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Banchi M, Cox MC, Bocci G. Metronomic chemotherapy in hematology: Lessons from preclinical and clinical studies to build a solid rationale for future schedules. Cancer Lett 2024; 591:216900. [PMID: 38636896 DOI: 10.1016/j.canlet.2024.216900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 03/05/2024] [Accepted: 04/15/2024] [Indexed: 04/20/2024]
Abstract
Metronomic chemotherapy (mCHEMO), based on frequent, regular administration of low, but pharmacologically active drug doses, optimizes antitumor efficacy by targeting multiple targets and reducing toxicity of antineoplastic drugs. This minireview will summarize preclinical and clinical studies on cytotoxic drugs given at weekly, daily, or at continuous metronomic schedules alone or in combination with novel targeted agents for hematological malignancies, including lymphoma, multiple myeloma, and leukemia. Most of the preclinical in vitro and in vivo studies have reported a significant benefit of both mCHEMO monotherapy and combinatorial regimens compared with chemotherapy at the maximum tolerated dose. However, the combination of mCHEMO with targeted drugs is still little explored in the hematologic clinical setting. Data obtained from preclinical studies on low dose metronomic chemotherapy in hematological malignancies clearly suggested the possibility to clinically investigate more tolerable and effective strategies for the treatment of patients with advanced hematological malignancies, or at least for those frail and elderly patients, who are not eligible or resistant to standard treatments.
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Affiliation(s)
- Marta Banchi
- Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa, Pisa, Italy
| | | | - Guido Bocci
- Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa, Pisa, Italy.
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2
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Wang L, Song J, Xiao X, Li D, Liu T, He X. Comparison of venetoclax and ivosidenib/enasidenib for unfit newly diagnosed patients with acute myeloid leukemia and IDH1/2 mutation: a network meta-analysis. J Chemother 2024; 36:202-207. [PMID: 37599456 DOI: 10.1080/1120009x.2023.2247200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/28/2023] [Accepted: 07/20/2023] [Indexed: 08/22/2023]
Abstract
Because of lacking of head-to-head comparison between venetoclax and IDH1/IDH2 inhibitors (ivosidenib/enasidenib) for newly diagnosed unfit patients with acute myeloid leukemia (AML), the optimal option for these patients still remains undefined. We searched relevant published reports. Three RCTs with 180 IDH1 mutant and 165 IDH2 mutant patients were identified. Indirect comparison of OS using fixed effects network meta-analysis (NMA) models indicated venetoclax plus azacitidine (Ven-Aza) significantly improved survival than enasidenib plus azacitidine (Ena-Aza) (HR:0.30, p = 0.005) for those newly diagnosed patients with AML and IDH2 Mutation. And, for those IDH2 mutation patients, Ven-Aza also had the highest probability of 98.3% (OS analysis) and 84.0% (CR/CRi analysis) to be the best intervention among these first-line treatment regimens (Ven-Aza, Ena-Aza and Aza). And, there was a favorable trend towards Ven-Aza in survival analysis (HR:0.69, p = 0.42), when compared to ivosidenib plus azacitidine (Ivo-Aza) for those newly diagnosed patients with AML and IDH1 Mutation. For those IDH1 Mutation, venetoclax plus azacitidine (Ven-Aza) had the highest probability of 65.8% (OS analysis) and 73.0% (CR/CRi analysis) to be the best intervention among these first-line treatment regimens (Ven-Aza, ivosidenib plus azacitidine (Ivo-Aza) and azacitidine (Aza)). In conclusion, venetoclax plus azacitidine could be a good option for unfit newly diagnosed patients with acute myeloid leukemia and IDH1/2 mutation. Considering our limits (only trial data-based network meta-analysis et al.), future trials directly comparing these regimens are warranted.
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Affiliation(s)
- Lida Wang
- Department of E.N.T, Weifang People's Hospital, Weifang, China
| | - Jiwu Song
- Department of Stomatology, Weifang People's Hospital, Weifang, Shandong, China
| | - Xiangming Xiao
- Department of General Surgery, Weifang People's Hospital, Weifang, China
| | - Dianfang Li
- Department of Hematology, Weifang People's Hospital, Weifang, Shandong, China
| | - Tianmeng Liu
- Weifang Medical University, Weifang People's Hospital, Weifang, Shandong, China
| | - Xiaopo He
- Department of Oral and Maxillofacial Surgery, Weifang People's Hospital, Weifang, China
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Izutsu K, Ubukawa K, Morishita T, Onishi Y, Ishizawa K, Fujii Y, Kimura N, Yokochi M, Naoe T. Glasdegib with intensive/nonintensive chemotherapy in Japanese patients with untreated acute myeloid leukemia or high-risk myelodysplastic syndromes. Cancer Sci 2024; 115:1250-1260. [PMID: 38327103 PMCID: PMC11006982 DOI: 10.1111/cas.16054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 11/21/2023] [Accepted: 12/06/2023] [Indexed: 02/09/2024] Open
Abstract
Glasdegib is a potent, selective, oral inhibitor of the hedgehog signaling pathway. In this phase I study, previously untreated Japanese patients with acute myeloid leukemia (AML) or high-risk myelodysplastic syndromes were treated with glasdegib (100 mg once daily) combinations: low-dose cytarabine (20 mg twice daily; cohort 1, n = 6; expansion cohort, n = 15); daunorubicin and cytarabine (60 mg/m2 i.v.; cohort 2, n = 6); or azacitidine (100 mg/m2 i.v.; cohort 3, n = 6). Patients, except cohort 2, were ineligible for intensive chemotherapy. The primary end-point was dose-limiting toxicity in cohorts 1-3 and disease-modifying response in the expansion cohort. Disease-modifying response rate was tested with the null hypothesis of 6.8%, which was set based on the results from the phase II BRIGHT AML 1003 study (NCT01546038). No dose-limiting toxicities were observed in cohorts 1 or 3; one patient in cohort 2 experienced a dose-limiting toxicity of grade 3 erythroderma. The most common grade ≥3 treatment-related adverse events were neutropenia and thrombocytopenia (66.7% each) in cohort 1 and thrombocytopenia (60.0%) in the expansion cohort. In the expansion cohort, the disease-modifying response rate was 46.7% (90% confidence interval, 24.4-70.0; p < 0.0001), with all patients achieving either a complete response or complete response with incomplete blood count recovery. Median overall survival was 13.9 months. In this study, the primary disease-modifying response end-point with glasdegib plus low-dose cytarabine was met. The study confirms the safety and efficacy of glasdegib plus low-dose cytarabine in Japanese patients with AML ineligible for intensive chemotherapy.
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Affiliation(s)
- Koji Izutsu
- Department of HematologyNational Cancer Center HospitalTokyoJapan
| | - Kumi Ubukawa
- Department of Hematology, Nephrology and RheumatologyAkita University HospitalAkitaJapan
| | - Takanobu Morishita
- Department of HematologyJapanese Red Cross Aichi Medical Center Nagoya Daiichi HospitalNagoyaAichiJapan
| | - Yasushi Onishi
- Department of HematologyTohoku University HospitalSendaiMiyagiJapan
| | - Kenichi Ishizawa
- Department of Internal Medicine IIIYamagata University HospitalYamagataJapan
| | | | | | | | - Tomoki Naoe
- National Hospital Organization Nagoya Medical CenterNagoyaJapan
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4
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Majid H, Masoom M, Bansal N, Ahmad W, Khan MF, Farooqui S, Bhurani D, Khan MA. Spectrum of infections in different regimens of post-induction chemotherapy in acute myeloid leukemia ( de-novo): A comparative retrospective study. Heliyon 2024; 10:e24561. [PMID: 38317981 PMCID: PMC10839883 DOI: 10.1016/j.heliyon.2024.e24561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/10/2024] [Accepted: 01/10/2024] [Indexed: 02/07/2024] Open
Abstract
Background Patients diagnosed with acute myeloid leukemia (AML) face a heightened susceptibility to infections, which significantly elevates their risk of mortality and disability. The intensity of the chemotherapy treatment and its specific focus on inhibiting myeloid cell divisions render patients especially vulnerable, particularly during the early stages of chemotherapy. This vulnerability is compounded by the occurrence of repeated episodes of prolonged neutropenia, leaving patients highly susceptible to infections. The compromised immune systems of these individuals make them more susceptible to infections, which adversely affect their physical health and overall well-being. Consequently, our study aimed to investigate the range of infections experienced by patients with newly diagnosed AML undergoing different induction chemotherapy. Methods This was a comparative retrospective study, conducted at a tertiary hospital providing comprehensive cancer care in North India. All newly diagnosed patients with AML, who received induction chemotherapy from January 1, 2012 to November 1, 2022, were identified from the hospital database and included in this study. Results Four hundred and twenty AML patients treated with either high-intensity or low-intensity induction chemotherapy was observed in this study. It was found that patients who received high-intensity treatment had a higher rate of clinically and microbiologically documented infections, fever without a known cause, and more cases of febrile neutropenia than those who got low-intensity treatment. These differences between the two groups were particularly evident on day 14 (p = 0.0002) and persisted through day 28 (p = 0.005). Conclusions These findings underscore the effectiveness and downside of high-intensity induction chemotherapy regimens, as evidenced by the higher incidence of infections observed. Further investigation through prospective clinical studies is warranted to better evaluate and validate the efficacy of this approach.
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Affiliation(s)
- Haya Majid
- Department of Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India
| | - Md Masoom
- Department of Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India
| | - Nitin Bansal
- Department of Haemato-Oncology & Bone Marrow Transplantation, Rajiv Gandhi Cancer Institute & Research Centre, Rohini, New Delhi, 110085, India
| | - Wasim Ahmad
- Department of Pharmacy, Mohammed Al-Mana College for Medical Sciences, Safaa, Dammam 34222, Saudi Arabia
| | - Mohd Faiyaz Khan
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Sadaf Farooqui
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Dinesh Bhurani
- Department of Haemato-Oncology & Bone Marrow Transplantation, Rajiv Gandhi Cancer Institute & Research Centre, Rohini, New Delhi, 110085, India
| | - Mohd Ashif Khan
- Department of Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India
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5
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Ravandi F, Cloos J, Buccisano F, Dillon R, Döhner K, Freeman SD, Hourigan CS, Ossenkoppele GJ, Roboz GJ, Subklewe M, Thiede C, Arnhardt I, Valk PJM, Venditti A, Wei AH, Walter RB, Heuser M. Measurable residual disease monitoring in patients with acute myeloid leukemia treated with lower-intensity therapy: Roadmap from an ELN-DAVID expert panel. Am J Hematol 2023; 98:1847-1855. [PMID: 37671649 PMCID: PMC10841357 DOI: 10.1002/ajh.27087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/15/2023] [Accepted: 08/21/2023] [Indexed: 09/07/2023]
Abstract
With the availability of effective targeted agents, significant changes have occurred in the management of patients with acute myeloid leukemia (AML) over the past several years, particularly for those considered unfit for intensive chemotherapy. While testing for measurable residual disease (MRD) is now routinely performed in patients treated with intensive chemotherapy to refine prognosis and, possibly, inform treatment decision-making, its value in the context of lower-intensity regimens is unclear. As such regimens have gained in popularity and can be associated with higher response rates, the need to better define the role of MRD assessment and the appropriate time points and assays used for this purpose has increased. This report outlines a roadmap for MRD testing in patients with AML treated with lower-intensity regimens. Experts from the European LeukemiaNet (ELN)-DAVID AML MRD working group reviewed all available data to propose a framework for MRD testing in future trials and clinical practice. A Delphi poll served to optimize consensus. Establishment of uniform standards for MRD assessments in lower-intensity regimens used in treating patients with AML is clinically relevant and important for optimizing testing and, ultimately, improving treatment outcomes of these patients.
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Affiliation(s)
- Farhad Ravandi
- Department of Leukemia, The University of Texas - MD Anderson Cancer Center, Houston
| | - Jacqueline Cloos
- Department of Hematology, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Francesco Buccisano
- Department of Biomedicine and Prevention, Hematology, University Tor Vergata, Rome, Italy
| | - Richard Dillon
- Department of Medical and Molecular Genetics, King’s College, London, United Kingdom
| | - Konstanze Döhner
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Sylvie D Freeman
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Christopher S Hourigan
- Laboratory of Myeloid Malignancy, Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda
| | - Gerrit J Ossenkoppele
- Department of Hematology, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Gail J Roboz
- Department of Medicine, Division of Hematology and Oncology, Weill Cornell Medicine, New York
| | - Marion Subklewe
- Department of Medicine III, University Hospital, Ludwig Maximilian University Munich, Germany
| | - Christian Thiede
- Department of Medicine I, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Isabell Arnhardt
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Peter J M Valk
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Adriano Venditti
- Department of Biomedicine and Prevention, Hematology, University Tor Vergata, Rome, Italy
| | - Andrew H Wei
- Department of Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, University of Melbourne and Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Roland B Walter
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle
| | - Michael Heuser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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6
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Huang X, Liu Y, Liu R, Zou X, Yang H. The efficacy and adverse events of arsenic trioxide for the patients with myelodysplastic syndrome: a systematic review and component network meta-analysis. Hematology 2023; 28:2274149. [PMID: 37908176 DOI: 10.1080/16078454.2023.2274149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 10/16/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Arsenic trioxide (ATO) might be effective for myelodysplastic syndrome (MDS) by apoptosis induction and demethylation. But ATO has not been widely recommended for small sample and conflicting conclusion of existing trials. This review aimed to systematically evaluate the efficacy of regimens containing ATO for the MDS and explore optimal combination. METHOD Randomized clinical trials (RCTs) about ATO regimens were retrieved from China National Knowledge Infrastructure, Embase and PubMed. With odds ratio (OR) as the effect size, network meta-analysis (NMA) and component network meta-analysis (CNMA) were conducted by R and 'netmeta' package, after study selection, quality assessment and data extraction. RESULT Thirty-night RCTs were included with a total of 2125 patients, including 1235 treated by ATO containing regimen. With support therapy alone as reference, no inconsistency and heterogeneity were observed. Although NMA did not demonstrate better efficacy of ATO alone, the result of CNMA indicated that ATO was effective in the improvement of overall remission (ORR) [OR = 2.09(1.61, 2.71)] and complete remission (CR) [OR = 1.66(1.25, 2.21)]. Five ATO-containing regimens reported could effectively improve ORR, some of them benefit in CR or hematological improvement (HI) as well. ATO + Traditional Chinese Medicine (TCM), ATO + Thalidomide (T)+TCM, ATO + Chemotherapy (Chem)+T + TCM were regarded as the optimal combination, which improved both ORR, CR and HI in theory. ATO did not increase the risk of common adverse events compared to supportive therapy [(OR = 0.90(0.67, 1.21)]. CONCLUSION ATO may be an effective and well-tolerant option for patients with myelodysplastic syndrome.
