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Affiliation(s)
- Hailong Tang
- Department of Hematology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
| | - Shuangshuang Jia
- Department of Hematology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
| | - Lei Bi
- Department of Hematology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
| | - Weijing Jia
- Department of Hematology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
| | - Guangxun Gao
- Department of Hematology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
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226
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Maiti A, DiNardo CD, Daver NG, Rausch CR, Ravandi F, Kadia TM, Pemmaraju N, Borthakur G, Bose P, Issa GC, Short NJ, Yilmaz M, Montalban-Bravo G, Ferrajoli A, Jabbour EJ, Jain N, Ohanian M, Takahashi K, Thompson PA, Loghavi S, Montalbano KS, Pierce S, Wierda WG, Kantarjian HM, Konopleva MY. Triplet therapy with venetoclax, FLT3 inhibitor and decitabine for FLT3-mutated acute myeloid leukemia. Blood Cancer J 2021; 11:25. [PMID: 33563904 PMCID: PMC7873265 DOI: 10.1038/s41408-021-00410-w] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 10/27/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022] Open
Affiliation(s)
- Abhishek Maiti
- 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
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Caitlin R Rausch
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ghayas C Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias J Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maro Ohanian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Koichi Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Philip A Thompson
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathryn S Montalbano
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sherry Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William G Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina Y Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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227
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Bazinet A, Assouline S. A review of FDA-approved acute myeloid leukemia therapies beyond '7 + 3'. Expert Rev Hematol 2021; 14:185-197. [PMID: 33430671 DOI: 10.1080/17474086.2021.1875814] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction: The standard anthracycline and cytarabine-based chemotherapy for acute myeloid leukemia (AML) has changed relatively little since the 1970s and produces unsatisfactory outcomes in many patients. In the past two decades, a better understanding of the pathophysiology and heterogeneity of this disease has led to promising new therapies, resulting in a flurry of new drug approvals.Areas covered: The MEDLINE database, ClinicalTrials.gov and conference proceedings were reviewed for the most salient literature concerning FDA-approved drugs for AML beyond standard chemotherapy: gemtuzumab ozogamicin, hypomethylating agents, Fms-like tyrosine kinase 3 (FLT3) inhibitors, isocitrate dehydrogenase (IDH) inhibitors, venetoclax, liposomal cytarabine and daunorubicin (CPX-351), and hedgehog pathway inhibitors. Key evidence for their efficacy is discussed. For each drug category, indications, typical usage and responses, major toxicities, and future directions for research are highlighted.Expert opinion: The treatment paradigm for AML is rapidly evolving. Promising new drugs targeting driver mutations have improved outcomes in specific AML subgroups. In parallel, advances in low-intensity therapies have allowed patients unfit for standard induction chemotherapy to achieve meaningful disease control. Further work is ongoing to identify synergistic drug combinations as well as optimal treatment selection guided by individual patient and disease features.
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Affiliation(s)
- Alexandre Bazinet
- Department of Hematology, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Sarit Assouline
- Department of Hematology, Jewish General Hospital, McGill University, Montreal, QC, Canada
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228
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Kennedy VE, Smith CC. FLT3 Mutations in Acute Myeloid Leukemia: Key Concepts and Emerging Controversies. Front Oncol 2021; 10:612880. [PMID: 33425766 PMCID: PMC7787101 DOI: 10.3389/fonc.2020.612880] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/19/2020] [Indexed: 12/27/2022] Open
Abstract
The FLT3 receptor is overexpressed on the majority of acute myeloid leukemia (AML) blasts. Mutations in FLT3 are the most common genetic alteration in AML, identified in approximately one third of newly diagnosed patients. FLT3 internal tandem duplication mutations (FLT3-ITD) are associated with increased relapse and inferior overall survival. Multiple small molecule inhibitors of FLT3 signaling have been identified, two of which (midostaurin and gilteritinib) are currently approved in the United States, and many more of which are in clinical trials. Despite significant advances, resistance to FLT3 inhibitors through secondary FLT3 mutations, upregulation of parallel pathways, and extracellular signaling remains an ongoing challenge. Novel therapeutic strategies to overcome resistance, including combining FLT3 inhibitors with other antileukemic agents, development of new FLT3 inhibitors, and FLT3-directed immunotherapy are in active clinical development. Multiple questions regarding FLT3-mutated AML remain. In this review, we highlight several of the current most intriguing controversies in the field including the role of FLT3 inhibitors in maintenance therapy, the role of hematopoietic cell transplantation in FLT3-mutated AML, use of FLT3 inhibitors in FLT3 wild-type disease, significance of non-canonical FLT3 mutations, and finally, emerging concerns regarding clonal evolution.
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Affiliation(s)
- Vanessa E Kennedy
- Division of Hematology and Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Catherine C Smith
- Division of Hematology and Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
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229
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Concentration-QTc analysis of quizartinib in patients with relapsed/refractory acute myeloid leukemia. Cancer Chemother Pharmacol 2021; 87:513-523. [PMID: 33415416 PMCID: PMC7946665 DOI: 10.1007/s00280-020-04204-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/16/2020] [Indexed: 11/29/2022]
Abstract
Purpose This analysis evaluated the relationship between concentrations of quizartinib and its active metabolite AC886 and QT interval corrected using Fridericia’s formula (QTcF) in patients with relapsed/refractory acute myeloid leukemia (AML) treated in the phase 3 QuANTUM-R study (NCT02039726). Methods The analysis dataset included 226 patients with AML. Quizartinib dihydrochloride was administered as daily doses of 20, 30, and 60 mg. Nonlinear mixed-effects modeling was performed using observed quizartinib and AC886 concentrations and time-matched mean electrocardiogram measurements. Results Observed QTcF increased with quizartinib and AC886 concentrations; the relationship was best described by a nonlinear maximum effect (Emax) model. The predicted mean increase in QTcF at the maximum concentration of quizartinib and AC886 associated with 60 mg/day was 21.1 ms (90% CI, 18.3–23.6 ms). Age, body weight, sex, race, baseline QTcF, QT-prolonging drug use, hypomagnesemia, and hypocalcemia were not significant predictors of QTcF. Hypokalemia (serum potassium < 3.5 mmol/L) was a statistically significant covariate affecting baseline QTcF, but no differences in ∆QTcF (change in QTcF from baseline) were predicted between patients with versus without hypokalemia at the same quizartinib concentration. The use of concomitant QT-prolonging drugs did not increase QTcF further. Conclusion QTcF increase was dependent on quizartinib and AC886 concentrations, but patient factors, including sex and age, did not affect the concentration–QTcF relationship. Because concomitant strong cytochrome P450 3A (CYP3A) inhibitor use significantly increases quizartinib concentration, these results support the clinical recommendation of quizartinib dose reduction in patients concurrently receiving a strong CYP3A inhibitor. Clinical Trial Registration NCT02039726 (registered January 20, 2014). Supplementary Information The online version contains supplementary material available at 10.1007/s00280-020-04204-y.
