351
|
Usuki K, Sakura T, Kobayashi Y, Miyamoto T, Iida H, Morita S, Bahceci E, Kaneko M, Kusano M, Yamada S, Takeshita S, Miyawaki S, Naoe T. Clinical profile of gilteritinib in Japanese patients with relapsed/refractory acute myeloid leukemia: An open-label phase 1 study. Cancer Sci 2018; 109:3235-3244. [PMID: 30039554 PMCID: PMC6172068 DOI: 10.1111/cas.13749] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/12/2018] [Indexed: 12/28/2022] Open
Abstract
Gilteritinib, a novel, highly specific, potent fms-like tyrosine kinase 3/AXL inhibitor, demonstrated antileukemic activity in patients with relapsed/refractory (R/R) acute myeloid leukemia (AML). In this open-label phase 1 study (NCT02181660), Japanese patients (aged ≥18 years) with R/R AML received once-daily gilteritinib, escalating from 20 to 300 mg/d. Primary endpoints were safety/tolerability, including the maximum tolerated dose (MTD) and the recommended dose (RD); secondary endpoints were antileukemic activity and pharmacokinetics (PK). Twenty-four Japanese patients with R/R AML received once-daily oral gilteritinib in 1 of 6 dose-escalation cohorts (20, 40, 80, 120, 200, and 300 mg/d). Gilteritinib was well tolerated. The MTD was 200 mg/d; dose-limiting toxicities were grade 3 tumor lysis syndrome (120 mg/d; n = 1); and grade 3 elevated blood lactate dehydrogenase, amylase, blood creatine phosphokinase levels, and syncope (all n = 2; 300 mg/d). The RD was 120 mg/d. The most common drug-related grade ≥3 adverse events were thrombocytopenia (n = 4 [16.7%]) and increased blood creatine phosphokinase (n = 3 [12.5%]). Gilteritinib had a dose-proportional PK profile. Among patients with mutated fms-like tyrosine kinase 3, the overall response rate (ORR) was 80% (n = 4 of 5; complete remission [CR] with incomplete platelet recovery, 1 [20%]; CR with incomplete hematologic recovery, 2 [40%]; partial remission (PR), 1 [20%]). Among patients with wild-type fms-like tyrosine kinase 3, ORR was 36.4%; (n = 4 of 11; CR, 1 [9.1%]; CR with incomplete platelet recovery, 2 [18.2%]; PR, 1 [9.1%]). In conclusion, gilteritinib was well tolerated and demonstrated antileukemic activity in a Japanese R/R AML population.
Collapse
Affiliation(s)
| | | | | | | | - Hiroatsu Iida
- National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | | | - Erkut Bahceci
- Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | | | | | | | | | | | - Tomoki Naoe
- National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| |
Collapse
|
352
|
de Boer B, Prick J, Pruis MG, Keane P, Imperato MR, Jaques J, Brouwers-Vos AZ, Hogeling SM, Woolthuis CM, Nijk MT, Diepstra A, Wandinger S, Versele M, Attar RM, Cockerill PN, Huls G, Vellenga E, Mulder AB, Bonifer C, Schuringa JJ. Prospective Isolation and Characterization of Genetically and Functionally Distinct AML Subclones. Cancer Cell 2018; 34:674-689.e8. [PMID: 30245083 DOI: 10.1016/j.ccell.2018.08.014] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 06/28/2018] [Accepted: 08/21/2018] [Indexed: 12/18/2022]
Abstract
Intra-tumor heterogeneity caused by clonal evolution is a major problem in cancer treatment. To address this problem, we performed label-free quantitative proteomics on primary acute myeloid leukemia (AML) samples. We identified 50 leukemia-enriched plasma membrane proteins enabling the prospective isolation of genetically distinct subclones from individual AML patients. Subclones differed in their regulatory phenotype, drug sensitivity, growth, and engraftment behavior, as determined by RNA sequencing, DNase I hypersensitive site mapping, transcription factor occupancy analysis, in vitro culture, and xenograft transplantation. Finally, we show that these markers can be used to identify and longitudinally track distinct leukemic clones in patients in routine diagnostics. Our study describes a strategy for a major improvement in stratifying cancer diagnosis and treatment.
Collapse
Affiliation(s)
- Bauke de Boer
- Department of Experimental Hematology, Cancer Research Centre Groningen (CRCG), University Medical Centre Groningen, University of Groningen, Hanzeplein 1, DA13, 9700 RB Groningen, the Netherlands
| | - Janine Prick
- Department of Experimental Hematology, Cancer Research Centre Groningen (CRCG), University Medical Centre Groningen, University of Groningen, Hanzeplein 1, DA13, 9700 RB Groningen, the Netherlands
| | - Maurien G Pruis
- Department of Experimental Hematology, Cancer Research Centre Groningen (CRCG), University Medical Centre Groningen, University of Groningen, Hanzeplein 1, DA13, 9700 RB Groningen, the Netherlands
| | - Peter Keane
- Institute for Cancer and Genomic Sciences, College of Medicine and Dentistry, University of Birmingham, B15 2TT Birmingham, UK
| | - Maria Rosaria Imperato
- Institute for Cancer and Genomic Sciences, College of Medicine and Dentistry, University of Birmingham, B15 2TT Birmingham, UK
| | - Jennifer Jaques
- Department of Experimental Hematology, Cancer Research Centre Groningen (CRCG), University Medical Centre Groningen, University of Groningen, Hanzeplein 1, DA13, 9700 RB Groningen, the Netherlands
| | - Annet Z Brouwers-Vos
- Department of Experimental Hematology, Cancer Research Centre Groningen (CRCG), University Medical Centre Groningen, University of Groningen, Hanzeplein 1, DA13, 9700 RB Groningen, the Netherlands
| | - Shanna M Hogeling
- Department of Experimental Hematology, Cancer Research Centre Groningen (CRCG), University Medical Centre Groningen, University of Groningen, Hanzeplein 1, DA13, 9700 RB Groningen, the Netherlands
| | - Carolien M Woolthuis
- Department of Experimental Hematology, Cancer Research Centre Groningen (CRCG), University Medical Centre Groningen, University of Groningen, Hanzeplein 1, DA13, 9700 RB Groningen, the Netherlands
| | - Marije T Nijk
- Department of Laboratory Medicine, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, the Netherlands
| | - Arjan Diepstra
- Department of Pathology and Medical Biology, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, the Netherlands
| | | | - Matthias Versele
- Janssen Research & Development, Turnhoutseweg 30, 2340 Beerse, Belgium
| | - Ricardo M Attar
- Janssen Research & Development, Turnhoutseweg 30, 2340 Beerse, Belgium
| | - Peter N Cockerill
- Institute for Cancer and Genomic Sciences, College of Medicine and Dentistry, University of Birmingham, B15 2TT Birmingham, UK
| | - Gerwin Huls
- Department of Experimental Hematology, Cancer Research Centre Groningen (CRCG), University Medical Centre Groningen, University of Groningen, Hanzeplein 1, DA13, 9700 RB Groningen, the Netherlands
| | - Edo Vellenga
- Department of Experimental Hematology, Cancer Research Centre Groningen (CRCG), University Medical Centre Groningen, University of Groningen, Hanzeplein 1, DA13, 9700 RB Groningen, the Netherlands
| | - André B Mulder
- Department of Laboratory Medicine, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, the Netherlands
| | - Constanze Bonifer
- Institute for Cancer and Genomic Sciences, College of Medicine and Dentistry, University of Birmingham, B15 2TT Birmingham, UK
| | - Jan Jacob Schuringa
- Department of Experimental Hematology, Cancer Research Centre Groningen (CRCG), University Medical Centre Groningen, University of Groningen, Hanzeplein 1, DA13, 9700 RB Groningen, the Netherlands.