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Affiliation(s)
- Xiaohua Huang
- Department of Hematology, The First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, People's Republic of China
| | - Yuan Liu
- The First Clinical Medicine College of Guangzhou University of Traditional Chinese Medicine, Guangzhou, People's Republic of China
| | - Ruixuan Liu
- The First Clinical Medicine College of Guangzhou University of Traditional Chinese Medicine, Guangzhou, People's Republic of China
| | - Xiaoqiu Zou
- Department of Traditional Chinese Medicine, Guangzhou Liwan Maternal and Child Health Hospital, Guangzhou, People's Republic of China
| | - Hongyong Yang
- Department of Hematology, The First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, People's Republic of China
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7
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Li X, Suh HS, Lachaine J, Schuh AC, Pratz K, Betts KA, Song J, Dua A, Bui CN. Comparative Efficacy of Venetoclax-Based Combination Therapies and Other Therapies in Treatment-Naive Patients With Acute Myeloid Leukemia Ineligible for Intensive Chemotherapy: A Network Meta-Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1689-1696. [PMID: 37741447 DOI: 10.1016/j.jval.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 07/11/2023] [Accepted: 09/11/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVES This network meta-analysis (NMA) assessed the efficacy of venetoclax (VEN) + azacitidine (AZA) and VEN + low-dose cytarabine (LDAC) compared with AZA, LDAC, and decitabine monotherapies and best supportive care (BSC) in adults with untreated acute myeloid leukemia ineligible for intensive chemotherapy. METHODS A systematic literature review and feasibility assessment was conducted to select phase III randomized controlled trials for inclusion in the NMA. Complete remission + complete remission with incomplete blood count recovery and overall survival (OS) were compared using a Bayesian fixed-effects NMA. Treatments were ranked using surface under the cumulative ranking curves (SUCRAs) with higher values indicating a higher likelihood of being effective. RESULTS A total of 1140 patients across 5 trials were included. VEN + LDAC (SUCRA 91.4%) and VEN + AZA (87.5%) were the highest ranked treatments for complete remission + complete remission with incomplete blood count recovery. VEN + LDAC was associated significantly higher response rates versus AZA (odds ratio 5.64), LDAC (6.39), and BSC (23.28). VEN + AZA was also associated significantly higher response rates than AZA (5.06), LDAC (5.74), and BSC (20.68). In terms of OS, VEN + AZA (SUCRA: 95.2%) and VEN + LDAC (75.9%) were the highest ranked treatments. VEN + AZA was associated with significant improvements in OS compared with AZA (hazard ratio 0.66), LDAC (0.57), and BSC (0.37), and VEN + LDAC was associated with significant improvements in OS compared with LDAC (0.70) and BSC (0.46). CONCLUSIONS VEN + AZA and VEN + LDAC demonstrated improved efficacy compared with alternative therapies among treatment-naive patients with acute myeloid leukemia ineligible for intensive chemotherapy.
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Affiliation(s)
- Xue Li
- China National Health Development Research Center, Beijing, China; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | | | - Andre C Schuh
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Keith Pratz
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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8
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Li J, Gao J, Liu A, Liu W, Xiong H, Liang C, Fang Y, Dai Y, Shao J, Yu H, Wang L, Wang L, Yang L, Yan M, Zhai X, Shi X, Tian X, Ju X, Chen Y, Wang J, Zhang L, Liang H, Chen S, Zhang J, Cao H, Jin J, Hu Q, Wang J, Wang Y, Zhou M, Han Y, Zhang R, Zhao W, Wang X, Lin L, Zhang R, Gao C, Xu L, Zhang Y, Fan J, Wu Y, Lin W, Yu J, Qi P, Huang P, Peng X, Peng Y, Wang T, Zheng H. Homoharringtonine-Based Induction Regimen Improved the Remission Rate and Survival Rate in Chinese Childhood AML: A Report From the CCLG-AML 2015 Protocol Study. J Clin Oncol 2023; 41:4881-4892. [PMID: 37531592 PMCID: PMC10617822 DOI: 10.1200/jco.22.02836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 05/26/2023] [Accepted: 06/14/2023] [Indexed: 08/04/2023] Open
Abstract
PURPOSE Homoharringtonine (HHT) is commonly used for the treatment of Chinese adult AML, and all-trans retinoic acid (ATRA) has been verified in acute promyelocytic leukemia (APL). However, the efficacy and safety of HHT-based induction therapy have not been confirmed for childhood AML, and ATRA-based treatment has not been evaluated among patients with non-APL AML. PATIENTS AND METHODS This open-label, multicenter, randomized Chinese Children's Leukemia Group-AML 2015 study was performed across 35 centers in China. Patients with newly diagnosed childhood AML were first randomly assigned to receive an HHT-based (H arm) or etoposide-based (E arm) induction regimen and then randomly allocated to receive cytarabine-based (AC arm) or ATRA-based (AT arm) maintenance therapy. The primary end points were the complete remission (CR) rate after induction therapy, and the secondary end points were the overall survival (OS) and event-free survival (EFS) at 3 years. RESULTS We enrolled 1,258 patients, of whom 1,253 were included in the intent-to-treat analysis. The overall CR rate was significantly higher in the H arm than in the E arm (79.9% v 73.9%, P = .014). According to the intention-to-treat analysis, the 3-year OS was 69.2% (95% CI, 65.1 to 72.9) in the H arm and 62.8% (95% CI, 58.7 to 66.6) in the E arm (P = .025); the 3-year EFS was 61.1% (95% CI, 56.8 to 65.0) in the H arm and 53.4% (95% CI, 49.2 to 57.3) in the E arm (P = .022). Among the per-protocol population, who received maintenance therapy, the 3-year EFS did not differ significantly across the four arms (H + AT arm: 70.7%, 95% CI, 61.1 to 78.3; H + AC arm: 74.8%, 95% CI, 67.0 to 81.0, P = .933; E + AC arm: 72.9%, 95% CI, 65.1 to 79.2, P = .789; E + AT arm: 66.2%, 95% CI, 56.8 to 74.0, P = .336). CONCLUSION HHT is an alternative combination regimen for childhood AML. The effects of ATRA-based maintenance are comparable with those of cytarabine-based maintenance therapy.
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Affiliation(s)
- Jing Li
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Beijing Key Laboratory of Pediatric Hematology Oncology, Beijing, China
- National Key Clinical Discipline of Pediatric Hematology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China
| | - Ju Gao
- West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Chronobiology (Sichuan University), National Health Commission of China, Chengdu, China
| | | | - Wei Liu
- Children's Hospital of Henan Province, Zhengzhou, China
| | - Hao Xiong
- Wuhan Children's Hospital, Wuhan, China
| | - Changda Liang
- Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Yongjun Fang
- Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yunpeng Dai
- Shandong First Medical University Affiliated Shandong Provincial Hospital, Jinan, China
| | - Jingbo Shao
- Shanghai Children's Hospital, Shanghai, China
| | - Hui Yu
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lingzhen Wang
- Affiliated Hospital of Qingdao University, Qingdao, China
| | - Li Wang
- Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Liangchun Yang
- Department of Pediatrics, Xiangya Hospital Central South University, Changsha, China
| | - Mei Yan
- The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xiaowen Zhai
- Children's Hospital of Fudan University, Shanghai, China
| | - Xiaodong Shi
- Capital Institute of Pediatrics' Children's Hospital, Beijing, China
| | - Xin Tian
- Kunming Children's Hospital, Kunming, China
| | - Xiuli Ju
- Qilu Hospital of Shandong University, Jinan, China
| | - Yan Chen
- Children's Hospital of Guizhou Province, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Jing Wang
- Children's Hospital of Shanxi Province, Taiyuan, China
| | - Leping Zhang
- Peking University People's Hospital, Beijing, China
| | - Hui Liang
- Women and Children's Hospital, Qingdao University, Qingdao, China
| | - Sen Chen
- Tianjin Children's Hospital, Tianjin, China
| | | | - Haixia Cao
- Qinghai Women's and Children's Hospital, Xining, China
| | - Jiao Jin
- The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Qun Hu
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Junlan Wang
- Northwest Women's and Children's Hospital, Xian, China
| | | | - Min Zhou
- Chengdu Women's and Children's Central Hospital, Chengdu, China
| | - Yueqin Han
- Children's Hospital of Liaocheng, Liaocheng, China
| | - Rong Zhang
- Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Weihong Zhao
- First Hospital, Peking University, Beijing, China
| | | | - Limin Lin
- Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Ruidong Zhang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Beijing Key Laboratory of Pediatric Hematology Oncology, Beijing, China
- National Key Clinical Discipline of Pediatric Hematology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China
| | - Chao Gao
- Beijing Key Laboratory of Pediatric Hematology Oncology, Beijing, China
- National Key Clinical Discipline of Pediatric Hematology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Laboratory of Hematologic Diseases, Beijing Pediatric Research Institute, Beijing, China
| | - Liting Xu
- Children's Hospital of Zhejiang University School of Medicine, the Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Yuanyuan Zhang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Beijing Key Laboratory of Pediatric Hematology Oncology, Beijing, China
- National Key Clinical Discipline of Pediatric Hematology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China
| | - Jia Fan
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Beijing Key Laboratory of Pediatric Hematology Oncology, Beijing, China
- National Key Clinical Discipline of Pediatric Hematology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China
| | - Ying Wu
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Beijing Key Laboratory of Pediatric Hematology Oncology, Beijing, China
- National Key Clinical Discipline of Pediatric Hematology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China
| | - Wei Lin
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Beijing Key Laboratory of Pediatric Hematology Oncology, Beijing, China
- National Key Clinical Discipline of Pediatric Hematology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China
| | - Jiaole Yu
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Beijing Key Laboratory of Pediatric Hematology Oncology, Beijing, China
- National Key Clinical Discipline of Pediatric Hematology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China
| | - Peijing Qi
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Beijing Key Laboratory of Pediatric Hematology Oncology, Beijing, China
- National Key Clinical Discipline of Pediatric Hematology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China
| | - Pengli Huang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Beijing Key Laboratory of Pediatric Hematology Oncology, Beijing, China
- National Key Clinical Discipline of Pediatric Hematology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China
| | - Xiaoxia Peng
- Center for Clinical Epidemiology and Evidence-Based Medicine, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yaguang Peng
- Center for Clinical Epidemiology and Evidence-Based Medicine, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Tianyou Wang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Beijing Key Laboratory of Pediatric Hematology Oncology, Beijing, China
- National Key Clinical Discipline of Pediatric Hematology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China
| | - Huyong Zheng
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Beijing Key Laboratory of Pediatric Hematology Oncology, Beijing, China
- National Key Clinical Discipline of Pediatric Hematology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China
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9
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Sekeres MA, Montesinos P, Novak J, Wang J, Jeyakumar D, Tomlinson B, Mayer J, Jou E, Robak T, Taussig DC, Dombret H, Merchant A, Shaik N, O'Brien T, Roh W, Liu X, Ma W, DiRienzo CG, Chan G, Cortes JE. Glasdegib plus intensive or non-intensive chemotherapy for untreated acute myeloid leukemia: results from the randomized, phase 3 BRIGHT AML 1019 trial. Leukemia 2023; 37:2017-2026. [PMID: 37604981 PMCID: PMC10539167 DOI: 10.1038/s41375-023-02001-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 07/25/2023] [Accepted: 08/08/2023] [Indexed: 08/23/2023]
Abstract
This is the primary report of the randomized, placebo-controlled phase 3 BRIGHT AML 1019 clinical trial of glasdegib in combination with intensive chemotherapy (cytarabine and daunorubicin) or non-intensive chemotherapy (azacitidine) in patients with untreated acute myeloid leukemia. Overall survival (primary endpoint) was similar between the glasdegib and placebo arms in the intensive (n = 404; hazard ratio [HR] 1.05; 95% confidence interval [CI]: 0.782-1.408; two-sided p = 0.749) and non-intensive (n = 325; HR 0.99; 95% CI: 0.768-1.289; two-sided p = 0.969) studies. The proportion of patients who experienced treatment-emergent adverse events was similar for glasdegib versus placebo (intensive: 99.0% vs. 98.5%; non-intensive: 99.4% vs. 98.8%). The most common treatment-emergent adverse events were nausea, febrile neutropenia, and anemia in the intensive study and anemia, constipation, and nausea in the non-intensive study. The addition of glasdegib to either cytarabine and daunorubicin or azacitidine did not significantly improve overall survival and the primary efficacy endpoint for the BRIGHT AML 1019 phase 3 trial was not met. Clinical trial registration: ClinicalTrials.gov: NCT03416179.
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Affiliation(s)
- Mikkael A Sekeres
- Division of Hematology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA.
| | - Pau Montesinos
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
- CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Jan Novak
- Department of Internal Medicine and Hematology, University Hospital Kralovske Vinohrady, Prague, Czech Republic
- Department of Haematology, 3rd Faculty of Medicine, Charles University and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Jianxiang Wang
- Department of Clinical Hematology, Institute of Hematology and Blood Diseases Hospital, Tianjin, China
| | - Deepa Jeyakumar
- University of California, Irvine, Chao Family Comprehensive Cancer Center, Orange, CA, USA
| | - Benjamin Tomlinson
- Division of Hematology, University Hospitals of Cleveland Seidman Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| | - Jiri Mayer
- Department of Internal Medicine Hematology and Oncology, University Hospital Brno and Masaryk University, Brno, Czech Republic
| | - Erin Jou
- Department of Hematology/Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Lodz, Poland
| | | | - Hervé Dombret
- Institut de Recherche Saint-Louis, Hôpital Saint-Louis Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Akil Merchant
- Division of Hematology and Cellular Therapy, Cedars Sinai Cancer, Los Angeles, CA, USA
| | | | | | - Whijae Roh
- Pfizer Oncology, Pfizer Inc, San Diego, CA, USA
| | - Xueli Liu
- Pfizer Oncology, Pfizer Inc, San Diego, CA, USA
| | - Wendy Ma
- Pfizer Oncology, Pfizer Inc, San Diego, CA, USA
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10
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Schlenk RF, Weber D, Krzykalla J, Kindler T, Wulf G, Hertenstein B, Salih HR, Südhoff T, Krauter J, Martens U, Wessendorf S, Runde V, Tischler HJ, Bentz M, Koller E, Heuser M, Thol F, Benner A, Ganser A, Döhner K, Döhner H. Randomized phase-III study of low-dose cytarabine and etoposide + /- all-trans retinoic acid in older unfit patients with NPM1-mutated acute myeloid leukemia. Sci Rep 2023; 13:14809. [PMID: 37684299 PMCID: PMC10491626 DOI: 10.1038/s41598-023-41964-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 09/04/2023] [Indexed: 09/10/2023] Open
Abstract
The aim of this randomized clinical trial was to evaluate the impact of all-trans retinoic acid (ATRA) in combination with non-intensive chemotherapy in older unfit patients (> 60 years) with newly diagnosed NPM1-mutated acute myeloid leukemia. Patients were randomized (1:1) to low-dose chemotherapy with or without open-label ATRA 45 mg/m2, days 8-28; the dose of ATRA was reduced to 45 mg/m2, days 8-10 and 15 mg/m2, days 11-28 after 75 patients due to toxicity. Up to 6 cycles of cytarabine 20 mg/day s.c., bid, days 1-7 and etoposide 100 mg/day, p.o. or i.v., days 1-3 with (ATRA) or without ATRA (CONTROL) were intended. The primary endpoint was overall survival (OS). Between May 2011 and September 2016, 144 patients (median age, 77 years; range, 64-92 years) were randomized (72, CONTROL; 72, ATRA). Baseline characteristics were balanced between the two study arms. The median number of treatment cycles was 2 in ATRA and 2.5 in CONTROL. OS was significantly shorter in the ATRA compared to the CONTROL arm (p = 0.023; median OS: 5 months versus 9.2 months, 2-years OS rate: 7% versus 10%, respectively). Rates of CR/CRi were not different between treatment arms; infections were more common in ATRA beyond treatment cycle one. The addition of ATRA to low-dose cytarabine plus etoposide in an older, unfit patient population was not beneficial, but rather led to an inferior outcome.The clinical trial is registered at clinicaltrialsregister.eu (EudraCT Number: 2010-023409-37, first posted 14/12/2010).