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230
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Moritake H, Tanaka S, Miyamura T, Nakayama H, Shiba N, Shimada A, Terui K, Yuza Y, Koh K, Goto H, Kakuda H, Saito A, Hasegawa D, Iwamoto S, Taga T, Adachi S, Tomizawa D. The outcomes of relapsed acute myeloid leukemia in children: Results from the Japanese Pediatric Leukemia/Lymphoma Study Group AML-05R study. Pediatr Blood Cancer 2021; 68:e28736. [PMID: 32991072 DOI: 10.1002/pbc.28736] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/04/2020] [Accepted: 09/06/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The prognosis of children with acute myeloid leukemia (AML) has improved with the efficacy of hematopoietic cell transplantation (HCT) as a second-line therapy and improvements in supportive care following anthracycline- and cytarabine-based chemotherapy; however, the outcomes of children with relapsed AML still remain unsatisfactory. PROCEDURE In order to identify prognostic factors and improve their prognosis, we analyzed 111 patients who relapsed after treatment with the Japanese Pediatric Leukemia/Lymphoma Study Group (JPLSG) AML-05 protocol and who were registered in the retrospective JPLSG AML-05R study. RESULTS The 5-year overall survival rate was 36.1%. The major determinant of survival was duration from the diagnosis to relapse. The mean duration in the nonsurviving group (10.1 ± 4.1 months) was shorter than that in the surviving group (16.3 ± 8.3 months) (P < .01). Moreover, achieving a second complete remission (CR2) prior to HCT was associated with a good prognosis (P < .01). Etoposide, cytarabine, and mitoxantrone (ECM)- or fludarabine, cytarabine, and granulocyte colony-stimulating factor (FLAG)-based regimens were therefore recommended for reinduction therapy (P < .01). A genetic analysis also revealed the prognostic significance of FMS-like tyrosine kinase 3 (FLT3)-internal tandem duplication as a poor prognostic marker (P = .04) and core binding factor-AML, t(8;21), and inv(16) as good prognostic markers (P < .01). CONCLUSIONS Achieving a CR2 prior to HCT is important in order to improve the prognosis of relapsed pediatric AML. Recent molecular targeted therapies, such as FLT3 inhibitors, may contribute to overcome their prognoses. Larger prospective investigations are necessary to establish individualized treatment strategies for patients with relapsed childhood AML.
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Affiliation(s)
- Hiroshi Moritake
- Division of Pediatrics, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Shiro Tanaka
- Department of Clinical Biostatistics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takako Miyamura
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideki Nakayama
- Department of Pediatrics, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Norio Shiba
- Department of Pediatrics, Yokohama City University Hospital, Yokohama, Japan
| | - Akira Shimada
- Department of Pediatrics, Okayama University, Okayama, Japan
| | - Kiminori Terui
- Department of Pediatrics, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuki Yuza
- Department of Hematology/Oncology, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroaki Goto
- Division of Hemato-oncology/Regenerative Medicine, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Harumi Kakuda
- Department of Hematology/Oncology, Chiba Children's Hospital, Chiba, Japan
| | - Akiko Saito
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Daisuke Hasegawa
- Department of Pediatrics, St. Luke's International Hospital, Tokyo, Japan
| | - Shotaro Iwamoto
- Department of Pediatrics, Mie University Graduate School of Medicine, Tsu, Japan
| | - Takashi Taga
- Department of Pediatrics, Shiga University of Medical Science, Otsu, Japan
| | - Souichi Adachi
- Department of Human Health Sciences, Kyoto University, Kyoto, Japan
| | - Daisuke Tomizawa
- Division of Leukemia and Lymphoma, Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
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231
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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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232
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Minetto P, Candoni A, Guolo F, Clavio M, Zannier ME, Miglino M, Dubbini MV, Carminati E, Sicuranza A, Ciofini S, Colombo N, Pugliese G, Marcolin R, Santoni A, Ballerini F, Lanino L, Cea M, Gobbi M, Bocchia M, Fanin R, Lemoli RM. Fludarabine, High-Dose Cytarabine and Idarubicin-Based Induction May Overcome the Negative Prognostic Impact of FLT3-ITD in NPM1 Mutated AML, Irrespectively of FLT3-ITD Allelic Burden. Cancers (Basel) 2020; 13:cancers13010034. [PMID: 33374216 PMCID: PMC7796342 DOI: 10.3390/cancers13010034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/15/2020] [Accepted: 12/21/2020] [Indexed: 12/19/2022] Open
Abstract
Simple Summary The prognostic relevance of molecular aberrations in acute myeloid leukemia (AML) has been prevalently tested in patients receiving conventional 3+7 induction. Recently, there has been a renewed interest in intensified inductions, but very few data are available on the impact of the most frequent genetic alterations with these alternative treatments. We analyzed a large multicentric cohort of younger AML patients harboring NPM1 and FLT3-ITD mutations receiving an intensified fludarabine-containing regimen (FLAI). Our data suggest that in NPM1 mut patients, FLAI may overcome the prognostic influence of co-mutated FLT3-ITD. The increased efficacy of this treatment seems to reduce the need for early consolidation with allogeneic transplant in double-mutated patients. Our data strongly support FLAI as an ideal backbone for combination with innovative targeted drugs, in order to further improve patients’ outcome. Abstract The mutations of NPM1 and FLT3-ITD represent the most frequent genetic aberration in acute myeloid leukemia. Indeed, the presence of an NPM1 mutation reduces the negative prognostic impact of FLT3-ITD in patients treated with conventional “3+7” induction. However, little information is available on their prognostic role with intensified regimens. Here, we investigated the efficacy of a fludarabine, high-dose cytarabine and idarubicin induction (FLAI) in 149 consecutive fit AML patients (median age 52) carrying the NPM1 and/or FLT3-ITD mutation, treated from 2008 to 2018. One-hundred-and-twenty-nine patients achieved CR (86.6%). After a median follow up of 68 months, 3-year overall survival was 58.6%. Multivariate analysis disclosed that both NPM1mut (p < 0.05) and ELN 2017 risk score (p < 0.05) were significant predictors of survival. NPM1-mutated patients had a favorable outcome, with no significant differences between patients with or without concomitant FLT3-ITD (p = 0.372), irrespective of FLT3-ITD allelic burden. Moreover, in landmark analysis, performing allogeneic transplantation (HSCT) in first CR proved to be beneficial only in ELN 2017 high-risk patients. Our data indicate that FLAI exerts a strong anti-leukemic effect in younger AML patients with NPM1mut and question the role of HSCT in 1st CR in NPM1mut patients with concomitant FLT3-ITD.