| |
Collapse
|
353
|
Thomas CM, Campbell P. FLT3 inhibitors in acute myeloid leukemia: Current and future. J Oncol Pharm Pract 2018; 25:163-171. [PMID: 30270754 DOI: 10.1177/1078155218802620] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
FMS-like tyrosine kinase 3 (FLT3) is a receptor tyrosine kinase that is responsible for the proliferation and survival of hematopoietic stem cells in acute myeloid leukemia. Although patients with FLT3 mutations have similar rates of remission following induction chemotherapy, relapse rates are significantly higher and patients with FLT3 mutations have significantly worse outcomes for overall survival and disease-free survival. Early FLT3 inhibitors, such as sorafenib, were non-selective and inhibited several tyrosine kinase receptors resulting in significant toxicity. The treatment of FLT3-positive acute myeloid leukemia has advanced recently with the development of a several FLT3-targeting agents that are either approved or in development. Midostaurin represents the first FDA-approved treatment targeted against FLT3, and there are several promising agents currently undergoing clinical trials. Although certain mutations confer resistance to earlier generation FLT3-targeted tyrosine kinase inhibitors, newer agents show activity in the presence of these mutations.
Collapse
Affiliation(s)
- Christan M Thomas
- Hematology/Oncology, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Peter Campbell
- Hematology/Oncology, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| |
Collapse
|
354
|
Katayama K, Noguchi K, Sugimoto Y. Heat shock protein 90 inhibitors overcome the resistance to Fms-like tyrosine kinase 3 inhibitors in acute myeloid leukemia. Oncotarget 2018; 9:34240-34258. [PMID: 30344940 PMCID: PMC6188142 DOI: 10.18632/oncotarget.26045] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 08/17/2018] [Indexed: 11/25/2022] Open
Abstract
Internal tandem duplication (ITD) in Fms-like tyrosine kinase 3 (FLT3) is frequently observed in acute myeloid leukemia (AML). Quizartinib, gilteritinib, and midostaurin are inhibitors against FLT3-ITD that have good efficacy for FLT3-ITD-positive AML patients. Long-term administration leads to drug resistance through acquired tyrosine kinase domain (TKD) mutations in FLT3-ITD, such as N676K, F691L, D835V, and Y842C. Here, our screen to detect inhibitors capable of overcoming resistance to FLT3 inhibitors identified heat shock protein (HSP) 90 inhibitors as potential candidates. Although Ba/F3 cells expressing FLT3-ITD with TKD mutations (Ba/F3-ITD+N676K, Ba/F3-ITD+F691L, Ba/F3-ITD+D835V, and Ba/F3-ITD+Y842C) showed various resistance patterns to FLT3 inhibitors compared with Ba/F3-ITD cells that express FLT3-ITD lacking TKD mutations, they were more sensitive to HSP90 inhibitors than Ba/F3 cells. Notably, the Ba/F3-ITD+D835V cells were the most sensitive to HSP90 inhibitors. Treatment with HSP90 inhibitors downregulated FLT3 and its downstream signaling and induced G1 arrest followed by apoptosis in Ba/F3-ITD+N676K, Ba/F3-ITD+F691L, Ba/F3-ITD+Y842C, and especially Ba/F3-ITD+D835V cells at lower concentrations compared with Ba/F3-ITD cells. The downregulation of FLT3-ITD+D835V was caused by rapid proteolysis in autophagy. Similar results were also observed in the quizartinib-resistant MV4-11 cells, QR1 and QR2, which were established by culturing cells in the presence of quizartinib and harbored FLT3-ITD+D835H and FLT3-ITD+D835V, respectively, in a single allele. Interestingly, the efficacies of HSP90 inhibitors in QR cells are reversely correlated with that of quizartib, but not to gilteritinib and midostaurin. Collectively, HSP90 inhibitors are good candidates to overcome drug resistance in AML with various FLT3-ITD TKD mutations.
Collapse
Affiliation(s)
- Kazuhiro Katayama
- Division of Chemotherapy, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Kohji Noguchi
- Division of Chemotherapy, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Yoshikazu Sugimoto
- Division of Chemotherapy, Faculty of Pharmacy, Keio University, Tokyo, Japan
| |
Collapse
|
355
|
McMahon CM, Perl AE. Management of primary refractory acute myeloid leukemia in the era of targeted therapies. Leuk Lymphoma 2018; 60:583-597. [PMID: 30234399 DOI: 10.1080/10428194.2018.1504937] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Primary refractory acute myeloid leukemia (AML), or primary induction failure, represents a continued challenge in clinical management. This review presents an overview of primary refractory disease and a discussion of risk factors for induction failure, including current evidence regarding the impact of karyotype and molecular mutation status on responsiveness to chemotherapy. We review the evidence for various treatment options for refractory AML including salvage chemotherapy regimens, allogeneic hematopoietic stem cell transplantation, targeted agents, and non-intensive therapies such as hypomethylating agents. A therapeutic approach to this patient population is presented, and several new and emerging therapies are reviewed.
Collapse
Affiliation(s)
- Christine M McMahon
- a Department of Medicine, Division of Hematology and Oncology , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , PA , USA
| | - Alexander E Perl
- a Department of Medicine, Division of Hematology and Oncology , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , PA , USA
| |
Collapse
|
356
|
Abstract
Determining which FLT3 inhibitor holds the greatest promise is a difficult task, as the drugs vary according to potency, specificity, protein-binding, drug interactions, and side effect profile. The best choice depends on when in the course of the disease the inhibitor will be used. Moreover, as the results of ongoing trials become available, newer agents could supplant former 'best' drugs. This paper reviews FLT3 inhibitors in combination with chemotherapy early in the disease in FLT3 mutant patients, as single agents or in combination in advanced disease, or in the post-transplant setting to provide separate answers to the main question.
Collapse
Affiliation(s)
- Richard M Stone
- Director, Adult Leukemia Program, Dana-Farber Cancer Institute, 450 Brookline Avenue, D2053, Boston, MA, 02215, USA.
| |
Collapse
|
357
|
Abstract
For several decades, few substantial therapeutic advances have been made for patients with acute myeloid leukaemia. However, since 2017 unprecedented growth has been seen in the number of drugs available for the treatment of acute myeloid leukaemia, with several new drugs receiving regulatory approval. In addition to advancing our therapeutic armamentarium, an increased understanding of the biology and genomic architecture of acute myeloid leukaemia has led to refined risk assessment of this disease, with consensus risk stratification guidelines now incorporating a growing number of recurrent molecular aberrations that aid in the selection of risk-adapted management strategies. Despite this promising recent progress, the outcomes of patients with acute myeloid leukaemia remain unsatisfactory, with more than half of patients ultimately dying from their disease. Enrolment of patients into clinical trials that evaluate novel drugs and rational combination therapies is imperative to continuing this progress and further improving the outcomes of patients with acute myeloid leukaemia.