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Affiliation(s)
- R F Schlenk
- NCT-Trial Center, National Center of Tumor Diseases, Heidelberg University Hospital and German Cancer Research Center, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany.
| | - D Weber
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - J Krzykalla
- Division of Biostatistics, German Cancer Research Center Heidelberg, Heidelberg, Germany
| | - T Kindler
- Department of Hematology, Medical Oncology and Pneumology, University Medical Center Mainz, Mainz, Germany
| | - G Wulf
- Department of Hematology and Oncology, University Hospital of Göttingen, Göttingen, Germany
| | - B Hertenstein
- Department of Hematology and Oncology, Klinikum Bremen Mitte, Bremen, Germany
| | - H R Salih
- Department of Hematology and Oncology, Eberhard-Karls University, Tübingen, Germany
| | - T Südhoff
- Department of Hematology and Oncology, Klinikum Passau, Passau, Germany
| | - J Krauter
- Department Hematology and Oncology, Braunschweig Municipal Hospital, Braunschweig, Germany
| | - U Martens
- Department of Hematology and Oncology, Klinikum am Gesundbrunnen, Heilbronn, Germany
| | - S Wessendorf
- Department of Hematology and Oncology, Klinikum Esslingen, Esslingen, Germany
| | - V Runde
- Department of Hematology/Oncology, Wilhelm-Anton Hospital Goch, Goch, Germany
| | - H J Tischler
- Department of Hematology and Oncology, University Hospital of Minden, Minden, Germany
| | - M Bentz
- Department of Hematology and Oncology, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - E Koller
- Department of Internal Medicine III, Hanuschkrankenhaus Wien, Wien, Austria
| | - M Heuser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - F Thol
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - A Benner
- Division of Biostatistics, German Cancer Research Center Heidelberg, Heidelberg, Germany
| | - A Ganser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - K Döhner
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - H Döhner
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
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11
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Bazinet A, Kantarjian H, Arani N, Popat U, Bataller A, Sasaki K, DiNardo CD, Daver N, Yilmaz M, Abbas HA, Short NJ, Issa G, Jabbour E, Pierce SA, Chen J, Garcia R, Konopleva M, Garcia-Manero G, Alousi A, Shpall EJ, Champlin RE, Borthakur G, Ravandi F, Kadia T. Evolving trends and outcomes in older patients with acute myeloid leukemia including allogeneic stem cell transplantation. Am J Hematol 2023; 98:1383-1393. [PMID: 37334870 DOI: 10.1002/ajh.26997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/26/2023] [Accepted: 06/07/2023] [Indexed: 06/21/2023]
Abstract
Outcomes in older patients with acute myeloid leukemia (AML) have historically been poor. Given advances in low-intensity therapy (LIT) and stem cell transplantation (SCT), we performed a retrospective single-center study to evaluate the contemporary outcomes of this population. We reviewed all patients ≥60 years with newly diagnosed AML between 2012 and 2021 and analyzed treatment and SCT-related trends and outcomes. We identified 1073 patients with a median age of 71 years. Adverse clinical and cytomolecular findings were frequent within this cohort. In total, 16% of patients were treated with intensive chemotherapy, 51% with LIT alone, and 32% with LIT plus venetoclax. The composite complete remission rate with LIT plus venetoclax was 72%, which was higher than with LIT alone (48%, p < .0001) and comparable to intensive chemotherapy (74%, p = .6). The median overall survival (OS) with intensive chemotherapy, LIT, and LIT plus venetoclax was 20.1, 8.9, and 12.1 months, respectively. 18% of patients received SCT. SCT rates were 37%, 10%, and 22% in patients treated with intensive chemotherapy, LIT, and LIT plus venetoclax, respectively. The 2-year OS, relapse-free survival (RFS), cumulative incidence (CI) of relapse, and CI of treatment-related mortality with frontline SCT (n = 139) were 59%, 52%, 27%, and 22%, respectively. By landmark analysis, patients undergoing frontline SCT had superior OS (median 39.6 vs. 21.4 months, p < .0001) and RFS (30.9 vs. 12.1 months, p < .0001) compared with responding patients who did not. Outcomes in older patients with AML are improving with more effective LIT. Measures should be pursued to increase access to SCT in older patients.
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Affiliation(s)
- Alexandre Bazinet
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naszrin Arani
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alex Bataller
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hussein A Abbas
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ghayas Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sherry A Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Julianne Chen
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ricky Garcia
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amin Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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12
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Hershenfeld SA, Atenafu EG, Chan S, Gupta V, Maze D, Schuh A, Sibai H, Yee K, Schimmer AD. Impact of Geographical Distance from Quaternary Treatment Center on Clinical Trial Participation, Intensive Induction Chemotherapy, and Outcomes in Patients with Newly Diagnosed Acute Myeloid Leukemia. Acta Haematol 2023; 146:366-372. [PMID: 37315549 DOI: 10.1159/000531484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/02/2023] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Care for patients with acute myeloid leukemia (AML) is centralized in the Ontario single-payer public healthcare system, with intensive induction chemotherapy and clinical trials only offered at specialized cancer centers with large catchment areas. METHODS We therefore conducted a retrospective single-center review of all AML patients assessed at a large specialized cancer center in Ontario, Canada. RESULTS Between 2012 and 2017, 1,310 patients were assessed by our center for upfront AML therapy. The median distance was 33.1 km, with 29% of patients living more than 50 km away from the center. There was no significant difference in probability of intensive induction chemotherapy or clinical trial by distance from center, both in univariate and multivariable analysis adjusting for age, sex, cytogenetics and molecular testing, and performance status. There was no significant difference in overall survival by distance from center on univariate and multivariable analysis. CONCLUSION In conclusion, geographic distance from treatment center does not appear to impact choice of upfront therapy, participation in clinical trials, or clinical outcomes in this study of newly diagnosed patients with AML treated in a single-payer environment.
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Affiliation(s)
| | - Eshetu G Atenafu
- Princess Margaret Cancer Center, University Health Network, ON, Toronto, Canada
| | - Steven Chan
- Princess Margaret Cancer Center, University Health Network, ON, Toronto, Canada
| | - Vikas Gupta
- Princess Margaret Cancer Center, University Health Network, ON, Toronto, Canada
| | - Dawn Maze
- Princess Margaret Cancer Center, University Health Network, ON, Toronto, Canada
| | - Andre Schuh
- Princess Margaret Cancer Center, University Health Network, ON, Toronto, Canada
| | - Hassan Sibai
- Princess Margaret Cancer Center, University Health Network, ON, Toronto, Canada
| | - Karen Yee
- Princess Margaret Cancer Center, University Health Network, ON, Toronto, Canada
| | - Arron D Schimmer
- Princess Margaret Cancer Center, University Health Network, ON, Toronto, Canada
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13
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Wei AH, Roberts AW. BCL2 Inhibition: A New Paradigm for the Treatment of AML and Beyond. Hemasphere 2023; 7:e912. [PMID: 37304937 PMCID: PMC10256369 DOI: 10.1097/hs9.0000000000000912] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Altering the natural history of acute myeloid leukemia (AML) in unfit and older patients has proved a highly challenging hurdle, despite several decades of concerted clinical trial effort. The arrival of venetoclax (VEN) to the clinical stage represents the most important therapeutic advance to date for older patients with AML. In this review, we will explain how and why VEN works, summarize its remarkable pathway to regulatory approval, and highlight the key milestones that have been important for its successful development in AML. We also provide perspectives on some of the challenges associated with using VEN in the clinic, emerging knowledge regarding mechanisms of treatment failure, and current clinical research directions likely to shape how this drug and others in this new class of anticancer agents are used in the future.
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Affiliation(s)
- Andrew H Wei
- Blood Cells and Blood Cancer Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
- Department of Clinical Hematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
- Victorian Comprehensive Cancer Centre, Melbourne, VIC, Australia
| | - Andrew W Roberts
- Blood Cells and Blood Cancer Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
- Department of Clinical Hematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
- Victorian Comprehensive Cancer Centre, Melbourne, VIC, Australia
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14
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Premnath N, Madanat YF. Paradigm Shift in the Management of Acute Myeloid Leukemia-Approved Options in 2023. Cancers (Basel) 2023; 15:cancers15113002. [PMID: 37296964 DOI: 10.3390/cancers15113002] [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: 04/21/2023] [Revised: 05/18/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023] Open
Abstract
The word Leukemia was coined nearly 200 years ago by Rudolf Virchow. Once a death sentence, Acute Myeloid Leukemia (AML) is now a treatable condition. The introduction of "7 + 3" chemotherapy, originally reported from the Roswell Park Memorial institute in Buffalo, New York, in 1973, changed the treatment paradigm for AML. About twenty-seven years later, FDA approved the first targeted agent, gemtuzumab, to be added to this backbone. During the last seven years, we have had ten new drugs approved for the management of patients with AML. Work by many dedicated scientists led to AML achieving the elite status of being the first cancer to have the whole genome sequenced using next-generation sequencing. In the year 2022, we witnessed the introduction of new classification systems for AML by the international consensus classification and the world health organization, both emphasizing molecular classification of the disease. In addition, the introduction of agents such as venetoclax and targeted therapies have changed the treatment paradigm in older patients ineligible for intensive therapy. In this review, we cover the rationale and evidence behind these regimens and provide insights into the newer agents.
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Affiliation(s)
- Naveen Premnath
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
| | - Yazan F Madanat
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
- Leukemia Program, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX 75235, USA
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15
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Piccini M, Mannelli F, Coltro G. The Role of Venetoclax in Relapsed/Refractory Acute Myeloid Leukemia: Past, Present, and Future Directions. Bioengineering (Basel) 2023; 10:bioengineering10050591. [PMID: 37237661 DOI: 10.3390/bioengineering10050591] [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: 02/05/2023] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
Relapsed and/or refractory (R/R) acute myeloid leukemia (AML) is hallmarked by dramatic prognosis. Treatment remains challenging, with allogeneic hematopoietic stem cell transplantation (HSCT) as the only curative option. The BCL-2 inhibitor venetoclax (VEN) has proven to be a promising therapy for AML and is currently the standard of care in combination with hypomethylating agents (HMAs) for newly diagnosed AML patients ineligible for induction chemotherapy. Given its satisfactory safety profile, VEN-based combinations are increasingly being investigated as a part of the therapeutic strategy for R/R AML. The current paper aims to provide a comprehensive review of the main evidence regarding VEN in the setting of R/R AML, with a specific focus on combinational strategies, including HMAs and cytotoxic chemotherapy, as well as different clinical settings, especially in view of the crucial role of HSCT. A discussion of what is known about drug resistance mechanisms and future combinational strategies is also provided. Overall, VEN-based regimes (mainly VEN + HMA) have provided unprecedented salvage treatment opportunities in patients with R/R AML, with low extra-hematological toxicity. On the other hand, the issue of overcoming resistance is one of the most important fields to be addressed in upcoming clinical research.
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Affiliation(s)
- Matteo Piccini
- Hematology Department, Azienda Ospedaliero-Universitaria Careggi, 50134 Florence, Italy
| | - Francesco Mannelli
- Hematology Department, Azienda Ospedaliero-Universitaria Careggi, 50134 Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliero-Universitaria Careggi, 50134 Florence, Italy
| | - Giacomo Coltro
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliero-Universitaria Careggi, 50134 Florence, Italy
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16
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Edmund J, Thaliath LJ, Meleveedu K. Acute myeloid leukemia in the medically unfit elderly patients. Leuk Res 2023; 130:107306. [PMID: 37163857 DOI: 10.1016/j.leukres.2023.107306] [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: 09/22/2022] [Revised: 04/29/2023] [Accepted: 05/01/2023] [Indexed: 05/12/2023]
Abstract
Acute Myeloid Leukemia is a clonal proliferative disorder whose incidence increases with age. While studies have shown that the elderly medically unfit patients have poorer outcomes with intensive chemotherapy, a vast majority of them are deemed ineligible for intensive chemotherapy. Multiple studies have also shown that poor performance status prior to treatment initiation affects the prognosis. An accurate comprehensive assessment is hence vital to the selection of such patients. The chemotherapy agents that have been used for AML in the medically unfit patients have also changed significantly in the past few years. In this review we focus on the importance of comprehensive geriatric assessment prior to chemotherapy initiation among patients who are 75 years and older and the treatment approaches available for the medically unfit, Acute Myeloid Leukemia patients.
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Affiliation(s)
- Joseph Edmund
- Hematology and Oncology, Roger Williams Medical Center, Providence, RI, USA
| | | | - Kapil Meleveedu
- Hematology and Oncology, Bone Marrow Transplant, University of Connecticut Health Center, CT, USA.