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Affiliation(s)
- Paola Minetto
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
- IRCCS-Ospedale Policlinico San Martino, 16132 Genova, Italy;
- Correspondence: (P.M.); (F.G.); Tel.: +39-10-555-4329 (P.M.); +39-10-555-4491 (F.G.)
| | - Anna Candoni
- Division of Hematology and Bone Marrow Transplantation, Azienda Sanitaria Universitaria Integrata di Udine, 33100 Udine, Italy; (A.C.); (M.E.Z.); (M.V.D.); (R.F.)
| | - Fabio Guolo
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
- IRCCS-Ospedale Policlinico San Martino, 16132 Genova, Italy;
- Correspondence: (P.M.); (F.G.); Tel.: +39-10-555-4329 (P.M.); +39-10-555-4491 (F.G.)
| | - Marino Clavio
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
- IRCCS-Ospedale Policlinico San Martino, 16132 Genova, Italy;
| | - Maria Elena Zannier
- Division of Hematology and Bone Marrow Transplantation, Azienda Sanitaria Universitaria Integrata di Udine, 33100 Udine, Italy; (A.C.); (M.E.Z.); (M.V.D.); (R.F.)
| | - Maurizio Miglino
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
- IRCCS-Ospedale Policlinico San Martino, 16132 Genova, Italy;
| | - Maria Vittoria Dubbini
- Division of Hematology and Bone Marrow Transplantation, Azienda Sanitaria Universitaria Integrata di Udine, 33100 Udine, Italy; (A.C.); (M.E.Z.); (M.V.D.); (R.F.)
| | - Enrico Carminati
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
- IRCCS-Ospedale Policlinico San Martino, 16132 Genova, Italy;
| | - Anna Sicuranza
- Hematology Unit, University of Siena, Azienda Ospedaliera Universitaria, 53100 Siena, Italy; (A.S.); (S.C.); (A.S.); (M.B.)
| | - Sara Ciofini
- Hematology Unit, University of Siena, Azienda Ospedaliera Universitaria, 53100 Siena, Italy; (A.S.); (S.C.); (A.S.); (M.B.)
| | | | - Girolamo Pugliese
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
- IRCCS-Ospedale Policlinico San Martino, 16132 Genova, Italy;
| | - Riccardo Marcolin
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
| | - Adele Santoni
- Hematology Unit, University of Siena, Azienda Ospedaliera Universitaria, 53100 Siena, Italy; (A.S.); (S.C.); (A.S.); (M.B.)
| | - Filippo Ballerini
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
- IRCCS-Ospedale Policlinico San Martino, 16132 Genova, Italy;
| | - Luca Lanino
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
| | - Michele Cea
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
- IRCCS-Ospedale Policlinico San Martino, 16132 Genova, Italy;
| | - Marco Gobbi
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
| | - Monica Bocchia
- Hematology Unit, University of Siena, Azienda Ospedaliera Universitaria, 53100 Siena, Italy; (A.S.); (S.C.); (A.S.); (M.B.)
| | - Renato Fanin
- Division of Hematology and Bone Marrow Transplantation, Azienda Sanitaria Universitaria Integrata di Udine, 33100 Udine, Italy; (A.C.); (M.E.Z.); (M.V.D.); (R.F.)
| | - Roberto Massimo Lemoli
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
- IRCCS-Ospedale Policlinico San Martino, 16132 Genova, Italy;
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Roussel X, Daguindau E, Berceanu A, Desbrosses Y, Warda W, Neto da Rocha M, Trad R, Deconinck E, Deschamps M, Ferrand C. Acute Myeloid Leukemia: From Biology to Clinical Practices Through Development and Pre-Clinical Therapeutics. Front Oncol 2020; 10:599933. [PMID: 33363031 PMCID: PMC7757414 DOI: 10.3389/fonc.2020.599933] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/02/2020] [Indexed: 12/19/2022] Open
Abstract
Recent studies have provided several insights into acute myeloid leukemia. Studies based on molecular biology have identified eight functional mutations involved in leukemogenesis, including driver and passenger mutations. Insight into Leukemia stem cells (LSCs) and assessment of cell surface markers have enabled characterization of LSCs from hematopoietic stem and progenitor cells. Clonal evolution has been described as having an effect similar to that of microenvironment alterations. Such biological findings have enabled the development of new targeted drugs, including drug inhibitors and monoclonal antibodies with blockage functions. Some recently approved targeted drugs have resulted in new therapeutic strategies that enhance standard intensive chemotherapy regimens as well as supportive care regimens. Besides the progress made in adoptive immunotherapy, since allogenic hematopoietic stem cell transplantation enabled the development of new T-cell transfer therapies, such as chimeric antigen receptor T-cell and transgenic TCR T-cell engineering, new promising strategies that are investigated.