Collapse
MESH Headings
- Aminoglycosides/therapeutic use
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Agents/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Consolidation Chemotherapy
- Cytarabine/administration & dosage
- Gemtuzumab
- Genomics
- Hematopoietic Stem Cell Transplantation
- Humans
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/therapy
- Patient Selection
- Recurrence
- Remission Induction
- Risk Assessment
- Risk Factors
- Staurosporine/analogs & derivatives
- Staurosporine/therapeutic use
Collapse
Affiliation(s)
- Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael E Rytting
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Pediatrics-Patient Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jorge E Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| |
Collapse
|
358
|
Post-remission strategies for the prevention of relapse following allogeneic hematopoietic cell transplantation for high-risk acute myeloid leukemia: expert review from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation. Bone Marrow Transplant 2018; 54:519-530. [PMID: 30104717 DOI: 10.1038/s41409-018-0286-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 06/25/2018] [Accepted: 06/28/2018] [Indexed: 01/06/2023]
Abstract
Acute myeloid leukemia (AML) is an aggressive hematopoietic malignancy generally associated with poor prognosis. Allogeneic hematopoietic cell transplantation (alloHCT) continues to be the most potent anti-leukemia treatment for adult patients with intermediate and high-risk AML. However, disease relapse after alloHCT remains unacceptably high and is the primary cause of treatment failure and mortality following alloHCT. It is therefore that post-transplant early cellular or pharmacologic maintenance or preemptive strategies to enhance the graft-versus-leukemia effect or to eradicate persistent minimal residual disease have been of renewed interest, particularly with the availability of more sensitive technologies to measure residual AML. Although preliminary studies have demonstrated improved outcomes with the use of post-alloHCT remission therapies, prospective randomized trials are required to determine their clinical efficacy and role in the treatment of AML. On behalf of the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation, we summarize the available evidence on the use and efficacy of available pharmacologic post-remission therapies, including hypomethylating agents, deacetylase inhibitors, and tyrosine kinase inhibitors, as well as cellular therapies, including preemptive and prophylactic donor lymphocyte infusions for the prevention of relapse of AML.
Collapse
|
359
|
Assi R, Ravandi F. FLT3 inhibitors in acute myeloid leukemia: Choosing the best when the optimal does not exist. Am J Hematol 2018; 93:553-563. [PMID: 29285788 DOI: 10.1002/ajh.25027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/21/2017] [Accepted: 12/26/2017] [Indexed: 12/27/2022]
Abstract
Despite significant advances in deciphering the molecular and cytogenetic pathways governing acute myeloid leukemia, improvements in treatment strategies and clinical outcomes have been limited. The discovery of FLT3 pathway and its potential role in leukemogenesis has generated excitement in the field and has provided a potential target for drug development. Despite setbacks encountered with first-generation inhibitors, we are witnessing an outbreak of novel agents with potent activity and improved pharmacodynamics which continue to generate promising results. The disease, however, remains a challenge to both patients and physicians with rapid emergence of resistance and subsequent treatment failure. Multiple unanswered questions remain as to which are the optimal FLT3-inhibitors and which strategies and combinations are likely to overcome resistance. This review revisits the development of FLT3-inhibitors, the pathways incriminated in their failure and summarizes available molecularly-designed strategies to design better clinical trials.
Collapse
Affiliation(s)
- Rita Assi
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Farhad Ravandi
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| |
Collapse
|
360
|
Clonal heterogeneity of FLT3-ITD detected by high-throughput amplicon sequencing correlates with adverse prognosis in acute myeloid leukemia. Oncotarget 2018; 9:30128-30145. [PMID: 30046393 PMCID: PMC6059024 DOI: 10.18632/oncotarget.25729] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 06/19/2018] [Indexed: 12/14/2022] Open
Abstract
In acute myeloid leukemia (AML), internal tandem duplications (ITDs) of FLT3 are frequent mutations associated with unfavorable prognosis. At diagnosis, the FLT3-ITD status is routinely assessed by fragment analysis, providing information about the length but not the position and sequence of the ITD. To overcome this limitation, we performed cDNA-based high-throughput amplicon sequencing (HTAS) in 250 FLT3-ITD positive AML patients, treated on German AML Cooperative Group (AMLCG) trials. FLT3-ITD status determined by routine diagnostics was confirmed by HTAS in 242 out of 250 patients (97%). The total number of ITDs detected by HTAS was higher than in routine diagnostics (n = 312 vs. n = 274). In particular, HTAS detected a higher number of ITDs per patient compared to fragment analysis, indicating higher sensitivity for subclonal ITDs. Patients with more than one ITD according to HTAS had a significantly shorter overall and relapse free survival. There was a close correlation between FLT3-ITD mRNA levels in fragment analysis and variant allele frequency in HTAS. However, the abundance of long ITDs (≥75nt) was underestimated by HTAS, as the size of the ITD affected the mappability of the corresponding sequence reads. In summary, this study demonstrates that HTAS is a feasible approach for FLT3-ITD detection in AML patients, delivering length, position, sequence and mutational burden of this alteration in a single assay with high sensitivity. Our findings provide insights into the clonal architecture of FLT3-ITD positive AML and have clinical implications.
Collapse
|
361
|
Phase 2b study of 2 dosing regimens of quizartinib monotherapy in FLT3-ITD-mutated, relapsed or refractory AML. Blood 2018; 132:598-607. [PMID: 29875101 DOI: 10.1182/blood-2018-01-821629] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 05/26/2018] [Indexed: 12/27/2022] Open
Abstract
This randomized, open-label, phase 2b study (NCT01565668) evaluated the efficacy and safety of 2 dosing regimens of quizartinib monotherapy in patients with relapsed/refractory (R/R) FLT3-internal tandem duplication (ITD)-mutated acute myeloid leukemia (AML) who previously underwent transplant or 1 second-line salvage therapy. Patients (N = 76) were randomly assigned to 30- or 60-mg/day doses (escalations to 60 or 90 mg/day, respectively, permitted for lack/loss of response) of single-agent oral quizartinib dihydrochloride. Allelic frequency of at least 10% was defined as FLT3-ITD-mutated disease. Coprimary endpoints were composite complete remission (CRc) rates and incidence of QT interval corrected by Fridericia's formula (QTcF) of more than 480 ms (grade 2 or greater). Secondary endpoints included overall survival (OS), duration of CRc, bridge to transplant, and safety. CRc rates were 47% in both groups, similar to earlier reports with higher quizartinib doses. Incidence of QTcF above 480 ms was 11% and 17%, and QTcF above 500 ms was 5% and 3% in the 30- and 60-mg groups, respectively, which is less than earlier reports with higher doses of quizartinib. Median OS (20.9 and 27.3 weeks), duration of CRc (4.2 and 9.1 weeks), and bridge to transplant rates (32% and 42%) were higher in the 60-mg groups than in the 30-mg group. Dose escalation occurred in 61% and 14% of patients in the 30- and 60-mg groups, respectively. This high clinical activity of quizartinib at the evaluated doses is consistent with previous reports with an improved safety profile. Need to dose-escalate more than half of patients who received quizartinib 30 mg also supports further investigation of treatment with quizartinib 60 mg/day.