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17
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El-Cheikh J, Bidaoui G, Saleh M, Moukalled N, Abou Dalle I, Bazarbachi A. Venetoclax: A New Partner in the Novel Treatment Era for Acute Myeloid Leukemia and Myelodysplastic Syndrome. Clin Hematol Int 2023:10.1007/s44228-023-00041-x. [PMID: 37071328 DOI: 10.1007/s44228-023-00041-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/09/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Acute Myeloid Leukemia (AML) and Myelodysplastic Syndrome (MDS) are two closely related blood cancers that are more frequent in older adults. AML is the most common type of adult acute leukemia, and MDS is characterized by ineffective blood cell production and abnormalities in the bone marrow and blood. Both can be resistant to treatment, often due to dysfunction in the process of apoptosis, the body's natural mechanism for cell death. Venetoclax, an orally-administered medication that selectively targets the BCL-2 protein, has shown promise in enhancing treatment sensitivity in some hematological malignancies by reducing the apoptotic threshold. This review aims to evaluate the effectiveness of venetoclax in treating AML and MDS, as well as potential mechanisms of resistance to the medication. METHODS A literature search was conducted utilizing PUBMED to capture all relevant research articles on the use of venetoclax as a therapy for both diseases. The MeSH terms "acute myeloid leukemia", "myelodysplastic syndrome" and "venetoclax" were searched. Furthermore, Clinicaltrials.gov was accessed to ensure the inclusion of all ongoing clinical trials. RESULTS Although Venetoclax showed modest results as a single-agent therapy in AML, venetoclax-based combination therapies? mainly with hypomethylating agents or low-dose cytarabine? yielded significantly positive results. Preliminary results oN the use of venetoclax-based combination therapy with HMA, mainly azacitidine, in unfit high-risk MDS also yielded optimistic results. Identification of mutations for which various drugs have been approved has spurred active investigation of venetoclax in combination trials. CONCLUSION Venetoclax-based combination therapies have been shown to induce rapid responses and increase overall survival in AML patients unfit for intensive chemotherapy. These therapies are also yielding positive preliminary results in high-risk MDS patients in phase I trials. Resistance to venetoclax and drug-related toxicity are two main obstacles that need to be overcome to reap the full benefits of this therapy.
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Affiliation(s)
- Jean El-Cheikh
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
- Department of Internal Medicine, Medical Center, Bone Marrow Transplantation Program, American University of Beirut, P.O. Box 113-6044, Beirut, Lebanon.
| | - Ghassan Bidaoui
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mustafa Saleh
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Nour Moukalled
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Iman Abou Dalle
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Bazarbachi
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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18
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Sasaki K, Ravandi F, Kadia TM, Borthakur G, Short NJ, Jain N, Daver NG, Jabbour EJ, Garcia-Manero G, Loghavi S, Patel KP, Montalban-Bravo G, Masarova L, DiNardo CD, Kantarjian HM. Prediction of survival with lower intensity therapy among older patients with acute myeloid leukemia. Cancer 2023; 129:1017-1029. [PMID: 36715486 DOI: 10.1002/cncr.34609] [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: 08/02/2022] [Revised: 10/05/2022] [Accepted: 10/21/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The aim of this study was to develop a prognostic model for survival in older/unfit patients with newly diagnosed acute myeloid leukemia (AML) who were treated with lower-intensity chemotherapy regimens. METHODS The authors reviewed all older/unfit patients with newly diagnosed AML who received lower-intensity chemotherapy from 2000 until 2020 at their institution. A total of 1462 patients were included. They were divided (3:1 basis) into a training (n = 1088) and a validation group (n = 374). RESULTS In the training cohort of 1088 patients (median age, 72 years), the multivariate analysis identified 11 consistent independent adverse factors associated with survival: older age, therapy-related myeloid neoplasm, existence of previous myelodysplastic syndrome or myeloproliferative neoplasms, poor performance status, pulmonary comorbidity, anemia, thrombocytopenia, elevated lactate dehydrogenase, cytogenetic abnormalities, and the presence of infection at diagnosis, and therapy not containing venetoclax. The 3-year survival rates were 52%, 24%, 10%, and 1% in favorable, intermediate, poor, and very poor risk, respectively. This survival model was validated in an independent cohort. In a subset of patients in whom molecular mutation profiles were performed in more recent times, adding the mutation profiles after accounting for the effects of previous factors identified IDH2 (favorable), NPM1 (favorable), and TP53 (unfavorable) mutations as molecular prognostic factors. CONCLUSION The proposed survival model with lower-intensity chemotherapy in older/unfit patients with newly diagnosed AML may help to advise patients on their expected outcome, to propose different strategies in first complete remission, and to compare the results of different existing or future investigational therapies. PLAIN LANGUAGE SUMMARY Lower intensity therapy can be considered for older patients to avoid severe toxicities and adverse events. However, survival prediction in AML was commonly developed in patients who received intensive chemotherapy. In this study, we have proposed a survival model to guide therapeutic approach in older patients who received lower-intensity therapy.
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Affiliation(s)
- Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elias J Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Keyur P Patel
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Lucia Masarova
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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19
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Babakhanlou R, Ravandi-Kashani F. Non-intensive acute myeloid leukemia therapies for older patients. Expert Rev Hematol 2023; 16:171-180. [PMID: 36864772 DOI: 10.1080/17474086.2023.2184342] [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: 03/04/2023]
Abstract
INTRODUCTION Acute myeloid leukemia (AML) is an aggressive disease predominantly affecting the elderly population. The elderly population represents a challenging group to treat and the prognosis is generally poor with significantly worse treatment outcomes compared to the younger population. While the goal of treatment for younger fit patients is cure and includes intensive chemotherapy and stem cell transplantation, these strategies are not always feasible for elderly unfit patients due to increased frailty, co-morbidities, and, subsequently, an increased risk of treatment-related toxicity and mortality. AREAS COVERED This review will discuss both patient- and disease-related factors, outline prognostication models and summarize current treatment options, including intensive and less intensive treatment strategies and novel agents. EXPERT OPINION Although recent years have seen major advances in the development of low-intensity therapies, there is still a lack of consensus on the optimal treatment for this patient group. Because of the heterogeneity of the disease, personalizing the treatment strategy is important and curative-oriented approaches should be selected wisely, rather than following a rigid hierarchical algorithm.
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Affiliation(s)
- Rodrick Babakhanlou
- Department of Leukemia, the University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Farhad Ravandi-Kashani
- Department of Leukemia, the University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
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20
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Cooperrider JH, Shukla N, Nawas MT, Patel AA. The Cup Runneth Over: Treatment Strategies for Newly Diagnosed Acute Myeloid Leukemia. JCO Oncol Pract 2023; 19:74-85. [PMID: 36223559 PMCID: PMC10476749 DOI: 10.1200/op.22.00342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/14/2022] [Accepted: 08/18/2022] [Indexed: 11/06/2022] Open
Abstract
Since 2017, the number of agents for acute myeloid leukemia (AML) has rapidly expanded. Given the increased therapeutic options, better identification of high-risk subsets of AML and more refined approaches to patient fitness assessment, the decisions surrounding selection of intensive chemotherapy versus lower-intensity treatment have grown increasingly more nuanced. In this review, we present available data for both standard and investigational approaches in the initial treatment of AML using an intensive chemotherapy backbone or a lower-intensity approach. We summarize management strategies in newly diagnosed secondary AML, considerations around allogeneic stem-cell transplantation, and the role of maintenance therapy. Finally, we highlight important areas of future investigation and novel agents that may hold promise in combination with standard therapies.
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Affiliation(s)
| | - Navika Shukla
- Department of Medicine, University of Chicago, Chicago, IL
| | - Mariam T. Nawas
- Section of Hematology-Oncology, Department of Medicine, University of Chicago, Chicago, IL
| | - Anand Ashwin Patel
- Section of Hematology-Oncology, Department of Medicine, University of Chicago, Chicago, IL
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21
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Berdel AF, Koch R, Gerss J, Hentrich M, Peceny R, Bartscht T, Steffen B, Bischoff M, Spiekermann K, Angenendt L, Mikesch JH, Kewitz T, Butterfass-Bahloul T, Serve H, Lenz G, Berdel WE, Krug U, Schliemann C. A randomized phase 2 trial of nintedanib and low-dose cytarabine in elderly patients with acute myeloid leukemia ineligible for intensive chemotherapy. Ann Hematol 2023; 102:63-72. [PMID: 36399194 PMCID: PMC9807538 DOI: 10.1007/s00277-022-05025-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 11/04/2022] [Indexed: 11/19/2022]
Abstract
We investigated the safety and efficacy of nintedanib added to low-dose cytarabine (LDAC) in a phase 1/2 study in patients 60 years or older with newly diagnosed or relapsed/refractory (r/r) AML ineligible for intensive chemotherapy. The results of the dose-finding phase 1 part have been previously published. Patients were randomized 1:1 to LDAC plus nintedanib or LDAC plus placebo stratified by AML status (newly diagnosed vs r/r). LDAC was applied subcutaneously at 20 mg twice daily on days 1 to 10. Nintedanib/placebo was orally administered twice daily on days 1 to 28 in 28-day cycles. The primary endpoint was overall survival (OS). Between 05/2017 and 09/2019, 31 patients were randomized and 30 were treated, before the study was terminated prematurely due to slow recruitment. Median (range) age of patients was 76 (60-84) years. Twenty-two patients (73%) had r/r AML. Median OS in patients treated with LDAC and nintedanib was 3.4 months, compared with 3.6 months in those treated in the placebo arm, with a HR adjusted for AML status of 1.19 (corresponding confirmatory adjusted 95% CI, 0.55-2.56; univariate log-rank P = 0.96). In the 22 patients with r/r AML, median OS was 3.0 months in the nintedanib and 3.6 months in the placebo arm (P = 0.36). One patient in the nintedanib and two patients in the placebo arm achieved a CR and entered maintenance treatment. Nintedanib showed no superior therapeutic activity over placebo when added to LDAC in elderly AML patients considered unfit for intensive chemotherapy. The trial was registered at clinicaltrials.gov NCT01488344.
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Affiliation(s)
- Andrew F Berdel
- Department of Medicine A, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Raphael Koch
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Joachim Gerss
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Marcus Hentrich
- Department of Hematology and Oncology, Red Cross Hospital, Munich, Germany
| | - Rudolf Peceny
- Department of Oncology, Hematology and Stem Cell Transplantation, Klinikum Osnabrück, Osnabrück, Germany
| | - Tobias Bartscht
- Department of Medicine I, University Hospital Lübeck, Lübeck, Germany
| | - Björn Steffen
- Department of Medicine II, University Hospital Frankfurt, Frankfurt, Germany
| | - Marina Bischoff
- Department of Hematology and Oncology, Klinikum Idar-Oberstein, Idar-Oberstein, Germany
| | - Karsten Spiekermann
- Department of Medicine III, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany
| | - Linus Angenendt
- Department of Medicine A, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Jan-Henrik Mikesch
- Department of Medicine A, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Tobias Kewitz
- Centre for Clinical Trials, University of Münster, Münster, Germany
| | | | - Hubert Serve
- Department of Medicine II, University Hospital Frankfurt, Frankfurt, Germany
| | - Georg Lenz
- Department of Medicine A, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Wolfgang E Berdel
- Department of Medicine A, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Utz Krug
- Department of Medicine A, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
- Department of Medicine, III, Hospital Leverkusen, Leverkusen, Germany
| | - Christoph Schliemann
- Department of Medicine A, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
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22
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Short NJ, Kantarjian H. Hypomethylating agents for the treatment of myelodysplastic syndromes and acute myeloid leukemia: Past discoveries and future directions. Am J Hematol 2022; 97:1616-1626. [PMID: 35871436 DOI: 10.1002/ajh.26667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/12/2022] [Accepted: 07/20/2022] [Indexed: 01/31/2023]
Abstract
Azacitidine and decitabine are hypomethylating agents that have dose-dependent epigenetic and cytotoxic effects and are widely used in the treatment of myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). In this review, we discuss the path to regulatory approval of azacitidine and decitabine, highlighting the substantial efforts that have been made to optimize the dosing schedule and administration of these drugs, including the development of new, oral formulations of both agents. We also review novel combination strategies that are being investigated in ongoing clinical trials for patients with MDS and AML, as well as efforts to expand the current indications of these agents.
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Affiliation(s)
- Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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23
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Gandhi A, Andrick B, Darling J, Truong T, Signorelli J. Oral Antineoplastics in Acute Myeloid Leukemia: A Comprehensive Review. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e1033-e1049. [PMID: 36192350 DOI: 10.1016/j.clml.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 01/26/2023]
Abstract
AML is a biologically and clinically heterogeneous disease that is associated with poor overall long-term survival. The expanding knowledge of genomic landscape in AML as well as advancements in molecular and chemical biology over the pathway in AML. After 40 years of stagnancy, the recent approval of numerous novel oral anti-leukemic agents for the treatment of AML has changed both the armamentarium of medications and treatment paradigms. These agents have unique clinical considerations in terms of administration, adverse effects, and monitoring parameters which may differ from clinician's historical expectations. Understanding the data, indication and clinical considerations for such novel oral anti-leukemic agents is paramount for clinicians caring patients with AML.