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Affiliation(s)
- Xavier Roussel
- Inserm EFS BFC, UMR1098 RIGHT, University Bourgogne Franche-Comté, Besançon, France
- Department of Hematology, University Hospital of Besançon, Besançon, France
| | - Etienne Daguindau
- Inserm EFS BFC, UMR1098 RIGHT, University Bourgogne Franche-Comté, Besançon, France
- Department of Hematology, University Hospital of Besançon, Besançon, France
| | - Ana Berceanu
- Department of Hematology, University Hospital of Besançon, Besançon, France
| | - Yohan Desbrosses
- Department of Hematology, University Hospital of Besançon, Besançon, France
| | - Walid Warda
- Inserm EFS BFC, UMR1098 RIGHT, University Bourgogne Franche-Comté, Besançon, France
| | | | - Rim Trad
- Inserm EFS BFC, UMR1098 RIGHT, University Bourgogne Franche-Comté, Besançon, France
| | - Eric Deconinck
- Inserm EFS BFC, UMR1098 RIGHT, University Bourgogne Franche-Comté, Besançon, France
- Department of Hematology, University Hospital of Besançon, Besançon, France
| | - Marina Deschamps
- Inserm EFS BFC, UMR1098 RIGHT, University Bourgogne Franche-Comté, Besançon, France
| | - Christophe Ferrand
- Inserm EFS BFC, UMR1098 RIGHT, University Bourgogne Franche-Comté, Besançon, France
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234
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Majothi S, Adams D, Loke J, Stevens SP, Wheatley K, Wilson JS. FLT3 inhibitors in acute myeloid leukaemia: assessment of clinical effectiveness, adverse events and future research-a systematic review and meta-analysis. Syst Rev 2020; 9:285. [PMID: 33287892 PMCID: PMC7722339 DOI: 10.1186/s13643-020-01540-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 11/22/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND FMS-like tyrosine kinase 3 (FLT3) is the most frequent mutation in AML. With two FLT3 inhibitors recently approved by the FDA (midostaurin and gilteritinib), there is a need to evaluate these targeted agents. PURPOSE To assess the clinical effectiveness of FLT3 inhibitors in AML patients. METHODS Standard systematic review methods were utilised. Searches were conducted to July 2020 for completed and in-progress randomised controlled trials of FLT3 inhibitors in AML. A fixed-effect meta-analysis was undertaken. RESULTS Eight completed trials involving 2656 patients and assessing five different FLT3 inhibitors (sorafenib, lestaurtinib, midostaurin, gilteritinib and quizartinib) were included. The pooled results were as follows (FLT3 inhibitor/control): overall survival hazard ratio (HR) = 0.83 (95% confidence interval [CI] 0.75 to 0.92, p = 0.0005), event-free survival HR = 0.85 (95% CI 0.77 to 0.94, p = 0.002), relapse-free survival HR = 0.76 (95% CI 0.64 to 0.90, p = 0.001), complete remission relative risk (RR) = 1.11 (95% CI 1.00 to 1.22. p = 0.05) and 60-day mortality RR = 1.04 (95% CI 0.77 to 1.40, p = 0.79). Relative risk of grade 3 and above vascular, dermatological, respiratory and hepatobiliary adverse events were found to be statistically significantly higher in the FLT3 inhibitor group compared to control, but the actual numbers of events were relatively small. Nineteen ongoing trials are still in progress, only one of which specifically targets older patients with AML. CONCLUSIONS There is evidence to support the use of FLT3 inhibitors in patients with AML, but more data is needed to verify the optimum use of the drugs regarding type of inhibitor, disease stage and patient characteristics, not only in relation to disease control, but adverse events and quality of life. There are a large number of ongoing trials; therefore, the results of this review are not a fait accompli; thus, is it recommended that the review be updated in a couple of years' time. Given the challenges in extracting the complete data set required to assess clinical effectiveness, it is highly recommended that ongoing and future trials improve transparency and consistency of reporting of all trial outcomes, particularly disease control and adverse events, to enable a global clinical effectiveness assessment. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017055581.
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Affiliation(s)
- S Majothi
- Cancer Research Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - D Adams
- Kingsmead Scientific Services Ltd, High Wycombe, Buckinghamshire, UK
| | - J Loke
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - S P Stevens
- Cancer Research Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - K Wheatley
- Cancer Research Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - J S Wilson
- Cancer Research Clinical Trials Unit, University of Birmingham, Birmingham, UK. .,Institute of Cancer & Genomic Sciences, Robert Aitken Institute of Clinical Research, University of Birmingham, Birmingham, UK.
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235
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Alotaibi AS, Yilmaz M, Kanagal-Shamanna R, Loghavi S, Kadia TM, DiNardo CD, Borthakur G, Konopleva M, Pierce SA, Wang SA, Tang G, Guerra V, Samra B, Pemmaraju N, Jabbour E, Short NJ, Issa GC, Ohanian M, Garcia-Manero G, Bhalla KN, Patel KP, Takahashi K, Andreeff M, Cortes JE, Kantarjian HM, Ravandi F, Daver N. Patterns of Resistance Differ in Patients with Acute Myeloid Leukemia Treated with Type I versus Type II FLT3 inhibitors. Blood Cancer Discov 2020; 2:125-134. [PMID: 33681815 DOI: 10.1158/2643-3230.bcd-20-0143] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Despite promising results with FLT3 inhibitors (FLT3i), response durations remain short. We studied pretreatment and relapse bone marrow samples from patients with FLT3-mutated AML treated with FLT3i-based therapies (secondary resistance cohort), and pretreatment bone marrow samples from patients with no response to FLT3i-based therapies (primary resistance cohort). Targeted next generation sequencing at relapse identified emergent mutations involving on-target FLT3, epigenetic modifiers, RAS/MAPK pathway, and less frequently WT1, and TP53. RAS/MAPK and FLT3-D835 mutations emerged most commonly following type I and type II FLT3i-based therapies, respectively. Patients with emergent mutations at relapse had inferior overall survival compared with those without emergent mutations. Among pretreatment RAS mutated patients, pretreatment cohort level variant allelic frequencies for RAS were higher in non-responders, particularly with type I FLT3i-based therapies, suggesting a potential role in primary resistance as well. These data demonstrate distinct pathways of resistance in FLT3-mutated AML treated with type I versus II FLT3i.