Collapse
|
362
|
FLT3 inhibitors for relapsed or refractory acute myeloid leukaemia. Lancet Oncol 2018; 19:849-850. [PMID: 29859852 DOI: 10.1016/s1470-2045(18)30335-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 04/25/2018] [Indexed: 11/22/2022]
|
363
|
Cortes J, Perl AE, Döhner H, Kantarjian H, Martinelli G, Kovacsovics T, Rousselot P, Steffen B, Dombret H, Estey E, Strickland S, Altman JK, Baldus CD, Burnett A, Krämer A, Russell N, Shah NP, Smith CC, Wang ES, Ifrah N, Gammon G, Trone D, Lazzaretto D, Levis M. Quizartinib, an FLT3 inhibitor, as monotherapy in patients with relapsed or refractory acute myeloid leukaemia: an open-label, multicentre, single-arm, phase 2 trial. Lancet Oncol 2018; 19:889-903. [PMID: 29859851 DOI: 10.1016/s1470-2045(18)30240-7] [Citation(s) in RCA: 187] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 03/09/2018] [Accepted: 03/12/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Old age and FMS-like tyrosine kinase 3 internal tandem duplication (FLT3-ITD) mutations in patients with acute myeloid leukaemia are associated with early relapse and poor survival. Quizartinib is an oral, highly potent, and selective next-generation FLT3 inhibitor with clinical antileukaemic activity in relapsed or refractory acute myeloid leukaemia. We aimed to assess the efficacy and safety of single-agent quizartinib in patients with relapsed or refractory acute myeloid leukaemia. METHODS We did an open-label, multicentre, single-arm, phase 2 trial at 76 hospitals and cancer centres in the USA, Europe, and Canada. We enrolled patients with morphologically documented primary acute myeloid leukaemia or acute myeloid leukaemia secondary to myelodysplastic syndromes and an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2 into two predefined, independent cohorts: patients who were aged 60 years or older with relapsed or refractory acute myeloid leukaemia within 1 year after first-line therapy (cohort 1), and those who were 18 years or older with relapsed or refractory disease following salvage chemotherapy or haemopoietic stem cell transplantation (cohort 2). Patients with an FLT3-ITD allelic frequency of more than 10% were considered as FLT3-ITD positive, whereas all other patients were considered as FLT3-ITD negative. Patients received quizartinib once daily as an oral solution; the initial 17 patients received 200 mg per day but the QTcF interval was prolonged for more than 60 ms above baseline in some of these patients. Subsequently, doses were amended for all patients to 135 mg per day for men and 90 mg per day for women. The co-primary endpoints were the proportion of patients who achieved a composite complete remission (defined as complete remission + complete remission with incomplete platelet recovery + complete remission with incomplete haematological recovery) and the proportion of patients who achieved a complete remission. Efficacy and safety analyses included all patients who received at least one dose of quizartinib (ie, the intention-to-treat population). Patients with a locally assessed post-treatment bone marrow aspirate or biopsy were included in efficacy analyses by response; all other patients were considered to have an unknown response. This study is registered with ClinicalTrials.gov, number NCT00989261, and with the European Clinical Trials Database, EudraCT 2009-013093-41, and is completed. FINDINGS Between Nov 19, 2009, and Oct 31, 2011, a total of 333 patients were enrolled (157 in cohort 1 and 176 in cohort 2). In cohort 1, 63 (56%) of 112 FLT3-ITD-positive patients and 16 (36%) of 44 FLT3-ITD-negative patients achieved composite complete remission, with three (3%) FLT3-ITD-positive patients and two (5%) FLT3-ITD-negative patients achieving complete remission. In cohort 2, 62 (46%) of 136 FLT3-ITD-positive patients achieved composite complete remission with five (4%) achieving complete remission, whereas 12 (30%) of 40 FLT3-ITD-negative patients achieved composite complete remission with one (3%) achieving complete remission. Across both cohorts (ie, the intention-to-treat population of 333 patients), grade 3 or worse treatment-related treatment-emergent adverse events in 5% or more of patients were febrile neutropenia (76 [23%] of 333), anaemia (75 [23%]), thrombocytopenia (39 [12%]), QT interval corrected using Fridericia's formula (QTcF) prolongation (33 [10%]), neutropenia (31 [9%]), leucopenia (22 [7%]), decreased platelet count (20 [6%]), and pneumonia (17 [5%]). Serious adverse events occurring in 5% or more of patients were febrile neutropenia (126 [38%] of 333; 76 treatment related), acute myeloid leukaemia progression (73 [22%]), pneumonia (40 [12%]; 14 treatment related), QTcF prolongation (33 [10%]; 32 treatment related), sepsis (25 [8%]; eight treatment related), and pyrexia (18 [5%]; nine treatment related). Notable serious adverse events occurring in less than 5% of patients were torsades de pointes (one [<1%]) and hepatic failure (two [1%]). In total, 125 (38%) of 333 patients died within the study treatment period, including the 30-day follow-up. 18 (5%) patients died because of an adverse event considered by the investigator to be treatment related (ten [6%] of 157 patients in cohort 1 and eight [5%] of 176 in cohort 2. INTERPRETATION Single-agent quizartinib was shown to be highly active and generally well tolerated in patients with relapsed or refractory acute myeloid leukaemia, particularly those with FLT3-ITD mutations. These findings confirm that targeting the FLT3-ITD driver mutation with a highly potent and selective FLT3 inhibitor is a promising clinical strategy to help improve clinical outcomes in patients with very few options. Phase 3 studies (NCT02039726; NCT02668653) will examine quizartinib at lower starting doses. FUNDING Ambit Biosciences/Daiichi Sankyo.