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Affiliation(s)
- Arpita Gandhi
- Assistant Director, Hematology/Oncology Clinical Pharmacy Specialist, Emory Healthcare, Atlanta, GA.
| | - Benjamin Andrick
- Assistant Professor, Clinical Research, Center for Pharmacy Innovations and Outcomes, Geisinger Health, Hematology/Oncology Pharmacy, Danville, PA
| | - Julianne Darling
- Manger of Education, National Community Oncology Dispensing Association, Inc., Cazenovia, NY
| | - Tuyet Truong
- Northeastern University School of Pharmacy, Boston, MA
| | - Jessie Signorelli
- Clinical Pharmacist Specialist, Hematology, Massachusetts General Hospital, Boston, MA
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24
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Usikova EV, Kaplanov KD, Vorob'ev VI, Lobanova TI, Ul'yanova MA, Kisilichina DG, Kobzev YN, Shikhbabaeva DI, Vinogradova OY, Ptushkin VV. Efficacy of the combination of venetoclax and hypomethylating agents in the treatment of patients with primary, relapsed and/or refractory acute myeloid leukemia. BULLETIN OF THE MEDICAL INSTITUTE "REAVIZ" (REHABILITATION, DOCTOR AND HEALTH) 2022. [DOI: 10.20340/vmi-rvz.2022.6.clin.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Relevance and goals. Treatment of patients with acute myeloid leukemia has traditionally been highly intensive and includes induction therapy using cytarabine and anathracyclines. In addition to new opportunities in the treatment of acute myeloid leukemia, the problem of toxicity of high-intensity therapy in elderly and young somatically burdened patients is quite acute. International clinical trials of phases I-III demonstrated a combination of high efficacy and acceptable hematological toxicity of combinations of hypomethylating agents and venetoclax in the first line of therapy, as well as in the treatment of resistant forms and relapses of acute myeloid leukemia in the older age group, which contributed to the study of the effectiveness of combinations of hypomethylating agents and venetoclax in the treatment of similar groups of young comorbid patients. In this work, we evaluated the efficiency of a combination of hypomethylating agents and venetoclax and overall and disease-free survival in patients with acute myeloid leukemia in routine practice.Methods. In the period from October 2017 to December 2021 on the basis of the Department of Hematology No. 11 and the Department of Bone Marrow and Hematopoietic Stem Cell Transplantation No. 56 of the Botkin Hospital (Moscow, Russia) 33 patients with acute myeloid leukemia received venetoclax therapy in combination with decitabine or azacitidine: 14 (42%) men and 19 (58%) women, median age was 60 years (23–83 years). In 42% (14 of 33) of cases, the regimen was prescribed for resistant course or relapse of acute myeloid leukemia and in 61% (20 of 33) as induction therapy. Three patients (15%) out of 19 from the group of newly diagnosed acute myeloid leukemia received this treatment regimen in the first line, taking into account the ECOG status 3-4. By August 2022, 13 (39%) patients are alive, 20 (61%) people have died. Overall survival, the rate of complete remission and complete remission with incomplete recovery, the rate of achieving negativity of minimal residual disease, the frequency of hematological toxicity and infectious complications were assessed. Statistical data processing used: frequency analysis using contingency tables (Fisher's exact test), survival analysis using the Kaplan-Meier method.Results. Complete remission and complete remission with incomplete recovery were achieved in 72.72% (24 of 33) of patients. In the group of primary acute myeloid leukemia, remissions were observed in 80% (16 out of 20) of cases, in the group with resistant course or recurrence of acute myeloid leukemia in 67% (8 out of 12) (p = 0.3). Determination of minimal residual disease by flow cytometry after the 1st course was performed for 54.54% (18 of 33) patients, while negativity was stated in 84.2% (14 of 18 patients) cases. In both groups, the incidence of hematological toxicity and infectious complications are comparable to those according to the literature data. The median follow-up was 9.5 months (1–47). Median overall survival was 39 months, 2-year overall survival was 63%, and overall 4-year survival was 39%. The disease-free survival rate was 33%.Conclusion. The combination of hypomethylating agents and venetoclax showed good efficacy and fairly high overall survival in patients of all age groups, both for primary acute myeloid leukemia and for relapses and resistant forms, regardless of previous therapy. Given the moderate hematological toxicity, as well as the relatively low rates of infectious complications during therapy, including the rather low mortality rates in case of COVID-19 infection in comparison with those on the background of high-intensity courses of therapy for acute myeloid leukemia, this scheme can be widely used not only in patients of the older age group, but also in young comorbid patients.
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Affiliation(s)
- E. V. Usikova
- Botkin City Clinical Hospital, Moscow City Hematology Center
| | - K. D. Kaplanov
- Botkin City Clinical Hospital, Moscow City Hematology Center
| | - V. I. Vorob'ev
- Botkin City Clinical Hospital, Moscow City Hematology Center
| | - T. I. Lobanova
- Botkin City Clinical Hospital, Moscow City Hematology Center
| | - M. A. Ul'yanova
- Botkin City Clinical Hospital, Moscow City Hematology Center
| | - D. G. Kisilichina
- Botkin City Clinical Hospital, Moscow City Hematology Center; Russian Medical Academy of Continuous Professional Education
| | - Yu. N. Kobzev
- Botkin City Clinical Hospital, Moscow City Hematology Center
| | | | - O. Yu. Vinogradova
- Botkin City Clinical Hospital, Moscow City Hematology Center; N.I. Pirogov Russian National Research Medical University
| | - V. V. Ptushkin
- Botkin City Clinical Hospital, Moscow City Hematology Center; N.I. Pirogov Russian National Research Medical University
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25
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Chen S, Hu Q, Tao X, Xia J, Wu T, Cheng B, Wang J. Retinoids in cancer chemoprevention and therapy: Meta-analysis of randomized controlled trials. Front Genet 2022; 13:1065320. [PMID: 36437918 PMCID: PMC9681997 DOI: 10.3389/fgene.2022.1065320] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 10/27/2022] [Indexed: 08/27/2023] Open
Abstract
Retinoids, natural and synthetic derivatives of vitamin A, have many regulatory functions in human body, including regulating cellular proliferation, differentiation, apoptosis. Moreover, retinoids have been used successfully for the treatment of certain malignancies, especially acute promyelocytic leukemia (APL) in adults and neuroblastoma in children. However, retinoids have not yet been translated into effective systemic treatments for most solid cancers. Some recent studies have shown that retinoids promote tumorigenesis. Therefore, we performed this meta-analysis to systematically evaluate the efficacy of retinoids in the chemoprevention and treatment of cancers. We performed literature search of several electronic databases, including PubMed, Embase and Cochrane Library from 2000 January to 2021 November. Various outcomes were applied to investigate the potential of retinoids for prevention and treatment of cancers. The primary outcomes in this study were disease recurrence and clinical response. The secondary outcomes included overall survival (OS), cancer development, disease progression and event-free survival. We identified 39 randomized controlled trials with 15,627 patients in this study. Our results showed that lower recurrence rate and better clinical response were obtained in retinoids treated patients with cancer or premalignancy as compared with control. The differences were statistically significant (RR = 0.85, 95% CI = 0.74-0.96, p = 0.01; RR = 1.24, 95% CI = 1.03-1.49, p = 0.02, respectively). Retinoids treatment was not associated with improvement in overall survival, cancer development, disease progression or event-free survival. Subgroup analysis conducted based on cancer type showed that patients benefited from retinoids treatment in APL, renal cell carcinoma, hepatocellular carcinoma, lung cancer, Kaposi sarcoma, and complete hydatidiform mole. No significant therapeutic effect was noted in head and neck cancer, acute myeloid leukemia (AML), melanoma, breast cancer, bladder cancer, cervical intraepithelial neoplasia (CIN) or cervical carcinoma. Subgroup analysis based on tumor classification demonstrated that retinoids group obtained a lower recurrence rate and better clinical response than control group in solid cancers. In conclusion, clinical application of retinoids was associated with reduction in disease recurrence and improvement in clinical response, illustrating that retinoids play a key role in cancer prevention and therapy. Further research is needed to broaden the utility of retinoids in other types of cancers. Systematic Review Registration: PROSPERO, identifier CRD42022296706.
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Affiliation(s)
- Shuting Chen
- Hospital of Stomatology, Sun Yat-Sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
- Guanghua School of Stomatology, Sun Yat-Sen University, Guangzhou, China
| | - Qinchao Hu
- Hospital of Stomatology, Sun Yat-Sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
- Guanghua School of Stomatology, Sun Yat-Sen University, Guangzhou, China
| | - Xiaoan Tao
- Hospital of Stomatology, Sun Yat-Sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
- Guanghua School of Stomatology, Sun Yat-Sen University, Guangzhou, China
| | - Juan Xia
- Hospital of Stomatology, Sun Yat-Sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
- Guanghua School of Stomatology, Sun Yat-Sen University, Guangzhou, China
| | - Tong Wu
- Hospital of Stomatology, Sun Yat-Sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
- Guanghua School of Stomatology, Sun Yat-Sen University, Guangzhou, China
| | - Bin Cheng
- Hospital of Stomatology, Sun Yat-Sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
- Guanghua School of Stomatology, Sun Yat-Sen University, Guangzhou, China
| | - Juan Wang
- Hospital of Stomatology, Sun Yat-Sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
- Guanghua School of Stomatology, Sun Yat-Sen University, Guangzhou, China
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26
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Dennis M, Copland M, Kaur H, Kell J, Nikolousis E, Mehta P, Palanicawandar R, Potter V, Raj K, Thomas I, Wilson A. Management of older patients with frailty and acute myeloid leukaemia: A British Society for Haematology good practice paper. Br J Haematol 2022; 199:205-221. [PMID: 36000944 DOI: 10.1111/bjh.18369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Mike Dennis
- The Christie NHS Foundation Trust, Manchester, UK
| | - Mhairi Copland
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Harpreet Kaur
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - Priyanka Mehta
- University Hospitals of Bristol and Weston NHS Trust, Bristol, UK
| | | | | | - Kavita Raj
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Andrew Wilson
- University College London Hospitals NHS Foundation Trust, London, UK
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How Genetics Can Drive Initial Therapy Choices for Older Patients with Acute Myeloid Leukemia. Curr Treat Options Oncol 2022; 23:1086-1103. [PMID: 35687257 PMCID: PMC9898635 DOI: 10.1007/s11864-022-00991-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2022] [Indexed: 02/06/2023]
Abstract
OPINION STATEMENT Treatment of older adults with acute myeloid leukemia (AML) is challenging. Therapy decisions must be guided by multiple factors including aging-related conditions (e.g., comorbidities, functional impairment), therapy benefits and risks, patient preferences, and disease characteristics. Balancing these factors requires understanding the unique, and frequently higher-risk cytogenetic and molecular characteristics of AML in older adult populations, which should caution providers not to reduce therapy intensity on the basis of age alone. Instead, geriatric assessments should be employed to determine fitness for therapy. Treatment options in AML are increasingly targeted to specific mutations or recognized to have differential benefits on the basis of genomics, and representation of older adults and geriatric outcome reporting in clinical trials is improving. Additionally, newer studies have begun to explore personalized therapy strategies on the basis of initial genetic testing. Review and refinement of practice guidelines for older patients on the basis of these advances is needed and is anticipated to remain an important topic in ongoing hematology/oncology clinical education.
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Kang JB, Chen L, Leng XJ, Wang JJ, Cheng Y, Wu SH, Ma YY, Yang LJ, Cao YH, Yang X, Tong ZJ, Wu JZ, Wang YB, Zhou H, Liu JC, Ding N, Dai WC, Yu YC, Xue X, Sun SL, Dai XB, Chang L, Wang XL, Li NG, Shi ZH. Synthesis and biological evaluation of 4-(4-aminophenyl)-6-methylisoxazolo[3,4-b] pyridin-3-amine covalent inhibitors as potential agents for the treatment of acute myeloid leukemia. Bioorg Med Chem 2022; 70:116937. [PMID: 35863236 DOI: 10.1016/j.bmc.2022.116937] [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: 05/29/2022] [Revised: 07/10/2022] [Accepted: 07/12/2022] [Indexed: 11/02/2022]
Abstract
Fms-like tyrosine kinase 3 (FLT3) mutation has been strongly associated with increased risk of relapse, and the irreversible covalent FLT3 inhibitors had the potential to overcome the drug-resistance. In this study, a series of simplified 4-(4-aminophenyl)-6-methylisoxazolo[3,4-b] pyridin-3-amine derivatives containing two types of Michael acceptors (vinyl sulfonamide, acrylamide) were conveniently synthesized to target FLT3 and its internal tandem duplications (ITD) mutants irreversibly. The kinase inhibitory activities showed that compound C14 displayed potent inhibition activities against FLT3 (IC50 = 256 nM) and FLT3-ITD by 73 % and 25.34 % respectively, at the concentration of 1 μM. The antitumor activities indicated that C14 had strong inhibitory activity against the human acute myeloid leukemia (AML) cell lines MOLM-13 (IC50 = 507 nM) harboring FLT3-ITD mutant, as well as MV4-11 (IC50 = 325 nM) bearing FLT3-ITD mutation. The biochemical analyses showed that these effects were related to the ability of C14 to inhibit FLT3 signal pathways, and C14 could induce apoptosis in MV4-11 cell as demonstrated by flow cytometry. Fortunately, C14 showed very weak potency against FLT3-independent human cervical cancer cell line HL-60 (IC50 > 10 μM), indicating that it might have no off-target toxic effects. In light of these data, compound C14 represents a novel covalent FLT3 kinase inhibitor for targeted therapy of AML.
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Affiliation(s)
- Ji-Bo Kang
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Lu Chen
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Xue-Jiao Leng
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Jing-Jing Wang
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Yang Cheng
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Shi-Han Wu
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Yi-Yuan Ma
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Li-Jin Yang
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Yu-Hao Cao
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Xiao Yang
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Zhen-Jiang Tong
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Jia-Zhen Wu
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Yi-Bo Wang
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Hai Zhou
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Jia-Chuan Liu
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Ning Ding
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Wei-Chen Dai
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Yan-Cheng Yu
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Xin Xue
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Shan-Liang Sun
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Xiao-Bin Dai
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China
| | - Liang Chang
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China.
| | - Xiao-Long Wang
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China.
| | - Nian-Guang Li
- National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing, Jiangsu 210023, China.
| | - Zhi-Hao Shi
- Laboratory of Molecular Design and Drug Discovery, School of Science, China Pharmaceutical University, 639 Longmian Avenue, Nanjing, Jiangsu 211198, China.
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Griffioen MS, de Leeuw DC, Janssen JJWM, Smit L. Targeting Acute Myeloid Leukemia with Venetoclax; Biomarkers for Sensitivity and Rationale for Venetoclax-Based Combination Therapies. Cancers (Basel) 2022; 14:cancers14143456. [PMID: 35884517 PMCID: PMC9318140 DOI: 10.3390/cancers14143456] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 07/12/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Venetoclax has proven to be a promising therapy for newly diagnosed, relapsed and refractory AML patients ineligible for induction chemotherapy. Current ongoing clinical trials are evaluating its effectivity as frontline therapy for all acute myeloid leukemia (AML) patients. However, response rates vary wildly, depending on patient characteristics and mutational profiles. This review elaborates on the efficacy and safety of venetoclax compared to conventional chemotherapy for treatment of AML patients, comparing the response rates, overall survival and adverse events. Moreover, it gives an overview of genetic and epigenetic AML cell characteristics that give enhanced or decreased response to venetoclax and offers insights into the pathogenesis of venetoclax sensitivity and resistance. Additionally, it suggests possible treatment combinations predicted to be successful based on identified mechanisms influencing venetoclax sensitivity of AML cells. Abstract Venetoclax is a BCL-2 inhibitor that effectively improves clinical outcomes in newly diagnosed, relapsed and refractory acute myeloid leukemia (AML) patients, with complete response rates (with and without complete blood count recovery) ranging between 34–90% and 21–33%, respectively. Here, we aim to give an overview of the efficacy of venetoclax-based therapy for AML patients, as compared to standard chemotherapy, and on factors and mechanisms involved in venetoclax sensitivity and resistance in AML (stem) cells, with the aim to obtain a perspective of response biomarkers and combination therapies that could enhance the sensitivity of AML cells to venetoclax. The presence of molecular aberrancies can predict responses to venetoclax, with a higher response in NPM1-, IDH1/2-, TET2- and relapsed or refractory RUNX1-mutated AML. Decreased sensitivity to venetoclax was observed in patients harboring FLT3-ITD, TP53, K/NRAS or PTPN11 mutations. Moreover, resistance to venetoclax was observed in AML with a monocytic phenotype and patients pre-treated with hypomethylating agents. Resistance to venetoclax can arise due to mutations in BCL-2 or pro-apoptotic proteins, an increased dependency on MCL-1, and usage of additional/alternative sources for energy metabolism, such as glycolysis and fatty acid metabolism. Clinical studies are testing combination therapies that may circumvent resistance, including venetoclax combined with FLT3- and MCL-1 inhibitors, to enhance venetoclax-induced cell death. Other treatments that can potentially synergize with venetoclax, including MEK1/2 and mitochondrial complex inhibitors, need to be evaluated in a clinical setting.