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Affiliation(s)
- Ahmad S Alotaibi
- The Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | - Musa Yilmaz
- The Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | | | - Sanam Loghavi
- The Department of Hematopathology, MD Anderson Cancer Center, Houston, Texas
| | - Tapan M Kadia
- The Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | | | - Gautam Borthakur
- The Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | - Marina Konopleva
- The Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | - Sherry A Pierce
- The Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | - Sa A Wang
- The Department of Hematopathology, MD Anderson Cancer Center, Houston, Texas
| | - Guilin Tang
- The Department of Hematopathology, MD Anderson Cancer Center, Houston, Texas
| | - Veronica Guerra
- The Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | - Bachar Samra
- The Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | - Naveen Pemmaraju
- The Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | - Elias Jabbour
- The Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | - Nicholas J Short
- The Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | - Ghayas C Issa
- The Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | - Maro Ohanian
- The Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | | | - Kapil N Bhalla
- The Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | - Keyur P Patel
- The Department of Hematopathology, MD Anderson Cancer Center, Houston, Texas
| | - Koichi Takahashi
- The Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | - Michael Andreeff
- The Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | - Jorge E Cortes
- Georgia Cancer Center, Augusta University, Augusta, Georgia
| | | | - Farhad Ravandi
- The Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | - Naval Daver
- The Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
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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: 11] [Impact Index Per Article: 2.8] [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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237
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Censored patients in Kaplan–Meier plots of cancer drugs: An empirical analysis of data sharing. Eur J Cancer 2020; 141:152-161. [DOI: 10.1016/j.ejca.2020.09.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/08/2020] [Accepted: 09/25/2020] [Indexed: 11/18/2022]
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238
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Molecular Mechanisms of Resistance to FLT3 Inhibitors in Acute Myeloid Leukemia: Ongoing Challenges and Future Treatments. Cells 2020; 9:cells9112493. [PMID: 33212779 PMCID: PMC7697863 DOI: 10.3390/cells9112493] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/07/2020] [Accepted: 11/13/2020] [Indexed: 12/17/2022] Open
Abstract
Treatment of FMS-like tyrosine kinase 3 (FLT3)-internal tandem duplication (ITD)-positive acute myeloid leukemia (AML) remains a challenge despite the development of novel FLT3-directed tyrosine kinase inhibitors (TKI); the relapse rate is still high even after allogeneic stem cell transplantation. In the era of next-generation FLT3-inhibitors, such as midostaurin and gilteritinib, we still observe primary and secondary resistance to TKI both in monotherapy and in combination with chemotherapy. Moreover, remissions are frequently short-lived even in the presence of continuous treatment with next-generation FLT3 inhibitors. In this comprehensive review, we focus on molecular mechanisms underlying the development of resistance to relevant FLT3 inhibitors and elucidate how this knowledge might help to develop new concepts for improving the response to FLT3-inhibitors and reducing the development of resistance in AML. Tailored treatment approaches that address additional molecular targets beyond FLT3 could overcome resistance and facilitate molecular responses in AML.
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239
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FLAMSA-Based Reduced-Intensity Conditioning versus Myeloablative Conditioning in Younger Patients with Relapsed/Refractory Acute Myeloid Leukemia with Active Disease at the Time of Allogeneic Stem Cell Transplantation: An Analysis from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2020; 26:2165-2173. [DOI: 10.1016/j.bbmt.2020.07.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 12/20/2022]
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Shi W, Jin W, Xia L, Hu Y. Novel agents targeting leukemia cells and immune microenvironment for prevention and treatment of relapse of acute myeloid leukemia after allogeneic hematopoietic stem cell transplantation. Acta Pharm Sin B 2020; 10:2125-2139. [PMID: 32837873 PMCID: PMC7326461 DOI: 10.1016/j.apsb.2020.06.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/27/2020] [Accepted: 06/05/2020] [Indexed: 12/20/2022] Open
Abstract
Relapse remains the worst life-threatening complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT) in patients with acute myeloid leukemia (AML), whose prognosis has been historically dismal. Given the rapid development of genomics and immunotherapies, the interference strategies for AML recurrence have been changing these years. More and more novel targeting agents that have received the U.S. Food and Drug Administration (FDA) approval for de novo AML treatment have been administrated in the salvage or maintenance therapy of post-HSCT relapse. Targeted strategies that regulate the immune microenvironment of and optimize the graft versus leukemia (GVL) effect of immune cells are gradually improved. Such agents not only have been proven to achieve clinical benefits from a single drug, but if combined with classic therapies, can significantly improve the poor prognosis of AML patients who relapse after allo-HSCT. This review will focus on currently available and promising upcoming agents and also discuss the challenges and limitations of targeted therapies in the allogeneic hematopoietic stem cell transplantation community.
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Affiliation(s)
- Wei Shi
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024, USA
| | - Weiwei Jin
- Department of Cardiovascular, Optical Valley School District, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan 430061, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan 430074, China
| | - Linghui Xia
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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241
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Banskota SU, Khanal N, Bhatt VR. A precision medicine approach to management of acute myeloid leukemia in older adults. Curr Opin Oncol 2020; 32:650-655. [PMID: 32826488 PMCID: PMC7737662 DOI: 10.1097/cco.0000000000000673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW Therapy selection in older adults with acute myeloid leukemia (AML) can be challenging because of a higher incidence of high-risk cytogenetic and molecular features conferring chemoresistance and poor functional status leading to increased treatment-related toxicities. The purpose of this review is to highlight the recent advances in precision medicine in AML that have shown promise to improve outcomes of older adults. RECENT FINDINGS The utilization of next generation sequencing to identify and target actionable mutations can influence therapy selection in one-third of patients and can result in higher response rates as well as survival compared with those who do not receive targeted therapy. Oral targeted agents are available for AML with IDH 1, IDH2, or FLT3 mutations. Low-intensity venetoclax-based regimens have shown high rates of responses in AML, particularly among those with NPM1 and IDH2 mutations; responses are often durable and associated with minimal residual disease (MRD) negativity. Multiple studies have demonstrated the prognostic significance of flow cytometric MRD, with potential implications for subsequent therapy. SUMMARY Novel approaches for AML risk-stratification, MRD assessment, and a precision medicine approach offer significant promise to improve survival and quality of life of older adults.