Collapse
MESH Headings
- Administration, Oral
- Adult
- Aged
- Benzothiazoles/therapeutic use
- Canada
- Disease-Free Survival
- Dose-Response Relationship, Drug
- Drug Administration Schedule
- Europe
- Female
- Humans
- Internationality
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/mortality
- Male
- Maximum Tolerated Dose
- Middle Aged
- Neoplasm Recurrence, Local/diagnosis
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/mortality
- Phenylurea Compounds/therapeutic use
- Prognosis
- Survival Rate
- Treatment Outcome
- United States
- Young Adult
- fms-Like Tyrosine Kinase 3/administration & dosage
- fms-Like Tyrosine Kinase 3/antagonists & inhibitors
Collapse
Affiliation(s)
- Jorge Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Alexander E Perl
- Division of Hematology and Oncology, Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA, USA
| | - Hartmut Döhner
- Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Giovanni Martinelli
- Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Meldola, Italy
| | - Tibor Kovacsovics
- Center for Hematologic Malignancies, Oregon Health & Science University, Portland, OR, USA
| | - Philippe Rousselot
- Service d'Hématologie et Oncologie, Hôpital de Versailles, Université Versailles Saint-Quentin-en-Yvelines Paris-Saclay U1173, Le Chesnay, France
| | - Björn Steffen
- Department of Medicine II, Hematology/Oncology, Goethe University, Frankfurt, Germany
| | - Hervé Dombret
- University Hospital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), University Paris Diderot, Paris, France
| | - Elihu Estey
- Seattle Cancer Care Alliance, University of Washington School of Medicine, Seattle, WA, USA
| | | | - Jessica K Altman
- Department of Medicine, Division of Hematology and Oncology, Robert H Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA
| | - Claudia D Baldus
- Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hematology and Oncology, Berlin, Germany
| | - Alan Burnett
- Department of Haematology, Cardiff University, Cardiff, Wales, UK
| | - Alwin Krämer
- Klinische Kooperationseinheit Molekulare Hämatologie/Onkologie, Medizinische Klinik V, Universität Heidelberg and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Nigel Russell
- Department of Haematology, Nottingham University Hospital, Nottingham, UK
| | - Neil P Shah
- Department of Medicine, Division of Hematology and Oncology, University of California at San Francisco, San Francisco, CA, USA
| | - Catherine C Smith
- Department of Medicine, Division of Hematology and Oncology, University of California at San Francisco, San Francisco, CA, USA
| | - Eunice S Wang
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Norbert Ifrah
- Service des Maladies du Sang, Centre Hospitalier Universitaire d'Angers, Angers, France
| | | | | | | | - Mark Levis
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
364
|
Gbadamosi B, Ezekwudo D, Bastola S, Jaiyesimi I. Predictive and Prognostic Markers in Adults With Acute Myeloid Leukemia: A Single-Institution Experience. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:e287-e294. [PMID: 29803615 DOI: 10.1016/j.clml.2018.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 04/26/2018] [Accepted: 05/02/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Acute myeloid leukemia (AML) is a heterogeneous malignancy with diverse genetic abnormalities, clinical presentations, and outcomes. Known predictive and prognostic factors in AML include age, performance status, comorbidities, cytogenetics, and molecular mutations. Identifying prognostic and predictive factors can inform the choice of induction therapy and outcomes prediction. PATIENTS AND METHODS A retrospective review was performed of 137 adult AML patients from 2010 to 2015. Predictors of complete remission (CR) and overall survival (OS) were determined for patients treated with 3+7 (3 days of anthracycline and 7 days of cytarabine) or hypomethylating agent. Variables associated with CR or OS were assessed using univariate Cox regression and a multivariate Cox model. RESULTS The average age was 65 years and 91 patients (66%), sample size is 137 patients had primary AML. Patients in the 3+7 induction group were younger, had a higher bone marrow blast percentage, and more de novo AML compared with those in the hypomethylating agent group (P < .001, P < .001, P = .005, respectively). Univariate logistic regression for CR showed a significant association between age (P < .001), choice of induction (P < .001), and monosomy (P = .015), although only induction with 3+7 (P < .001) and absence of monosomy (P = .042) remained significant in multivariate analysis. Univariate Cox regression indicated that age (P = .003), AML status (de novo or secondary; P = .0277), choice of induction (P = .030), and monosomy (P = .010) had a significant association with OS. Only younger age (P = .018) and absence of monosomy (P = .022) were predictive of OS in multivariate Cox analysis. CONCLUSION Positive predictors of CR in adult AML include absence of monosomy and induction treatment with 3+7; whereas positive predictors of OS are younger age and absence of monosomy.
Collapse
Affiliation(s)
- Bolanle Gbadamosi
- Department of Hematology and Oncology, Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI.
| | - Daniel Ezekwudo
- Department of Hematology and Oncology, Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Sanjog Bastola
- Department of Internal Medicine, Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Ishmael Jaiyesimi
- Department of Hematology and Oncology, Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| |
Collapse
|
365
|
Acute myeloid leukemia induction with cladribine: Outcomes by age and leukemia risk. Leuk Res 2018; 68:72-78. [DOI: 10.1016/j.leukres.2018.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 03/01/2018] [Accepted: 03/05/2018] [Indexed: 11/18/2022]
|
366
|
DeStefano CB, Hourigan CS. Personalizing initial therapy in acute myeloid leukemia: incorporating novel agents into clinical practice. Ther Adv Hematol 2018; 9:109-121. [PMID: 29713444 DOI: 10.1177/2040620718761778] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
While the past decade has seen a revolution in understanding of the genetic and molecular etiology of the disease, in clinical practice, initial therapy for acute myeloid leukemia (AML) patients has been a relatively straightforward choice between intensive combination cytotoxic induction therapy as used for decades or less-intensive hypomethylating therapy. The year 2017, however, witnessed US Food and Drug Administration approvals of midostaurin, enasidenib, gemtuzumab ozogamicin and CPX-351 for AML patients, with many other promising agents currently in clinical trials. This review discusses these options, highlights unanswered questions regarding optimal combinations and proposes some suggested approaches for the personalization of initial therapy for AML patients.
Collapse
Affiliation(s)
- Christin B DeStefano
- Laboratory of Myeloid Malignancies, National Institutes of Health, Bethesda, MD, USA Department of Hematology, MedStar Washington Cancer Institute, Washington, DC, USA
| | - Christopher S Hourigan
- Laboratory of Myeloid Malignancies, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10-CRC, Room 5-5130, 10 Center Drive, Bethesda, MD 20814-1476, USA
| |
Collapse
|
367
|
Krevvata M, Shan X, Zhou C, Dos Santos C, Habineza Ndikuyeze G, Secreto A, Glover J, Trotman W, Brake-Silla G, Nunez-Cruz S, Wertheim G, Ra HJ, Griffiths E, Papachristou C, Danet-Desnoyers G, Carroll M. Cytokines increase engraftment of human acute myeloid leukemia cells in immunocompromised mice but not engraftment of human myelodysplastic syndrome cells. Haematologica 2018; 103:959-971. [PMID: 29545344 PMCID: PMC6058784 DOI: 10.3324/haematol.2017.183202] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/22/2018] [Indexed: 11/09/2022] Open
Abstract
Patient-derived xenotransplantation models of human myeloid diseases including acute myeloid leukemia, myelodysplastic syndromes and myeloproliferative neoplasms are essential for studying the biology of the diseases in pre-clinical studies. However, few studies have used these models for comparative purposes. Previous work has shown that acute myeloid leukemia blasts respond to human hematopoietic cytokines whereas myelodysplastic syndrome cells do not. We compared the engraftment of acute myeloid leukemia cells and myelodysplastic syndrome cells in NSG mice to that in NSG-S mice, which have transgene expression of human cytokines. We observed that only 50% of all primary acute myeloid leukemia samples (n=77) transplanted in NSG mice provided useful levels of engraftment (>0.5% human blasts in bone marrow). In contrast, 82% of primary acute myeloid leukemia samples engrafted in NSG-S mice with higher leukemic burden and shortened survival. Additionally, all of 5 injected samples from patients with myelodysplastic syndrome showed persistent engraftment on week 6; however, engraftment was mostly low (<2%), did not increase over time, and was only transiently affected by the use of NSG-S mice. Co-injection of mesenchymal stem cells did not enhance human myelodysplastic syndrome cell engraftment. Overall, we conclude that engraftment of acute myeloid leukemia samples is more robust compared to that of myelodysplastic syndrome samples and unlike those, acute myeloid leukemia cells respond positively to human cytokines, whereas myelodysplastic syndrome cells demonstrate a general unresponsiveness to them.
Collapse
Affiliation(s)
- Maria Krevvata
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Xiaochuan Shan
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Chenghui Zhou
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Cedric Dos Santos
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Georges Habineza Ndikuyeze
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Anthony Secreto
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joshua Glover
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Winifred Trotman
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Gisela Brake-Silla
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Selene Nunez-Cruz
- Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Gerald Wertheim
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Hyun-Jeong Ra
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Gwenn Danet-Desnoyers
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Martin Carroll
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA .,Veterans Administration Hospital, Philadelphia, PA, USA
| |
Collapse
|
368
|
Gorcea CM, Burthem J, Tholouli E. ASP2215 in the treatment of relapsed/refractory acute myeloid leukemia with FLT3 mutation: background and design of the ADMIRAL trial. Future Oncol 2018; 14:1995-2004. [PMID: 29498296 DOI: 10.2217/fon-2017-0582] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Acute myeloid leukemia (AML) is a heterogeneous disease with cure rates of only 30-40% in patients <60 years old. Cytogenetic and molecular markers have improved our understanding of the different prognostic entities in AML. FLT3 mutations are present in 30-40% of AML cases, conferring a poor prognosis with reduced survival. AXL activates FLT3, impacting adversely on outcome. Both FLT3 and AXL constitute promising molecular targets. ASP2215 (gilteritinib) is a novel, dual FLT3/AXL inhibitor with promising early phase trial data (NCT02014558). A Phase III randomized multicenter clinical trial, comparing ASP2215 to salvage chemotherapy in relapsed/refractory AML with FLT3-mutations is now open to recruitment (NCT02421939). Trial design and objectives are discussed here.