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Affiliation(s)
- Mila S Griffioen
- Department of Hematology, Amsterdam UMC, Location VUmc, Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - David C de Leeuw
- Department of Hematology, Amsterdam UMC, Location VUmc, Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Jeroen J W M Janssen
- Department of Hematology, Amsterdam UMC, Location VUmc, Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Linda Smit
- Department of Hematology, Amsterdam UMC, Location VUmc, Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
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Roldán Pérez A, Vázquez Paganini JA, Penalva Moreno MJ, Giménez Mesa E, Vilches Moreno AS, Nuñez‐Torrón Stock C, Herráez García R. Real‐life experience of venetoclax and hypomethylating agents in acute myeloid leukemia patients not candidates for intensive chemotherapy or who are refractory/relapsed: A single‐centre experience. Clin Case Rep 2022; 10:e6116. [PMID: 35898750 PMCID: PMC9309735 DOI: 10.1002/ccr3.6116] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/01/2022] [Accepted: 07/05/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Alicia Roldán Pérez
- Department of Hemotherapy and Haematology Hospital Universitario Infanta Sofia San Sebastián de los Reyes Spain
| | | | - M. José Penalva Moreno
- Department of Hemotherapy and Haematology Hospital Universitario Infanta Sofia San Sebastián de los Reyes Spain
| | - Eugenio Giménez Mesa
- Department of Hemotherapy and Haematology Hospital Universitario Infanta Sofia San Sebastián de los Reyes Spain
| | - Alba Sara Vilches Moreno
- Department of Hemotherapy and Haematology Hospital Universitario Infanta Sofia San Sebastián de los Reyes Spain
| | - Claudia Nuñez‐Torrón Stock
- Department of Hemotherapy and Haematology Hospital Universitario Infanta Sofia San Sebastián de los Reyes Spain
| | - Regina Herráez García
- Department of Hemotherapy and Haematology Hospital Universitario Infanta Sofia San Sebastián de los Reyes Spain
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Pratz KW, Panayiotidis P, Recher C, Wei X, Jonas BA, Montesinos P, Ivanov V, Schuh AC, DiNardo CD, Novak J, Pejsa V, Stevens D, Yeh SP, Kim I, Turgut M, Fracchiolla N, Yamamoto K, Ofran Y, Wei AH, Bui CN, Benjamin K, Kamalakar R, Potluri J, Mendes W, Devine J, Fiedler W. Venetoclax combinations delay the time to deterioration of HRQoL in unfit patients with acute myeloid leukemia. Blood Cancer J 2022; 12:71. [PMID: 35443742 PMCID: PMC9021259 DOI: 10.1038/s41408-022-00668-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/24/2022] [Accepted: 04/01/2022] [Indexed: 12/17/2022] Open
Abstract
Phase 3 trials Viale-A and Viale-C evaluated health-related quality of life (HRQoL) in patients with AML unfit for intensive chemotherapy who received venetoclax (VEN) + (AZA) (Viale-A) or low-dose cytarabine (LDAC) (Viale-C) or placebo (PBO) + AZA or LDAC. Patient-reported outcomes included: EORTC QLQ-C30 global health status (GHS/QoL) and physical functioning (PF), PROMIS Cancer Fatigue Short Form 7a (Fatigue), and EQ-5D-5L health status visual analog scale (HS-VAS). Time to deterioration (TTD), defined as worsening from baseline in meaningful change thresholds (MCT) of ≥10, 5, or 7 points for GHS/QoL or PF, fatigue, and HS-VAS, respectively, was assessed; differences between groups were analyzed using Kaplan-Meier and unadjusted log-rank analyses. VEN + AZA vs PBO + AZA patients had longer TTD in GHS/QoL (P = 0.066) and fatigue (P = 0.189), and significantly longer TTD in PF (P = 0.028) and HS-VAS (P < 0.001). VEN + LDAC vs PBO + LDAC patients had significantly longer TTD in GHS/QoL (P = 0.011), PF (P = 0.020), and fatigue (P = 0.004), and a trend in HS-VAS (P = 0.057). Approximately 43%, 35%, 32%, and 18% of patients treated with VEN + AZA, AZA + PBO, VEN + LDAC, or LDAC + PBO, respectively, saw improvements >MCT in GHS/QoL. Overall, VEN may positively impact HRQoL in patients with AML ineligible for intensive chemotherapy, leading to longer preservation of functioning and overall health status.
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Affiliation(s)
- Keith W Pratz
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA.
| | - Panayiotis Panayiotidis
- National and Kapodistrian University of Athens Medical School, Laiko General Hospital, Athens, Greece
| | - Christian Recher
- Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Université de Toulouse 3 Paul Sabatier, Toulouse, France
| | - Xudong Wei
- The Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Zhengzhou, China
| | - Brian A Jonas
- Department of Internal Medicine, Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Pau Montesinos
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Vladimir Ivanov
- Almazov National Medical Research Center, Saint Petersburg, Russian Federation
| | - Andre C Schuh
- Princess Margaret Cancer Centre and University of Toronto, Toronto, ON, Canada
| | - Courtney D DiNardo
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jan Novak
- Department of Internal Medicine and Hematology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Vlatko Pejsa
- Department of Hematology, University Hospital Dubrava, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Don Stevens
- Norton Cancer Institute, Louisville, KY, USA
| | - Su-Peng Yeh
- Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Inho Kim
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Mehmet Turgut
- Department of Internal Medicine, Division of Hematology, Ondokuz Mayıs University Faculty of Medicine, Samsun, Turkey
| | - Nicola Fracchiolla
- Hematology Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Kazuhito Yamamoto
- Department of Hematology and Cell Therapy, Aichi Cancer Center, Nagoya, Japan
| | - Yishai Ofran
- Department of Hematology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Andrew H Wei
- Australian Center for Blood Diseases, The Alfred Hospital and Monash University, Melbourne, Australia
| | | | | | | | | | | | | | - Walter Fiedler
- Department of Oncology, Hematology and Bone Marrow Transplantation With Section Pneumology, Hubertus Wald University Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Labrador J, Saiz-Rodríguez M, de Miguel D, de Laiglesia A, Rodríguez-Medina C, Vidriales MB, Pérez-Encinas M, Sánchez-Sánchez MJ, Cuello R, Roldán-Pérez A, Vives S, Benzo-Callejo G, Colorado M, García-Fortes M, Sayas MJ, Olivier C, Recio I, Conde-Royo D, Bienert-García Á, Vahi M, Muñoz-García C, Seri-Merino C, Tormo M, Vall-llovera F, Foncillas MÁ, Martínez-Cuadrón D, Sanz MÁ, Montesinos P. Use of Venetoclax in Patients with Relapsed or Refractory Acute Myeloid Leukemia: The PETHEMA Registry Experience. Cancers (Basel) 2022; 14:cancers14071734. [PMID: 35406512 PMCID: PMC8997036 DOI: 10.3390/cancers14071734] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/12/2022] [Accepted: 03/24/2022] [Indexed: 12/20/2022] Open
Abstract
Simple Summary The use of venetoclax combined with hypomethylating agents or low-dose cytarabine in patients with newly diagnosed acute myeloid leukemia unfit for intensive chemotherapy was recently approved. However, the evidence in relapse or refractory patients is still scarce. The cohort of patients included in our study was heavily pretreated and had a poor performance status. It is still necessary to identify those patients at higher risk of early death who would not benefit from this type of treatment. For these ultra-high-risk patients, other treatment strategies should be followed. Abstract The effectiveness of venetoclax (VEN) in relapsed or refractory acute myeloid leukemia (RR-AML) has not been well established. This retrospective, multicenter, observational database studied the effectiveness of VEN in a cohort of 51 RR-AML patients and evaluated for predictors of response and overall survival (OS). The median age was 68 years, most were at high risk, 61% received ≥2 therapies for AML, 49% had received hypomethylating agents, and ECOG was ≥2 in 52%. Complete remission (CR) rate, including CR with incomplete hematological recovery (CRi), was 12.4%. Additionally, 10.4% experienced partial response (PR). The CR/CRi was higher in combination with azacitidine (AZA; 17.9%) than with decitabine (DEC; 6.7%) and low-dose cytarabine (LDAC; 0%). Mutated NPM1 was associated with increased CR/CRi. Median OS was 104 days (95% CI: 56–151). For the combination with AZA, DEC, and LDAC, median OS was 120 days, 104 days, and 69 days, respectively; p = 0.875. Treatment response and ECOG 0 influenced OS in a multivariate model. A total of 28% of patients required interruption of VEN because of toxicity. Our real-life series describes a marginal probability of CR/CRi and poor OS after VEN-based salvage. Patients included had very poor-risk features and were heavily pretreated. The small percentage of responders did not reach the median OS.
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Affiliation(s)
- Jorge Labrador
- Hematology Deparment, Hospital Universitario de Burgos, 09006 Burgos, Spain
- Research Unit, Fundación Burgos por la Investigación de la Salud (FBIS), Hospital Universitario de Burgos, 09006 Burgos, Spain;
- Correspondence: (J.L.); (P.M.)
| | - Miriam Saiz-Rodríguez
- Research Unit, Fundación Burgos por la Investigación de la Salud (FBIS), Hospital Universitario de Burgos, 09006 Burgos, Spain;
| | - Dunia de Miguel
- Hematology Deparment, Hospital Universitario de Guadalajara, 19002 Guadalajara, Spain;
| | | | - Carlos Rodríguez-Medina
- Hematology Deparment, Hospital de Gran Canaria Dr. Negrin, 35010 Las Palmas de Gran Canaria, Spain;
| | | | - Manuel Pérez-Encinas
- Hematology Deparment, Hospital Clínico Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Spain;
| | | | - Rebeca Cuello
- Hematology Deparment, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain;
| | - Alicia Roldán-Pérez
- Hematology Deparment, Hospital Universitario Infanta Sofía, 28703 Madrid, Spain;
| | - Susana Vives
- Hematology Deparment, Hospital Germans Trias i Pujol-ICO, 08907 Badalona, Spain;
| | | | - Mercedes Colorado
- Hematology Deparment, Hospital Universitario Marqués de Valdecilla, 39008 Santander, Spain;
| | - María García-Fortes
- Hematology Deparment, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain;
| | - María José Sayas
- Hematology Deparment, Hospital Universitario Doctor Peset, 46017 Valencia, Spain;
| | - Carmen Olivier
- Hematology Deparment, Hospital General de Segovia, 40002 Segovia, Spain;
| | - Isabel Recio
- Hematology Deparment, Complejo Asistencial de Ávila, 05071 Ávila, Spain;
| | - Diego Conde-Royo
- Hematology Deparment, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, 28805 Madrid, Spain;
| | - Álvaro Bienert-García
- Hematology Deparment, Hospital Universitario de Canarias, 38320 Santa Cruz de Tenerife, Spain;
| | - María Vahi
- Hematology Deparment, Hospital Universitario Virgen de Valme, 41014 Sevilla, Spain;
| | - Carmen Muñoz-García
- Hematology Deparment, Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain;
| | - Cristina Seri-Merino
- Hematology Deparment, Hospital Central de la Defensa Gómez Ulla, 28047 Madrid, Spain;
| | - Mar Tormo
- Hematology Deparment, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain;
| | - Ferran Vall-llovera
- Hematology Deparment, Hospital Universitari Mutua Terrasa, 08221 Barcelona, Spain;
| | | | - David Martínez-Cuadrón
- Hematology Deparment; Hospital Universitari I Politécnic La Fe, 46026 Valencia, Spain; (D.M.-C.); (M.Á.S.)
| | - Miguel Ángel Sanz
- Hematology Deparment; Hospital Universitari I Politécnic La Fe, 46026 Valencia, Spain; (D.M.-C.); (M.Á.S.)
| | - Pau Montesinos
- Hematology Deparment; Hospital Universitari I Politécnic La Fe, 46026 Valencia, Spain; (D.M.-C.); (M.Á.S.)
- Correspondence: (J.L.); (P.M.)
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Ha H, Jeong Y, Lim JH, Suh YJ. Treatment Pattern, Financial Burden and Outcomes in Elderly Patients with Acute Myeloid Leukemia in Korea: A Nationwide Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042317. [PMID: 35206499 PMCID: PMC8872510 DOI: 10.3390/ijerph19042317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/11/2022] [Accepted: 02/12/2022] [Indexed: 12/10/2022]
Abstract
Although approximately 50% of patients with acute myeloid leukemia (AML) are diagnosed over the age of 60 years, there is currently no established consensus on the treatment of elderly AML patients. Herein, we aimed to explore the incidence, medical expenditure, treatment, and outcomes of elderly AML patients in Korea by analyzing a nationwide cohort. We employed the Korean National Health Insurance Service-Senior cohort, which represents 10% of a random selection from a total of 5.5 million subjects aged 60 years or older. AML patients were identified according to the main diagnostic criteria of acute leukemia. Treatment for AML was divided into high- (high-dose cytarabine ± idarubicin) and low- (low-dose cytarabine or hypomethylating agents) intensity chemo-therapy and classified according to the chemotherapeutics protocol. We analyzed the survival outcomes and medical expenditures. Among 558,147 elderly patients, 471 were diagnosed with AML, and 195 (41.4%) were treated with chemotherapy. The median age was 65 years, and the median overall survival (OS) was 4.93 months (95% confidence interval, 4.47–5.43). Median OS was longer in patients undergoing chemotherapy than those in the best supportive care group (6.28 vs. 3.45 months, p < 0.001), and the difference was prominent in patients aged < 70 years. Twenty-eight (5.9%) patients received high-intensity chemotherapy, while 146 (31.0%) received low-intensity chemotherapy. The difference in median OS according to dose intensity was 4.6 months, which was longer in the high-intensity chemotherapy group (9.8 vs. 5.2 months in low-intensity group); however, the difference was not statistically significant. Patients who received high-intensity chemotherapy recorded longer hospital stays and incurred greater expenses on initial hospitalization. Elderly AML patients in Korea exhibited clinical benefits from chemotherapy. Although patients should be carefully selected for intensive treatment, chemotherapy, including low-intensity treatment, can be considered in elderly patients. Moreover, prospective studies on new agents or new treatment strategies are needed.