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Affiliation(s)
| | - Nabin Khanal
- Franciscan Physician Network Oncology & Hematology Specialists, St Francis hospital, Indianapolis, IN
| | - Vijaya Raj Bhatt
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE
- Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE
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242
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Daver N, Wei AH, Pollyea DA, Fathi AT, Vyas P, DiNardo CD. New directions for emerging therapies in acute myeloid leukemia: the next chapter. Blood Cancer J 2020; 10:107. [PMID: 33127875 PMCID: PMC7599225 DOI: 10.1038/s41408-020-00376-1] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/23/2020] [Accepted: 10/09/2020] [Indexed: 02/07/2023] Open
Abstract
Conventional therapy for acute myeloid leukemia is composed of remission induction with cytarabine- and anthracycline-containing regimens, followed by consolidation therapy, including allogeneic stem cell transplantation, to prolong remission. In recent years, there has been a significant shift toward the use of novel and effective, target-directed therapies, including inhibitors of mutant FMS-like tyrosine kinase 3 (FLT3) and isocitrate dehydrogenase (IDH), the B-cell lymphoma 2 inhibitor venetoclax, and the hedgehog pathway inhibitor glasdegib. In older patients the combination of a hypomethylating agent or low-dose cytarabine, venetoclax achieved composite response rates that approximate those seen with standard induction regimens in similar populations, but with potentially less toxicity and early mortality. Preclinical data suggest synergy between venetoclax and FLT3- and IDH-targeted therapies, and doublets of venetoclax with inhibitors targeting these mutations have shown promising clinical activity in early stage trials. Triplet regimens involving the hypomethylating agent and venetoclax with FLT3 or IDH1/2 inhibitor, the TP53-modulating agent APR-246 and magrolimab, myeloid cell leukemia-1 inhibitors, or immune therapies such as CD123 antibody-drug conjugates and programmed cell death protein 1 inhibitors are currently being evaluated. It is hoped that such triplets, when applied in appropriate patient subsets, will further enhance remission rates, and more importantly remission durations and survival.
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Affiliation(s)
- Naval Daver
- MD Anderson Cancer Center, Houston, TX, USA.
| | - Andrew H Wei
- The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Daniel A Pollyea
- University of Colorado Department of Medicine, Division of Hematology, Aurora, CO, USA
| | | | - Paresh Vyas
- MRC Molecular Haematology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford Comprehensive BRC, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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4-Hydroxyphenyl Retinamide Preferentially Targets FLT3 Mutated Acute Myeloid Leukemia via ROS Induction and NF-κB Inhibition. Curr Med Sci 2020; 40:810-816. [PMID: 33123895 DOI: 10.1007/s11596-020-2259-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/06/2020] [Indexed: 10/23/2022]
Abstract
FMS-like tyrosine kinase 3 (FLT3) mutation is strongly associated with poor prognosis in acute myeloid leukemia (AML). Though many FLT3 inhibitors have been developed for clinical application with 34%-56% complete remission rate, patients would develop resistance sooner or later after initial response to tyrosine kinase inhibitors (TKIs), such as gilteritinib. And increasing studies have shown that several resistance related mutations of FLT3 emerged during the AML progression. Thus, further investigation is warranted for these FLT3mut AML patients to achieve a better treatment outcome. 4-Hydroxyphenyl retinamide (4-HPR) has been investigated extensively in animal models and clinical trials as an anticancer/chemopreventive agent and is currently used for protection against cancer development/recurrence, with minimal side effects. In this study, we performed gene-set enrichment analysis and found that down-regulated genes induced by 4-HPR were associated with FLT3-ITD gene sets. CD34+ AML stem/progenitor cells separated from 32 AML samples were treated with 4-HPR. Correlation analysis showed that AML cells with FLT3-ITD genetic alteration were more sensitive to 4-HPR treatment than those without FLT3-ITD. Next, we treated 22 primary AML cells with 4-HPR and found that 4-HPR was more toxic to AML cells with FLT3-ITD. These results indicated that 4-HPR was preferentially cytotoxic to all FLT3-ITD AML+ cells irrespective of stem/progenitor cells or blast cells. 4-HPR-induced reactive oxygen species (ROS) production and NF-κB inhibition might be the reason of 4-HPR selectivity on FLT3 mutated AML cells.
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244
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Yilmaz M, Alfayez M, DiNardo CD, Borthakur G, Kadia TM, Konopleva MY, Loghavi S, Kanagal-Shamanna R, Patel KP, Jabbour EJ, Garcia-Manero G, Pemmaraju N, Pierce SA, Ghayas I, Short NJ, Montalban-Bravo G, Takahashi K, Assi R, Alotaibi AS, Ohanian M, Andreeff M, Cortes JE, Kantarjian HM, Ravandi F, Daver NG. Outcomes with sequential FLT3-inhibitor-based therapies in patients with AML. J Hematol Oncol 2020; 13:132. [PMID: 33032648 PMCID: PMC7542942 DOI: 10.1186/s13045-020-00964-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/21/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Second-generation FLT3-inhibitors (FLT3i) demonstrated single-agent composite CR rates (CRc) of 45-55% in patients with relapsed/refractory (R/R) FLT3-mutated AML in phase II/III trials. However, > 85% of patients treated were prior FLT3i naïve. The response rates to sequential FLT3i exposure remain poorly defined. METHODS We retrospectively reviewed patients with FLT3-mutated AML between November 2006 and December 2019. RESULTS In frontline patients treated with a FLT3i (cohort 1), the CRc rates and median overall survival (OS) with the first (n = 56), second (n = 32), and third FLT3i-based (n = 8) therapy were 77%, 31%, and 25%, and 16.7 months, 6.0 months, and 1.4 months, respectively. In patients receiving a FLT3i-based therapy for the first time in a R/R AML setting (cohort 2), the CRc rates and median OS were 45%, 21%, and 10%, and 7.9 months, 4.0 months, and 4.1 months with the first (n = 183), second (n = 89), and third/fourth (n = 29) FLT3i-based therapy, respectively. In cohort 1, CRc rates with single-agent FLT3i (n = 21) versus FLT3i-based combinations (n = 19) in second/third sequential FLT3i exposures were 19% versus 42%, respectively. In cohort 2, the CRc rates with single-agent FLT3i (n = 82) versus FLT3i-based combinations (n = 101) in first FLT3i exposure were 34% versus 53%, respectively, and those with single-agent FLT3i (n = 63) versus FLT3i-based combinations (n = 55) in second/third/fourth sequential FLT3i exposures were 13% versus 25%, respectively. CONCLUSION CRc rates drop progressively with sequential exposure to FLT3i's in FLT3-mutated AML. In all settings, CRc rates were higher with FLT3i-based combinations compared with single-agent FLT3i therapy in similar FLT3i exposure settings.
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Affiliation(s)
- Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Mansour Alfayez
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Marina Y Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rashmi Kanagal-Shamanna
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keyur P Patel
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias J Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Sherry A Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Issa Ghayas
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Guillermo Montalban-Bravo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Koichi Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Rita Assi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Ahmad S Alotaibi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Maro Ohanian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Michael Andreeff
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Jorge E Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA.