Collapse
Affiliation(s)
- Claudia M Gorcea
- Department of Clinical Haematology, Manchester Royal Infirmary, Manchester Foundation Trust, Manchester, UK
| | - John Burthem
- Department of Clinical Haematology, Manchester Royal Infirmary, Manchester Foundation Trust, Manchester, UK
| | - Eleni Tholouli
- Department of Clinical Haematology, Manchester Royal Infirmary, Manchester Foundation Trust, Manchester, UK
| |
Collapse
|
369
|
Abstract
Conventional treatments for acute leukemia include chemotherapy, radiation therapy, and intensive combined treatments (including bone marrow transplant or stem cell transplants). Novel treatment approaches are in active development. Recently, protein kinase inhibitors are on clinical trials and offer hope as new drugs for acute leukemia treatment. This review will provide a brief summary of the protein kinase inhibitors in clinical applications for acute leukemia treatment.
Collapse
|
370
|
Cosemans JMEM. At the MERcy of platelet primers. J Thromb Haemost 2018; 16:349-351. [PMID: 29194956 DOI: 10.1111/jth.13915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Indexed: 11/26/2022]
Affiliation(s)
- J M E M Cosemans
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
371
|
Kayser S, Levis MJ. Advances in targeted therapy for acute myeloid leukaemia. Br J Haematol 2018; 180:484-500. [PMID: 29193012 PMCID: PMC5801209 DOI: 10.1111/bjh.15032] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 10/09/2017] [Accepted: 10/10/2017] [Indexed: 12/21/2022]
Abstract
In the past few years, research in the underlying pathogenic mechanisms of acute myeloid leukaemia (AML) has led to remarkable advances in our understanding of the disease. Cytogenetic and molecular aberrations are the most important factors in determining response to chemotherapy as well as long-term outcome, but beyond prognostication are potential therapeutic targets. Our increased understanding of the pathogenesis of AML, facilitated by next-generation sequencing, has spurred the development of new compounds in the treatment of AML, particularly the creation of small molecules that target the disease on a molecular level. Various new agents, such as tyrosine kinase inhibitors, immune checkpoint inhibitors, monoclonal or bispecific T-cell engager antibodies, metabolic and pro-apoptotic agents are currently investigated within clinical trials. The highest response rates are often achieved when new molecularly targeted therapies are combined with standard chemotherapy. Presented here is an overview of novel therapies currently being evaluated in AML.
Collapse
Affiliation(s)
- Sabine Kayser
- Department of Internal Medicine V, University Hospital of Heidelberg, Heidelberg, Germany
- Clinical Cooperation Unit Molecular Haematology/Oncology, German Cancer Research Centre (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Mark J. Levis
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
372
|
Prospective randomization of post-remission therapy comparing autologous peripheral blood stem cell transplantation versus high-dose cytarabine consolidation for acute myelogenous leukemia in first remission. Int J Hematol 2017; 107:468-477. [PMID: 29243031 DOI: 10.1007/s12185-017-2389-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 12/06/2017] [Accepted: 12/07/2017] [Indexed: 12/14/2022]
Abstract
We prospectively compared outcomes of autologous stem cell transplantation (ASCT) versus high-dose cytarabine (HiDAC) consolidation as post-remission therapy for favorable- and intermediate-risk acute myelogenous leukemia (AML) in first complete remission (CR1). Two-hundred-forty patients under 65 years with AML-M1, M2, M4, or M5 subtypes were enrolled. After induction, 153 patients did not undergo randomization, while the remaining 87 who achieved CR1 were prospectively randomized to HiDAC (n = 45) or ASCT arm (n = 42). In the HiDAC arm, 43 patients completed three cycles of HiDAC, whereas in ASCT arm 22 patients completed two cycles of consolidation consisting of intermediate-dose cytarabine plus mitoxantrone or etoposide followed by ASCT. The three-year disease-free survival (DFS) rate was 41% in HiDAC and 55% in ASCT arm (p = 0.25). Three-year overall survival (OS) rates were 77 and 68% (p = 0.67). Incidence of relapse was 54 and 41% (p = 0.22). There was no significant difference in nonrelapse mortality between two arms (p = 0.88). Patients in the ASCT arm tended to have higher DFS rates and lower relapse rates than patients in HiDAC; however, there was no significant improvement in OS in patients with favorable- and intermediate-risk AML in CR1. Patients with AML are not benefited by the intensified chemotherapy represented by ASCT.
Collapse
|
373
|
Perl AE. The role of targeted therapy in the management of patients with AML. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:54-65. [PMID: 29222237 PMCID: PMC6142552 DOI: 10.1182/asheducation-2017.1.54] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Drug therapy for acute myeloid leukemia (AML) is finally undergoing major changes in 2017. This is due to the US Food and Drug Administration's approval of several new, targeted agents (midostaurin, enasidenib, and gemtuzumab ozogamicin). Paired with the recent approval of a novel liposomal formulation of daunorubicin/cytarabine (CPX-351/Vyxeos), the standard of care is changing rapidly in AML for subgroups. This review will focus on currently approved agents and promising novel agents in development and will highlight controversial areas in targeted treatment.
Collapse
Affiliation(s)
- Alexander E Perl
- Division of Hematology/Oncology, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| |
Collapse
|
374
|
Aziz H, Ping CY, Alias H, Ab Mutalib NS, Jamal R. Gene Mutations as Emerging Biomarkers and Therapeutic Targets for Relapsed Acute Myeloid Leukemia. Front Pharmacol 2017; 8:897. [PMID: 29270125 PMCID: PMC5725465 DOI: 10.3389/fphar.2017.00897] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 11/24/2017] [Indexed: 12/19/2022] Open
Abstract
It is believed that there are key differences in the genomic profile between adult and childhood acute myeloid leukemia (AML). Relapse is the significant contributor of mortality in patients with AML and remains as the leading cause of cancer death among children, posing great challenges in the treatment of AML. The knowledge about the genomic lesions in childhood AML is still premature as most genomic events defined in children were derived from adult cohorts. However, the emerging technologies of next generation sequencing have narrowed the gap of knowledge in the biology of AML by the detection of gene mutations for each sub-type which have led to the improvement in terms of prognostication as well as the use of targeted therapies. In this review, we describe the recent understanding of the genomic landscape including the prevalence of mutation, prognostic impact, and targeted therapies that will provide an insight into the pathogenesis of AML relapse in both adult and childhood cases.