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Affiliation(s)
- Hyerim Ha
- Department of Internal Medicine, Inha University Hospital, Incheon 22332, Korea;
| | - Yujin Jeong
- Department of Biostatistics, Korea University College of Medicine, Seoul 02841, Korea;
| | - Joo Han Lim
- Department of Internal Medicine, Inha University Hospital, Incheon 22332, Korea;
- Correspondence: (J.H.L.); (Y.J.S.); Tel.: +82-32-890-2581 (J.H.L.); +82-32-890-2833 (Y.J.S.)
| | - Young Ju Suh
- Department of Biomedical Sciences, College of Medicine, Inha University, Incheon 22332, Korea
- Correspondence: (J.H.L.); (Y.J.S.); Tel.: +82-32-890-2581 (J.H.L.); +82-32-890-2833 (Y.J.S.)
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Physician and patient perceptions on randomization of treatment intensity for unfit adults with acute myeloid leukemia and other high-grade myeloid neoplasm. Leukemia 2022; 36:1386-1389. [PMID: 35173273 DOI: 10.1038/s41375-022-01524-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/26/2022] [Accepted: 02/03/2022] [Indexed: 11/12/2022]
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Qin Y, Kuang P, Liu T. Venetoclax combined with hypomethylating agents or low-dose cytarabine as induction chemotherapy for patients with untreated acute myeloid leukemia ineligible for intensive chemotherapy: a systematic review and meta-analysis. Clin Exp Med 2022; 23:219-227. [DOI: 10.1007/s10238-021-00784-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 12/10/2021] [Indexed: 11/03/2022]
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Kantarjian HM, Jain N, Garcia-Manero G, Welch MA, Ravandi F, Wierda WG, Jabbour EJ. The cure of leukemia through the optimist's prism. Cancer 2022; 128:240-259. [PMID: 34614211 PMCID: PMC8738114 DOI: 10.1002/cncr.33933] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 01/17/2023]
Abstract
Progress is occurring at a dizzying rate across all leukemias. Since the authors' review of the topic in Cancer in 2018, numerous discoveries have been made that have improved the therapy and outcomes of several leukemia subsets. Hairy cell leukemia is potentially curable with a single course of cladribine followed by rituximab (10-year survival, ≥90%). Acute promyelocytic leukemia is curable at a rate of 80% to 90% with a nonchemotherapy regimen of all-trans retinoic acid and arsenic trioxide. The cure rate for core-binding factor acute myeloid leukemia (AML) is ≥75% with fludarabine, high-dose cytarabine, and gemtuzumab ozogamicin. Survival for patients with chronic myeloid leukemia is close to that for an age-matched normal population with BCR-ABL1 tyrosine kinase inhibitors (TKIs). Chronic lymphocytic leukemia, a previously incurable disease, may now be potentially curable with a finite duration of therapy with Bruton tyrosine kinase inhibitors and venetoclax. The estimated 5-year survival rate for patients with Philadelphia chromosome-positive acute lymphoblastic leukemia (ALL) exceeds 70% with intensive chemotherapy and ponatinib, a third-generation BCR-ABL1 TKI, and more recent nonchemotherapy regimens using dasatinib or ponatinib with blinatumomab are producing outstanding results. Survival in both younger and older patients with ALL has improved with the addition of antibodies targeting CD20, CD19 (blinatumomab), and CD22 (inotuzumab) to chemotherapy. Several recent drug discoveries (venetoclax, FLT3 and IDH inhibitors, and oral hypomethylating agents) are also improving outcomes for younger and older patients with AML and for those with higher risk myelodysplastic syndrome.
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Affiliation(s)
- Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Mary Alma Welch
- 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
| | - William G Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elias J Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Sasaki K, Kadia T, Begna K, DiNardo CD, Borthakur G, Short NJ, Jain N, Daver N, Jabbour E, Garcia‐Manero G, Bravo GM, Masarova L, Pierce S, Konopleva M, Ravandi F, Tefferi A, Kantarjian H. Prediction of early (4-week) mortality in acute myeloid leukemia with intensive chemotherapy. Am J Hematol 2022; 97:68-78. [PMID: 34716921 DOI: 10.1002/ajh.26395] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 12/19/2022]
Abstract
The progress with intensive chemotherapy and supportive care measures has improved survival in patients with newly diagnosed acute myeloid leukemia (AML). Given the recent development of effective low intensity therapies, an optimal decision on the therapy intensity may improve survival through the avoidance of early mortality. We reviewed the outcome of 3728 patients with newly diagnosed AML who received intensive chemotherapy between August 1980 and May 2020. Intensive chemotherapy was defined as a cumulative cytarabine dose ≥ 700 mg/m2 during induction therapy. We divided the whole cohort into a training and validation group at a 3:1 ratio. The population was divided into a training (2790 patients) and a validation cohort (938 patients). The median age was 55 years (range, 15-99). Among them, 442 patients (12%) had core-binding factor AML. Binary logistic regression identified older age, worse performance status, hyperbilirubinemia, elevated creatinine, hyperuricemia, cytogenetic abnormalities other than CBF and -Y, and pneumonia as adverse prognostic factors for an early 4-week mortality. This risk classification for early mortality was verified in the validation cohort of patients. In the validation cohort of more recently treated patients from 2000 to 2017, the 4-week mortality rates with intensive chemotherapy were 2%, 14%, and 50% in the low-, high-, and very high-risk group, respectively. The mortality rates with low intensity therapies were 3%, 9%, and 20%, respectively. The risk classification guides treatment intensity by the assessment of age, frailty, organ dysfunction, cytogenetic abnormality, and infection to avoid early mortality.
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Affiliation(s)
- Koji Sasaki
- Department of Leukemia MD Anderson Cancer Center Houston Texas USA
| | - Tapan Kadia
- Department of Leukemia MD Anderson Cancer Center Houston Texas USA
| | - Kebede Begna
- Department of Medicine, Division of Hematology Mayo Clinic Rochester Minnesota USA
| | | | - Gautam Borthakur
- Department of Leukemia MD Anderson Cancer Center Houston Texas USA
| | | | - Nitin Jain
- Department of Leukemia MD Anderson Cancer Center Houston Texas USA
| | - Naval Daver
- Department of Leukemia MD Anderson Cancer Center Houston Texas USA
| | - Elias Jabbour
- Department of Leukemia MD Anderson Cancer Center Houston Texas USA
| | | | | | - Lucia Masarova
- Department of Leukemia MD Anderson Cancer Center Houston Texas USA
| | - Sherry Pierce
- Department of Leukemia MD Anderson Cancer Center Houston Texas USA
| | - Marina Konopleva
- Department of Leukemia MD Anderson Cancer Center Houston Texas USA
| | - Farhad Ravandi
- Department of Leukemia MD Anderson Cancer Center Houston Texas USA
| | - Ayalew Tefferi
- Department of Medicine, Division of Hematology Mayo Clinic Rochester Minnesota USA
| | - Hagop Kantarjian
- Department of Leukemia MD Anderson Cancer Center Houston Texas USA
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Abstract
ABSTRACT Venetoclax has transformed the therapeutic landscape of acute myeloid leukemia (AML). Hypomethylating agents with venetoclax (HMA-VEN) have significantly improved outcomes and have become the standard therapy for older/unfit patients with newly diagnosed AML and are comparable to intensive chemotherapy in salvage setting. Venetoclax with intensive chemotherapy have shown high response rates in both frontline and salvage setting in younger patients, and triplet combinations with HMA-VEN and FLT3 inhibitors have shown encouraging results in FLT3mut AML. While patients with NPM1mut, IDH1/2mut experience favorable outcomes, those with TP53mut and secondary AML may experience minimal benefit from the addition of venetoclax. Despite improved outcomes, severe cytopenias and infectious complications are common with venetoclax-based regimens. Early response evaluation, dose reductions, venetoclax interruptions, use of growth factors, and prophylactic antimicrobials may minimize such myelosuppression and risk of infections. Outcomes after failure of frontline HMA-VEN are dismal, and novel approaches are needed to abrogate primary and acquired resistance.
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The Evolution of Research and Therapy With Hypomethylating Agents in Acute Myeloid Leukemia and Myelodysplastic Syndrome: New Directions for Old Drugs. Cancer J 2022; 28:29-36. [DOI: 10.1097/ppo.0000000000000568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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40
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Loke J, Metzner M, Boucher R, Jackson A, Hopkins L, Pavlu J, Tholouli E, Drummond M, Peniket A, Bishop R, Fox S, Vyas P, Craddock C. Combination romidepsin and azacitidine therapy is well tolerated and clinically active in adults with high-risk acute myeloid leukaemia ineligible for intensive chemotherapy. Br J Haematol 2022; 196:368-373. [PMID: 34490623 DOI: 10.1111/bjh.17823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/24/2021] [Indexed: 11/30/2022]
Abstract
Azacitidine (AZA) is important in the management of patients with acute myeloid leukaemia (AML) who are ineligible for intensive chemotherapy. Romidepsin (ROM) is a histone deacetylase inhibitor which synergises with AZA in vitro. The ROMAZA trial established the maximum tolerated dose (MTD) of combined ROM/AZA therapy in patients with AML, as ROM 12 mg/m2 on Days 8 and 15, with AZA 75 mg/m2 administered for 7/28 day cycle. Nine of the 38 (23·7%) patients treated at the MTD were classified as responders by Cycle 6 (best response: complete remission [CR]/incomplete CR n = 7, partial response n = 2). Correlative next-generation sequencing studies demonstrated important insights into therapy resistance.
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Affiliation(s)
- Justin Loke
- Centre for Clinical Haematology, University Hospital Birmingham, UK
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Marlen Metzner
- MRC Molecular Haematology Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Rebecca Boucher
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Aimee Jackson
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Louise Hopkins
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Jiri Pavlu
- Centre for Haematology, Imperial College London at Hammersmith Hospital, London, UK
| | - Eleni Tholouli
- Department of Clinical Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Mark Drummond
- Beatson West of Scotland Cancer Centre, UK
- University of Glasgow, Glasgow, UK
| | - Andy Peniket
- NIHR Oxford Biomedical Research Centre, Oxford, UK
- Oxford University Hospitals Foundation NHS Trust, Oxford, UK
| | - Rebecca Bishop
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Sonia Fox
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Paresh Vyas
- MRC Molecular Haematology Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
- Oxford University Hospitals Foundation NHS Trust, Oxford, UK
| | - Charles Craddock
- Centre for Clinical Haematology, University Hospital Birmingham, UK
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
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Dennis M, Thomas IF, Ariti C, Upton L, Burnett AK, Gilkes A, Radia R, Hemmaway C, Mehta P, Knapper S, Clark RE, Copland M, Russell N, Hills RK. Randomized evaluation of quizartinib and low-dose ara-C vs low-dose ara-C in older acute myeloid leukemia patients. Blood Adv 2021; 5:5621-5625. [PMID: 34597366 PMCID: PMC8714727 DOI: 10.1182/bloodadvances.2021005038] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 08/02/2021] [Indexed: 11/20/2022] Open
Abstract
Survival for older patients with acute myeloid leukemia (AML) unsuitable for intensive chemotherapy is unsatisfactory. Standard nonintensive therapies have low response rates and only extend life by a few months. Quizartinib is an oral Fms-like tyrosine kinase 3 (FLT3) inhibitor with reported activity in wild-type patients. As part of the AML LI trial, we undertook a randomized evaluation of low-dose ara-C (LDAC) with or without quizartinib in patients not fit for intensive chemotherapy. Overall, survival was not improved (202 patients), but in the 27 FLT3-ITD patients, the addition of quizartinib to LDAC improved response (P = .05) with complete remission/complete remission with incomplete haematological recovery for quizartinib + LDAC in 5/13 (38%) vs 0/14 (0%) in patients receiving LDAC alone. Overall survival (OS) in these FLT3-ITD+ patients was also significantly improved at 2 years for quizartinib + LDAC (hazard ratio 0.36; 95% confidence intervals: 0.16, 0.85, P = .04). Median OS was 13.7 months compared with 4.2 months with LDAC alone. This is the first report of an FLT3-targeted therapy added to standard nonintensive chemotherapy that has improved survival in this population. Quizartinib merits consideration for future triplet-based treatment approaches. This trial was registered at www.clinicaltrials.gov as ISRCTN #ISRCTN40571019 and EUDRACT @2011-000749-19.
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Affiliation(s)
| | - Ian F. Thomas
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Cono Ariti
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Laura Upton
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Alan K. Burnett
- Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Amanda Gilkes
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Rohini Radia
- Department of Haematology, Nottingham University Hospital, Nottingham, United Kingdom
| | | | - Priyanka Mehta
- Department of Haematology, Queen's Hospital, Romford, United Kingdom
- Department of Haematology, University Hospitals Bristol, Bristol, United Kingdom
| | - Steven Knapper
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Richard E. Clark
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom; and
| | - Mhairi Copland
- Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Nigel Russell
- Department of Haematology, Nottingham University Hospital, Nottingham, United Kingdom
| | - Robert K. Hills
- Nuffield Department of Population Health, Oxford, United Kingdom
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Hleihel R, El Hajj H, Wu HC, Berthier C, Zhu HH, Massoud R, Chakhachiro Z, El Sabban M, De The H, Bazarbachi A. A Pin1/PML/P53 axis activated by retinoic acid in NPM-1c acute myeloid leukemia. Haematologica 2021; 106:3090-3099. [PMID: 34047175 PMCID: PMC8634200 DOI: 10.3324/haematol.2020.274878] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 05/03/2021] [Indexed: 11/09/2022] Open
Abstract
Retinoic acid (RA) was proposed to increase survival of chemotherapy- treated patients with nucleophosmin-1 (NPM-1c)-mutated acute myeloid leukemia. We reported that, ex vivo, RA triggers NPM-1c degradation, P53 activation and growth arrest. PML organizes domains that control senescence or proteolysis. Here, we demonstrate that PML is required to initiate RA-driven NPM-1c degradation, P53 activation and cell death. Mechanistically, RA enhances PML basal expression through inhibition of activated Pin1, prior to NPM-1c degradation. Such PML induction drives P53 activation, favoring blast response to chemotherapy or arsenic in vivo. This RA/PML/P53 cascade could mechanistically explain RA-facilitated chemotherapy response in patients with NPM-1c mutated acute myeloid leukemia.