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Ganguly S, Cortes JE, Krämer A, Levis MJ, Martinelli G, Perl AE, Russell NH, Arunachalam M, Santos CD, Gammon G, Lesegretain A, Mires DE, Pham H, Wang Y, Khaled SK. Clinical Outcomes in Patients with FLT3-ITD-Mutated Relapsed/Refractory Acute Myelogenous Leukemia Undergoing Hematopoietic Stem Cell Transplantation after Quizartinib or Salvage Chemotherapy in the QuANTUM-R Trial. Transplant Cell Ther 2020; 27:153-162. [PMID: 33017662 DOI: 10.1016/j.bbmt.2020.09.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/23/2020] [Accepted: 09/27/2020] [Indexed: 12/14/2022]
Abstract
Despite the substantial clinical activity of fms-related tyrosine kinase 3 (FLT3) inhibitors in relapsed or refractory (R/R) FLT3-ITD‒positive acute myelogenous leukemia (AML), durable remissions and prolonged survival in this population require allogeneic hematopoietic stem cell transplantation (allo-HSCT). Quizartinib, a once-daily oral, highly potent, and selective FLT3 inhibitor, significantly prolonged overall survival (OS) and improved clinical benefit compared with salvage chemotherapy (median OS, 6.2 months versus 4.7 months; hazard ratio [HR], .76; 95% confidence interval [CI], .58 to .98; P = .018; composite complete remission [CRc] rate, 48% versus 27%; median duration of CRc, 2.8 months versus 1.2 months; mortality rate, .8% versus 14% by day 30, 7% versus 24% by day 60) in patients with R/R FLT3-ITD AML in the phase 3 QuANTUM-R trial. In this post hoc analysis, we described the characteristics of and clinical outcomes in patients who underwent on-study HSCT in QuANTUM-R at the investigator's discretion and institutional practices. Of 367 randomized patients, 78 (32%) in the quizartinib arm and 14 (11%) in the salvage chemotherapy arm underwent on-study allo-HSCT without any intervening therapy for AML after quizartinib or study-specified salvage chemotherapy. Pooled data of patients from both treatment arms showed a longer median overall survival (OS) in transplant recipients versus those treated without allo-HSCT (12.2 months versus 4.4 months; HR, .315; 95% CI, .233 to .427). Pooled data also showed a longer median OS in patients with a last recorded response of CRc before allo-HSCT versus patients without a CRc (20.1 months versus 8.8 months; HR, .506; 95% CI, .296 to .864). By treatment arm, the median OS was 25.1 months with quizartinib and 20.1 months with salvage chemotherapy in patients with a last recorded response of CRc before allo-HSCT. Forty-eight patients in the quizartinib arm continued quizartinib treatment after allo-HSCT. In the 31 patients with a last recorded response of CRc before allo-HSCT who continued quizartinib after allo-HSCT, the median OS was 27.1 months. Continuation of quizartinib after allo-HSCT was tolerable, and no new safety signals were identified. These results suggest that post-transplantation survival following salvage chemotherapy and quizartinib treatment are similar. However, quizartinib response occurs more frequently than with salvage chemotherapy, potentially allowing more patients to undergo transplantation and achieve durable clinical benefit. In addition, post-transplant quizartinib was found to be tolerable and may be associated with prolonged survival in some patients, highlighting its potential value in the management of patients with FLT3-ITD R/R AML.
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Affiliation(s)
- Siddhartha Ganguly
- Division of Hematological Malignancies and Cellular Therapeutics, The University of Kansas Health System, Kansas City, Kansas.
| | - Jorge E Cortes
- Division of Hematology and SCT, Georgia Cancer Center, Augusta, GA
| | - Alwin Krämer
- Clinical Cooperation Unit Molecular Hematology/Oncology, Heidelberg University and German Cancer Research Center, Heidelberg, Germany
| | - Mark J Levis
- Hematologic Malignancies and Bone Marrow Transplant Program, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
| | - Giovanni Martinelli
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, IRCCS, Meldola, Italy
| | - Alexander E Perl
- Division of Hematology/Oncology, Perelman Center for Advanced Medicine, Abramson Cancer Center of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nigel H Russell
- Department of Haematology, Centre for Clinical Haematology, Nottingham University Hospital, Nottingham, UK
| | - Meena Arunachalam
- Global Medical Affairs, Oncology, Daiichi Sankyo, Inc, Basking Ridge, New Jersey
| | - Cedric Dos Santos
- Translational Sciences, Global Oncology R&D, Daiichi Sankyo, Inc, Basking Ridge, New Jersey
| | - Guy Gammon
- Global Medical Affairs, Oncology, Daiichi Sankyo, Inc, Basking Ridge, New Jersey
| | | | - Derek E Mires
- Global Oncology R&D, Daiichi Sankyo, Inc, Basking Ridge, New Jersey
| | - Hoang Pham
- Clinical Safety, Global Oncology, Daiichi Sankyo, Inc, Basking Ridge, New Jersey
| | - Yibin Wang
- Biostatistics, Daiichi Sankyo, Inc, Basking Ridge, New Jersey
| | - Samer K Khaled
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
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Mosquera Orgueira A, Bao Pérez L, Mosquera Torre A, Peleteiro Raíndo A, Cid López M, Díaz Arias JÁ, Ferreiro Ferro R, Antelo Rodríguez B, González Pérez MS, Albors Ferreiro M, Alonso Vence N, Pérez Encinas MM, Bello López JL, Martinelli G, Cerchione C. FLT3 inhibitors in the treatment of acute myeloid leukemia: current status and future perspectives. Minerva Med 2020; 111:427-442. [PMID: 32955823 DOI: 10.23736/s0026-4806.20.06989-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Mutations in the FMS-like tyrosine kinase 3 (FLT3) gene arise in 25-30% of all acute myeloid leukemia (AML) patients. These mutations lead to constitutive activation of the protein product and are divided in two broad types: internal tandem duplication (ITD) of the juxtamembrane domain (25% of cases) and point mutations in the tyrosine kinase domain (TKD). Patients with FLT3 ITD mutations have a high relapse risk and inferior cure rates, whereas the role of FLT3 TKD mutations still remains to be clarified. Additionally, growing research indicates that FLT3 status evolves through a disease continuum (clonal evolution), where AML cases can acquire FLT3 mutations at relapse - not present in the moment of diagnosis. Several FLT3 inhibitors have been tested in patients with FLT3-mutated AML. These drugs exhibit different kinase inhibitory profiles, pharmacokinetics and adverse events. First-generation multi-kinase inhibitors (sorafenib, midostaurin, lestaurtinib) are characterized by a broad-spectrum of drug targets, whereas second-generation inhibitors (quizartinib, crenolanib, gilteritinib) show more potent and specific FLT3 inhibition, and are thereby accompanied by less toxic effects. Notwithstanding, all FLT3 inhibitors face primary and acquired mechanisms of resistance, and therefore the combinations with other drugs (standard chemotherapy, hypomethylating agents, checkpoint inhibitors) and its application in different clinical settings (upfront therapy, maintenance, relapsed or refractory disease) are under study in a myriad of clinical trials. This review focuses on the role of FLT3 mutations in AML, pharmacological features of FLT3 inhibitors, known mechanisms of drug resistance and accumulated evidence for the use of FLT3 inhibitors in different clinical settings.