Collapse
Affiliation(s)
- Habsah Aziz
- UKM Medical Molecular Biology Institute, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Chow Y Ping
- UKM Medical Molecular Biology Institute, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Hamidah Alias
- Department of Paediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | | | - Rahman Jamal
- UKM Medical Molecular Biology Institute, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| |
Collapse
|
375
|
Gallogly MM, Perl AE, Lazarus HM. Midostaurin and emerging FLT3 inhibitors for the treatment of adults with newly diagnosed acute myeloid leukemia with the FLT3 mutation. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2017. [DOI: 10.1080/23808993.2017.1406798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Molly M. Gallogly
- University Hospitals Cleveland Medical Center, Department of Medicine, Division of Hematology and Oncology, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Alexander E. Perl
- University of Pennsylvania, Division of Hematology Oncology, Perelman Center for Advanced Medicine, Philadelphia, PA, USA
| | | |
Collapse
|
376
|
|
377
|
The role of targeted therapy in the management of patients with AML. Blood Adv 2017; 1:2281-2294. [PMID: 29296877 DOI: 10.1182/bloodadvances.2017009829] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 09/12/2017] [Indexed: 12/25/2022] Open
Abstract
Drug therapy for acute myeloid leukemia (AML) is finally undergoing major changes in 2017. This is due to the US Food and Drug Administration's approval of several new, targeted agents (midostaurin, enasidenib, and gemtuzumab ozogamicin). Paired with the recent approval of a novel liposomal formulation of daunorubicin/cytarabine (CPX-351/Vyxeos), the standard of care is changing rapidly in AML for subgroups. This review will focus on currently approved agents and promising novel agents in development and will highlight controversial areas in targeted treatment.
Collapse
|
378
|
Luskin MR, DeAngelo DJ. Midostaurin/PKC412 for the treatment of newly diagnosed FLT3 mutation-positive acute myeloid leukemia. Expert Rev Hematol 2017; 10:1033-1045. [PMID: 29069942 DOI: 10.1080/17474086.2017.1397510] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Acute myeloid leukemia (AML) is an aggressive hematologic malignancy with inadequate treatment options. Approximately one-third of cases have a FLT3-ITD or FLT3-TKD mutation which leads to constitutive tyrosine kinase activation which contributes to leukemogenesis. The FLT3-ITD mutation is associated with a particularly poor prognosis. Midostaurin is a multi-kinase inhibitor active against the FLT3 receptor. Midostaurin was approved by the US FDA in April 2017 for treatment of newly diagnosed FLT3-mutant AML in combination with chemotherapy. Areas covered: Standard treatment of FLT3-mutant AML and outcomes. Early clinical development of midostaurin including pharmacokinetics and metabolism. The development of midostaurin in FLT3-mutant AML is then outlined including review of the phase I, II, and III trials of midostaurin as a single agent and in combination with chemotherapy. Expert commentary: The approval of midostaurin represents the first new therapy for AML in several decades. It is also the first targeted therapy approved for AML. Future studies will focus on defining mechanisms of resistance to midostaurin as well as establishing the role of midostaurin in combination with hypomethylating agents and as maintenance therapy. Second generation, more potent and selective FLT3 inhibitors are also in development; these agents need to be compared to midostaurin.
Collapse
Affiliation(s)
- Marlise R Luskin
- a Department of Medical Oncology , Dana-Farber Cancer Institute , Boston , MA , USA.,b Harvard Medical School , Boston , MA , USA
| | - Daniel J DeAngelo
- a Department of Medical Oncology , Dana-Farber Cancer Institute , Boston , MA , USA.,b Harvard Medical School , Boston , MA , USA
| |
Collapse
|
379
|
Kapoor S, Natarajan K, Baldwin PR, Doshi KA, Lapidus RG, Mathias TJ, Scarpa M, Trotta R, Davila E, Kraus M, Huszar D, Tron AE, Perrotti D, Baer MR. Concurrent Inhibition of Pim and FLT3 Kinases Enhances Apoptosis of FLT3-ITD Acute Myeloid Leukemia Cells through Increased Mcl-1 Proteasomal Degradation. Clin Cancer Res 2017; 24:234-247. [PMID: 29074603 DOI: 10.1158/1078-0432.ccr-17-1629] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 09/27/2017] [Accepted: 10/19/2017] [Indexed: 01/01/2023]
Abstract
Purpose:fms-like tyrosine kinase 3 internal tandem duplication (FLT3-ITD) is present in 30% of acute myeloid leukemia (AML), and these patients have short disease-free survival. FLT3 inhibitors have limited and transient clinical activity, and concurrent treatment with inhibitors of parallel or downstream signaling may improve responses. The oncogenic serine/threonine kinase Pim-1 is upregulated downstream of FLT3-ITD and also promotes its signaling in a positive feedback loop, suggesting benefit of combined Pim and FLT3 inhibition.Experimental Design: Combinations of clinically active Pim and FLT3 inhibitors were studied in vitro and in vivoResults: Concurrent treatment with the pan-Pim inhibitor AZD1208 and FLT3 inhibitors at clinically applicable concentrations abrogated in vitro growth of FLT3-ITD, but not wild-type FLT3 (FLT3-WT), cell lines. AZD1208 cotreatment increased FLT3 inhibitor-induced apoptosis of FLT3-ITD, but not FLT3-WT, cells measured by sub-G1 fraction, annexin V labeling, mitochondrial membrane potential, and PARP and caspase-3 cleavage. Concurrent treatment with AZD1208 and the FLT3 inhibitor quizartinib decreased growth of MV4-11 cells, with FLT3-ITD, in mouse xenografts, and prolonged survival, enhanced apoptosis of FLT3-ITD primary AML blasts, but not FLT3-WT blasts or remission marrow cells, and decreased FLT3-ITD AML blast colony formation. Mechanistically, AZD1208 and quizartinib cotreatment decreased expression of the antiapoptotic protein Mcl-1. Decrease in Mcl-1 protein expression was abrogated by treatment with the proteasome inhibitor MG132, and was preceded by downregulation of the Mcl-1 deubiquitinase USP9X, a novel mechanism of Mcl-1 regulation in AML.Conclusions: The data support clinical testing of Pim and FLT3 inhibitor combination therapy for FLT3-ITD AML. Clin Cancer Res; 24(1); 234-47. ©2017 AACR.