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MESH Headings
- Humans
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Promyelocytic, Acute/drug therapy
- Leukemia, Promyelocytic, Acute/genetics
- Leukemia, Promyelocytic, Acute/metabolism
- NIMA-Interacting Peptidylprolyl Isomerase/genetics
- NIMA-Interacting Peptidylprolyl Isomerase/metabolism
- Nuclear Proteins/genetics
- Nuclear Proteins/metabolism
- Oncogene Proteins, Fusion/metabolism
- Tretinoin/pharmacology
- Tretinoin/therapeutic use
- Tumor Suppressor Protein p53/genetics
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Affiliation(s)
- Rita Hleihel
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon; Department of Anatomy, Cell Biology and Physiological Sciences, American University of Beirut, Beirut, Lebanon
| | - Hiba El Hajj
- Department of Experimental Pathology, Microbiology and Immunology, Beirut
| | - Hsin-Chieh Wu
- Université de Paris, INSERM UMR 944, CNRS UMR 7212, Equipe labellisée par la Ligue Nationale contre le Cancer, IRSL, Hôpital St. Louis, Paris, College de France, PSL University, CIRB, INSERM UMR 1050, CNRS UMR 7241, Paris
| | - Caroline Berthier
- Université de Paris, INSERM UMR 944, CNRS UMR 7212, Equipe labellisée par la Ligue Nationale contre le Cancer, IRSL, Hôpital St. Louis, Paris; College de France, PSL University, CIRB, INSERM UMR 1050, CNRS UMR 7241, Paris
| | - Hong-Hu Zhu
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou
| | - Radwan Massoud
- Department of Internal Medicine, American University of Beirut, Beirut
| | - Zaher Chakhachiro
- Department of Pathology and Laboratory Medicine, American University of Beirut, Beirut
| | - Marwan El Sabban
- Department of Anatomy, Cell Biology and Physiological Sciences, American University of Beirut, Beirut
| | - Hugues De The
- Université de Paris, INSERM UMR 944, CNRS UMR 7212, Equipe labellisée par la Ligue Nationale contre le Cancer, IRSL, Hôpital St. Louis, Paris; College de France, PSL University, CIRB, INSERM UMR 1050, CNRS UMR 7241, Paris
| | - Ali Bazarbachi
- Department of Internal Medicine, American University of Beirut, Beirut; Department of Anatomy, Cell Biology and Physiological Sciences, American University of Beirut, Beirut.
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43
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Healy FM, Dahal LN, Jones JRE, Floisand Y, Woolley JF. Recent Progress in Interferon Therapy for Myeloid Malignancies. Front Oncol 2021; 11:769628. [PMID: 34778087 PMCID: PMC8586418 DOI: 10.3389/fonc.2021.769628] [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: 09/14/2021] [Accepted: 10/13/2021] [Indexed: 12/29/2022] Open
Abstract
Myeloid malignancies are a heterogeneous group of clonal haematopoietic disorders, caused by abnormalities in haematopoietic stem cells (HSCs) and myeloid progenitor cells that originate in the bone marrow niche. Each of these disorders are unique and present their own challenges with regards to treatment. Acute myeloid leukaemia (AML) is considered the most aggressive myeloid malignancy, only potentially curable with intensive cytotoxic chemotherapy with or without allogeneic haematopoietic stem cell transplantation. In comparison, patients diagnosed with chronic myeloid leukaemia (CML) and treated with tyrosine kinase inhibitors (TKIs) have a high rate of long-term survival. However, drug resistance and relapse are major issues in both these diseases. A growing body of evidence suggests that Interferons (IFNs) may be a useful therapy for myeloid malignancies, particularly in circumstances where patients are resistant to existing front-line therapies and have risk of relapse following haematopoietic stem cell transplant. IFNs are a major class of cytokines which are known to play an integral role in the non-specific immune response. IFN therapy has potential as a combination therapy in AML patients to reduce the impact of minimal residual disease on relapse. Alongside this, IFNs can potentially sensitize leukaemic cells to TKIs in resistant CML patients. There is evidence also that IFNs have a therapeutic role in myeloproliferative neoplasms (MPNs) such as polycythaemia vera (PV) and primary myelofibrosis (PMF), where they can restore polyclonality in patients. Novel formulations have improved the clinical effectiveness of IFNs. Low dose pegylated IFN formulations improve pharmacokinetics and improve patient tolerance to therapies, thereby minimizing the risk of haematological toxicities. Herein, we will discuss recent developments and the current understanding of the molecular and clinical implications of Type I IFNs for the treatment of myeloid malignancies.
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Affiliation(s)
- Fiona M Healy
- Department of Pharmacology & Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Lekh N Dahal
- Department of Pharmacology & Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Jack R E Jones
- Department of Pharmacology & Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Yngvar Floisand
- Department of Molecular & Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom.,The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - John F Woolley
- Department of Pharmacology & Therapeutics, University of Liverpool, Liverpool, United Kingdom
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Venetoclax in Acute Myeloid Leukemia: Molecular Basis, Evidences for Preclinical and Clinical Efficacy and Strategies to Target Resistance. Cancers (Basel) 2021; 13:cancers13225608. [PMID: 34830763 PMCID: PMC8615921 DOI: 10.3390/cancers13225608] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 10/23/2021] [Accepted: 11/03/2021] [Indexed: 12/27/2022] Open
Abstract
Venetoclax is a BH3-mimetics agent specifically interacting with the antiapoptotic protein BCL-2, facilitating cytochrome c release from mitochondria, subsequent caspases activation, and cell death. Utilization of venetoclax has profoundly changed the landscape of treatment for the poor-prognosis category of AML patients unfit for intensive chemotherapy. In the phase III VIALE-A study, Venetoclax, in combination with the hypomethylating agent azacitidine, showed a 65% overall response rate and 14.7-month overall survival, in comparison with 22% and 8 months in the control arm. These results led to the widespread use of venetoclax in this indication. Other combination regimens, consisting of low-intensity, intensive, or targeted therapies are currently under evaluation. Despite promising results, preventing relapses or resistance to venetoclax is still an unmet clinical need. Numerous studies have been conducted to identify and overcome venetoclax resistance in preclinical models or in clinical trials, including the inhibition of other antiapoptotic proteins, the induction of proapoptotic BH3-only proteins, and/or the targeting of the mitochondrial metabolism and machinery.
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45
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Mechanisms of Hydroxyurea-Induced Cellular Senescence: An Oxidative Stress Connection? OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2021; 2021:7753857. [PMID: 34707779 PMCID: PMC8545575 DOI: 10.1155/2021/7753857] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/09/2021] [Accepted: 09/25/2021] [Indexed: 01/10/2023]
Abstract
Hydroxyurea (HU) is a water-soluble antiproliferative agent used for decades in neoplastic and nonneoplastic conditions. HU is considered an essential medicine because of its cytoreduction functions. HU is an antimetabolite that inhibits ribonucleotide reductase, which causes a depletion of the deoxyribonucleotide pool and dramatically reduces cell proliferation. The proliferation arrest, depending on drug concentration and exposure, may promote a cellular senescence phenotype associated with cancer cell therapy resistance and inflammation, influencing neighboring cell functions, immunosuppression, and potential cancer relapse. HU can induce cellular senescence in both healthy and transformed cells in vitro, in part, because of increased reactive oxygen species (ROS). Here, we analyze the main molecular mechanisms involved in cytotoxic/genotoxic HU function, the potential to increase intracellular ROS levels, and the principal features of cellular senescence induction. Understanding the mechanisms involved in HU's ability to induce cellular senescence may help to improve current chemotherapy strategies and control undesirable treatment effects in cancer patients and other diseases.
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46
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Harnessing the benefits of available targeted therapies in acute myeloid leukaemia. LANCET HAEMATOLOGY 2021; 8:e922-e933. [PMID: 34687602 DOI: 10.1016/s2352-3026(21)00270-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/09/2021] [Accepted: 08/19/2021] [Indexed: 12/16/2022]
Abstract
Research has resulted in regulatory approval of nine agents for acute myeloid leukaemia indications by the US Food and Drug Administration since 2017: the Bcl-2 inhibitor, venetoclax; two FLT3 inhibitors, midostaurin and gilteritinib; two IDH inhibitors, ivosidenib (IDH1 inhibitor) and enasidenib (IDH2 inhibitor); the anti-CD33 antibody-drug conjugate, gemtuzumab ozogamicin; the oral, poorly absorbable hypomethylating agent, azacitidine; the liposomal formulation of cytarabine and daunorubicin (5:1 ratio), CPX-351; and the hedgehog signalling pathway inhibitor, glasdegib. A 100% absorbable oral formulation of the hypomethylating agent decitabine was approved for the treatment of myelodysplastic syndrome and chronic myelomonocytic leukaemia, and might be used as an alternative to parenteral hypomethylating agents. Several of the approvals are as single-agent therapies or in specific combinations for narrow indications, thus offering poor treatment value. In this Review, we discuss ongoing research into combinations containing these commercially available targeted therapies for acute myeloid leukaemia.
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47
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6-month follow-up of VIALE-C demonstrates improved and durable efficacy in patients with untreated AML ineligible for intensive chemotherapy (141/150). Blood Cancer J 2021; 11:163. [PMID: 34599139 PMCID: PMC8486817 DOI: 10.1038/s41408-021-00555-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/10/2021] [Accepted: 07/14/2021] [Indexed: 11/08/2022] Open
Abstract
VIALE-C compared the safety and efficacy of venetoclax or placebo plus low-dose cytarabine (+LDAC) in patients with untreated AML ineligible for intensive chemotherapy. Overall, 211 patients were enrolled (n = 143, venetoclax; n = 68, placebo). At the primary analysis, the study did not meet its primary endpoint of a statistically significant improvement in overall survival (OS), however, ~60% of patients had been on study for ≤6-months. Here, we present an additional 6-months of follow-up of VIALE-C (median follow-up 17.5 months; range 0.1-23.5). Median OS was (venetoclax +LDAC vs. placebo +LDAC) 8.4 vs. 4.1 months (HR = 0.70, 95% CI 0.50,0.99; P = 0.040); a 30% reduction in the risk of death with venetoclax. Complete response (CR)/CR with incomplete hematologic recovery (CRi) rates were 48.3% vs. 13.2%. Transfusion independence rates (RBC) were 43% vs.19% and median event-free survival was 4.9 vs. 2.1 months (HR = 0.61; 95% CI 0.44,0.84; P = 0.002). These results represent improved efficacy over the primary analysis. Incidence of grade ≥3 adverse events were similar between study arms and overall safety profiles were comparable to the primary analysis. These data support venetoclax +LDAC as a frontline treatment option for patients with AML ineligible for intensive chemotherapy.This trial was registered at www.clinicaltrials.gov as #NCT03069352.
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48
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Wei AH, Roboz GJ, Kantarjian HM. Harnessing the Therapeutic Value of Venetoclax: A Breakthrough Therapy in Acute Myeloid Leukemia. J Clin Oncol 2021; 39:2742-2748. [PMID: 34086506 PMCID: PMC9851684 DOI: 10.1200/jco.21.00080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Andrew H. Wei
- Department of Clinical Haematology, Alfred Hospital and Monash University, Melbourne, Victoria, Australia,Andrew H. Wei, MBBS, PhD, The Alfred Hospital, Commercial Rd, Melbourne 3004, Victoria, Australia; e-mail:
| | - Gail J. Roboz
- Weill Cornell Medicine and New York Presbyterian Hospital, New York, NY
| | - Hagop M. Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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Adjunctive Volasertib in Patients With Acute Myeloid Leukemia not Eligible for Standard Induction Therapy: A Randomized, Phase 3 Trial. Hemasphere 2021; 5:e617. [PMID: 34350385 PMCID: PMC8328241 DOI: 10.1097/hs9.0000000000000617] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 06/09/2021] [Indexed: 12/13/2022] Open
Abstract
In this phase 3 trial, older patients with acute myeloid leukemia ineligible for intensive chemotherapy were randomized 2:1 to receive the polo-like kinase inhibitor, volasertib (V; 350 mg intravenous on days 1 and 15 in 4-wk cycles), combined with low-dose cytarabine (LDAC; 20 mg subcutaneous, twice daily, days 1–10; n = 444), or LDAC plus placebo (P; n = 222). Primary endpoint was objective response rate (ORR); key secondary endpoint was overall survival (OS). Primary ORR analysis at recruitment completion included patients randomized ≥5 months beforehand; ORR was 25.2% for V+LDAC and 16.8% for P+LDAC (n = 371; odds ratio 1.66 [95% confidence interval (CI), 0.95–2.89]; P = 0.071). At final analysis (≥574 OS events), median OS was 5.6 months for V+LDAC and 6.5 months for P+LDAC (n = 666; hazard ratio 0.97 [95% CI, 0.8–1.2]; P = 0.757). The most common adverse events (AEs) were infections/infestations (grouped term; V+LDAC, 81.3%; P+LDAC, 63.5%) and febrile neutropenia (V+LDAC, 60.4%; P+LDAC, 29.3%). Fatal AEs occurred in 31.2% with V+LDAC versus 18.0% with P+LDAC, most commonly infections/infestations (V+LDAC, 17.1%; P+LDAC, 6.3%). Lack of OS benefit with V+LDAC versus P+LDAC may reflect increased early mortality with V+LDAC from myelosuppression and infections.
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3+7 Combined Chemotherapy for Acute Myeloid Leukemia: Is It Time to Say Goodbye? Curr Oncol Rep 2021; 23:120. [PMID: 34350512 DOI: 10.1007/s11912-021-01108-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW With the recent approval of multiple new drugs for the treatment of acute myeloid leukemia (AML), the relevance of conventional treatment approaches, such as daunorubicin and cytarabine ("3+7") induction chemotherapy, has been challenged. We review the AML risk stratification, the efficacy of the newly approved drugs, and the role of "3+7". RECENT FINDINGS Treatment of AML is becoming more niched with specific subtypes more appropriately treated with gemtuzumab, midostaurin, and CPX-351. Although lower intensity therapies can yield high response rates, they are less efficient at preventing relapses. The only curative potential for poor-risk AML is still an allogeneic stem cell transplant. The number of AML subtypes where 3+7 alone is an appropriate therapeutic option is shrinking. However, it remains the backbone for combination therapy with newer agents in patients suitable for intensive chemotherapy.
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