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Affiliation(s)
- Adrián Mosquera Orgueira
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain - .,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain - .,University of Santiago de Compostela, Santiago de Compostela, Spain -
| | - Laura Bao Pérez
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain
| | - Alicia Mosquera Torre
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain
| | - Andrés Peleteiro Raíndo
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain.,University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Miguel Cid López
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain.,University of Santiago de Compostela, Santiago de Compostela, Spain
| | - José Á Díaz Arias
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain
| | - Roi Ferreiro Ferro
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Beatriz Antelo Rodríguez
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain.,University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Marta S González Pérez
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain
| | - Manuel Albors Ferreiro
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain
| | - Natalia Alonso Vence
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain
| | - Manuel M Pérez Encinas
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain.,University of Santiago de Compostela, Santiago de Compostela, Spain
| | - José L Bello López
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain.,University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Giovanni Martinelli
- Unit of Hematology, 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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Abdul-Hamil NA, Wong GC, Nagarajan C, Martinelli G, Cherchione C. Midostaurin in acute myeloid leukemia: current evidence and practical considerations in routine clinical use. Minerva Med 2020; 111:443-454. [PMID: 32955824 DOI: 10.23736/s0026-4806.20.07014-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Mutation within the FMS-like tyrosine kinase 3 (FLT3) gene are one of the most frequent genetic alterations in acute myeloid leukemia. A high mutation fraction of FLT3-ITD molecules on the surface of leukemia cells is associated with short remissions and overall adverse outcomes in AML. In this article we summarize the clinical trial data of midostaurin - one of the FLT3 inhibitors. We review its use in various combinations both in relapsed/refractory acute myeloid leukemia as well as in the newly diagnosed patients and recollect the evidence of its use as maintenance therapy post allogenic stem cell transplantation. We enumerate the practical issues faced in the use of midostaurin like antifungal prophylaxis, dosage of concomitant chemotherapy agents as well as available data on sequencing of the FLT3 inhibitors. Lastly, we provide our perspective of the future directions for FLT3 inhibition especially midostaurin, the underlying resistance mechanisms and the need for standardization of the FLT3 tests.
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Affiliation(s)
- Nurul A Abdul-Hamil
- Department of Hematology, Singapore General Hospital, Singapore, Singapore -
| | - Gee C Wong
- Department of Hematology, Singapore General Hospital, Singapore, Singapore.,SingHealth Duke-NUS Blood Cancer Center, Singapore, Singapore
| | - Chandramouli Nagarajan
- Department of Hematology, Singapore General Hospital, Singapore, Singapore.,SingHealth Duke-NUS Blood Cancer Center, Singapore, Singapore
| | - Giovanni Martinelli
- Unit of Hematology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy
| | - Claudio Cherchione
- Unit of Hematology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy
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Megías-Vericat JE, Martínez-Cuadrón D, Solana-Altabella A, Montesinos P. Precision medicine in acute myeloid leukemia: where are we now and what does the future hold? Expert Rev Hematol 2020; 13:1057-1065. [PMID: 32869672 DOI: 10.1080/17474086.2020.1818559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Precision medicine has revolutionized the diagnostic and therapeutic management of acute myeloid leukemia (AML), from standardized schemes based on chemotherapy to tailored approaches according to molecular and genetic profile and targeted therapy. AREAS COVERED The main topics of precision medicine in AML were reviewed in MEDLINE, EMBASE, and Cochrane Central Register databases, and future directions in this therapeutic area were addressed. This review included targeted therapies, drug-sensitivity tests and predictive biomarkers, and genetic studies employing pharmacogenetic and deep sequencing strategies. EXPERT OPINION Precision medicine has opened the door to personalized therapy for specific AML patient populations with promising results. Several targeted therapies have been approved or are being tested for specific mutations (i.e. FLT3, IDH, BCL-2, TP53), obtaining improvements in clinical outcomes and less toxicity as compared with intensive treatment, allowing potential combination therapy. Ongoing trials and real data will establish the role of these molecules in monotherapy or combined in different AML settings (front-line, relapsed/refractory, or post-transplant). Experience in drug-sensitivity predictors and pharmacogenetic biomarkers is encouraging and could be useful tools in the next years, but we need a better understanding of AML biology and pathogenesis as well as confirmatory studies to demonstrate the utility in clinical practice.
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Affiliation(s)
| | - David Martínez-Cuadrón
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe , Valencia, Spain.,CIBERONC, Instituto de Salud Carlos III , Madrid, Spain
| | - Antonio Solana-Altabella
- Servicio de Farmacia, Área del Medicamento, Hospital Universitari i Politècnic La Fe , Valencia, Spain
| | - Pau Montesinos
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe , Valencia, Spain.,CIBERONC, Instituto de Salud Carlos III , Madrid, Spain
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Mohty M. Maintenance after allogeneic HSCT in acute myeloid leukaemia. Lancet Oncol 2020; 21:1130-1132. [DOI: 10.1016/s1470-2045(20)30434-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
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250
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Smith CC. FLT3 Inhibition in Acute Myeloid Leukemia. CLINICAL LYMPHOMA MYELOMA AND LEUKEMIA 2020; 20 Suppl 1:S5-S6. [DOI: 10.1016/s2152-2650(20)30441-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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