Collapse
Affiliation(s)
- Shivani Kapoor
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland
| | - Karthika Natarajan
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland.,Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Patrick R Baldwin
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland.,Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kshama A Doshi
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland
| | - Rena G Lapidus
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland.,Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Trevor J Mathias
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland
| | - Mario Scarpa
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland
| | - Rossana Trotta
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland.,Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Eduardo Davila
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland.,Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland.,Veterans Affairs Medical Center, Baltimore, Maryland
| | | | | | | | - Danilo Perrotti
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland.,Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Maria R Baer
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland. .,Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland.,Veterans Affairs Medical Center, Baltimore, Maryland
| |
Collapse
|
380
|
Minson KA, DeRyckere D, Graham DK. The Current State of FLT3 Inhibition in Acute Myeloid Leukemia - Pitfalls and Promises. ACTA ACUST UNITED AC 2017; 2. [PMID: 29806049 PMCID: PMC5964994 DOI: 10.4172/2576-1471.1000166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Katherine A Minson
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University, USA.,Department of Pediatrics, Atlanta, GA, USA
| | - Deborah DeRyckere
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University, USA
| | - Douglas K Graham
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University, USA
| |
Collapse
|
381
|
Ustun C, Ruggeri A, Weisdorf DJ. UCB HCT in FLT3+ AML. Oncotarget 2017; 8:81733-81734. [PMID: 29137217 PMCID: PMC5669843 DOI: 10.18632/oncotarget.21048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Indexed: 11/25/2022] Open
Affiliation(s)
- Celalettin Ustun
- Celalettin Ustun: Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Annalisa Ruggeri
- Celalettin Ustun: Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Daniel J Weisdorf
- Celalettin Ustun: Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
382
|
Kayser S, Levis MJ, Schlenk RF. Midostaurin treatment in FLT3-mutated acute myeloid leukemia and systemic mastocytosis. Expert Rev Clin Pharmacol 2017; 10:1177-1189. [PMID: 28960095 DOI: 10.1080/17512433.2017.1387051] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION A number of tyrosine kinase inhibitors (TKIs) have been developed that inhibit the constitutively activated kinase activity caused by activating tyrosine kinase mutations, such as FLT3 or KIT, thus interrupting signaling pathways. Currently, midostaurin is the only approved TKI as monotherapy for aggressive systemic mastocytosis (SM), SM with associated hematological neoplasm, or mast cell leukemia displaying a KIT mutation as well as in combination with standard intensive chemotherapy for adult patients with newly diagnosed FLT3-mutated acute myeloid leukemia (AML). Areas covered: We provide a concise review of the pharmacology, tolerability and clinical efficacy of midostaurin and emerging new treatment options for ASM and FLT3-mutated AML. Expert commentary: Currently, midostaurin is the only approved TKI in aggressive SM, SM with associated hematological neoplasm, or mast cell leukemia inducing responses including complete remissions. With regard to AML, midostaurin is the first drug to receive regulatory approval in this indication in the molecularly defined subgroup of AML with FLT3 mutations. By introduction of this new standard in AML with FLT3 mutations, the bare has been raised for future approvals of next generation FLT3 inhibitors which will be based increasingly on head to head comparisons with midostaurin.
Collapse
Affiliation(s)
- Sabine Kayser
- a Department of Internal Medicine V , University Hospital of Heidelberg , Heidelberg , Germany.,b Clinical Cooperation Unit Molecular Hematology/Oncology , German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg , Heidelberg , Germany
| | - Mark J Levis
- c Sidney Kimmel Comprehensive Cancer Center , Johns Hopkins University , Baltimore , MD , USA
| | | |
Collapse
|
383
|
Ruvolo PP, Ma H, Ruvolo VR, Zhang X, Mu H, Schober W, Hernandez I, Gallardo M, Khoury JD, Cortes J, Andreeff M, Post SM. Anexelekto/MER tyrosine kinase inhibitor ONO-7475 arrests growth and kills FMS-like tyrosine kinase 3-internal tandem duplication mutant acute myeloid leukemia cells by diverse mechanisms. Haematologica 2017; 102:2048-2057. [PMID: 28912176 PMCID: PMC5709104 DOI: 10.3324/haematol.2017.168856] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 09/07/2017] [Indexed: 12/23/2022] Open
Abstract
Nearly one-third of patients with acute myeloid leukemia have FMS-like tyrosine kinase 3 mutations and thus have poor survival prospects. Receptor tyrosine kinase anexelekto is critical for FMS-like tyrosine kinase 3 signaling and participates in FMS-like tyrosine kinase 3 inhibitor resistance mechanisms. Thus, strategies targeting anexelekto could prove useful for acute myeloid leukemia therapy. ONO-7475 is an inhibitor with high specificity for anexelekto and MER tyrosine kinase. Herein, we report that ONO-7475 potently arrested growth and induced apoptosis in acute myeloid leukemia with internal tandem duplication mutation of FMS-like tyrosine kinase 3. MER tyrosine kinase-lacking MOLM13 cells were sensitive to ONO-7475, while MER tyrosine kinase expressing OCI-AML3 cells were resistant, suggesting that the drug acts via anexelekto in acute myeloid leukemia cells. Reverse phase protein analysis of ONO-7475 treated cells revealed that cell cycle regulators like cyclin dependent kinase 1, cyclin B1, polo-like kinase 1, and retinoblastoma were suppressed. ONO-7475 suppressed cyclin dependent kinase 1, cyclin B1, polo-like kinase 1 gene expression suggesting that anexelekto may regulate the cell cycle, at least in part, via transcriptional mechanisms. Importantly, ONO-7475 was effective in a human FMS-like tyrosine kinase 3 with internal tandem duplication mutant murine xenograft model. Mice fed a diet containing ONO-7475 exhibited significantly longer survival and, interestingly, blocked leukemia cell infiltration in the liver. In summary, ONO-7475 effectively kills acute myeloid leukemia cells in vitro and in vivo by mechanisms that involve disruption of diverse survival and proliferation pathways.
Collapse
Affiliation(s)
- Peter P Ruvolo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA .,Section of Molecular Hematology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Huaxian Ma
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vivian R Ruvolo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Section of Molecular Hematology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiaorui Zhang
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hong Mu
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Section of Molecular Hematology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wendy Schober
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Section of Molecular Hematology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ivonne Hernandez
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Section of Molecular Hematology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Miguel Gallardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph D Khoury
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jorge Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael Andreeff
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Section of Molecular Hematology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sean M Post
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
384
|
Daver N, Kantarjian H. FLT3 inhibition in acute myeloid leukaemia. Lancet Oncol 2017; 18:988-989. [PMID: 28759368 DOI: 10.1016/s1470-2045(17)30509-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 06/19/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Naval Daver
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Hagop Kantarjian
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX 77030, USA
| |
Collapse
|
385
|
Sexauer AN, Tasian SK. Targeting FLT3 Signaling in Childhood Acute Myeloid Leukemia. Front Pediatr 2017; 5:248. [PMID: 29209600 PMCID: PMC5702014 DOI: 10.3389/fped.2017.00248] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/06/2017] [Indexed: 11/13/2022] Open
Abstract
Acute myeloid leukemia (AML) is the second most common leukemia of childhood and is associated with high rates of chemotherapy resistance and relapse. Clinical outcomes for children with AML treated with maximally intensive multi-agent chemotherapy lag far behind those of children with the more common acute lymphoblastic leukemia, demonstrating continued need for new therapeutic approaches to decrease relapse risk and improve long-term survival. Mutations in the FMS-like tyrosine kinase-3 receptor gene (FLT3) occur in approximately 25% of children and adults with AML and are associated with particularly poor prognoses. Identification and development of targeted FLT3 inhibitors represents a major precision medicine paradigm shift in the treatment of patients with AML. While further development of many first-generation FLT3 inhibitors was hampered by limited potency and significant toxicity due to effects upon other kinases, the more selective second- and third-generation FLT3 inhibitors have demonstrated excellent tolerability and remarkable efficacy in the relapsed/refractory and now de novo FLT3-mutated AML settings. While these newest and most promising inhibitors have largely been studied in the adult population, pediatric investigation of FLT3 inhibitors with chemotherapy is relatively recently ongoing or planned. Successful development of FLT3 inhibitor-based therapies will be essential to improve outcomes in children with this high-risk subtype of AML.
Collapse
Affiliation(s)
- Amy N Sexauer
- Dana-Farber Cancer Institute, Boston, MA, United States.,Boston Children's Hospital, Department of Pediatrics, Division of Pediatric Hematology/Oncology/Stem Cell Transplant, Boston, MA, United States
| | - Sarah K Tasian
- Children's Hospital of Philadelphia, Division of Oncology, Center for Childhood Cancer Research, Philadelphia, PA, United States.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|