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Rausch J, Ullrich E, Kühn MW. Epigenetic targeting to enhance acute myeloid leukemia-directed immunotherapy. Front Immunol 2023; 14:1269012. [PMID: 37809078 PMCID: PMC10556528 DOI: 10.3389/fimmu.2023.1269012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/05/2023] [Indexed: 10/10/2023] Open
Abstract
AML is a malignant disease of hematopoietic progenitor cells with unsatisfactory treatment outcome, especially in patients that are ineligible for intensive chemotherapy. Immunotherapy, comprising checkpoint inhibition, T-cell engaging antibody constructs, and cellular therapies, has dramatically improved the outcome of patients with solid tumors and lymphatic neoplasms. In AML, these approaches have been far less successful. Discussed reasons are the relatively low mutational burden of AML blasts and the difficulty in defining AML-specific antigens not expressed on hematopoietic progenitor cells. On the other hand, epigenetic dysregulation is an essential driver of leukemogenesis, and non-selective hypomethylating agents (HMAs) are the current backbone of non-intensive treatment. The first clinical trials that evaluated whether HMAs may improve immune checkpoint inhibitors' efficacy showed modest efficacy except for the anti-CD47 antibody that was substantially more efficient against AML when combined with azacitidine. Combining bispecific antibodies or cellular treatments with HMAs is subject to ongoing clinical investigation, and efficacy data are awaited shortly. More selective second-generation inhibitors targeting specific chromatin regulators have demonstrated promising preclinical activity against AML and are currently evaluated in clinical trials. These drugs that commonly cause leukemia cell differentiation potentially sensitize AML to immune-based treatments by co-regulating immune checkpoints, providing a pro-inflammatory environment, and inducing (neo)-antigen expression. Combining selective targeted epigenetic drugs with (cellular) immunotherapy is, therefore, a promising approach to avoid unintended effects and augment efficacy. Future studies will provide detailed information on how these compounds influence specific immune functions that may enable translation into clinical assessment.
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Affiliation(s)
- Johanna Rausch
- Department of Hematology and Medical Oncology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
- German Cancer Consortium (DKTK) Partner Site Frankfurt/Mainz and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Evelyn Ullrich
- German Cancer Consortium (DKTK) Partner Site Frankfurt/Mainz and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Children’s Hospital, Experimental Immunology, Johann Wolfgang Goethe University, Frankfurt, Germany
- Frankfurt Cancer Institute, Goethe University, Frankfurt, Germany
- University Cancer Center (UCT), Frankfurt, Germany
| | - Michael W.M. Kühn
- Department of Hematology and Medical Oncology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
- German Cancer Consortium (DKTK) Partner Site Frankfurt/Mainz and German Cancer Research Center (DKFZ), Heidelberg, Germany
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2
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Renneville A, Patnaik MM, Chan O, Padron E, Solary E. Increasing recognition and emerging therapies argue for dedicated clinical trials in chronic myelomonocytic leukemia. Leukemia 2021; 35:2739-2751. [PMID: 34175902 DOI: 10.1038/s41375-021-01330-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 02/06/2023]
Abstract
Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping features of myelodysplastic syndromes (MDS) and myeloproliferative neoplasms (MPN). Median overall survival of this aggressive myeloid malignancy is only 2-3 years, with a 15-30% risk of acute leukemic transformation. The paucity of clinical trials specifically designed for CMML has made therapeutic management of CMML patients challenging. As a result, treatment paradigms for CMML patients are largely borrowed from MDS and MPN. The standard of care still relies on hydroxyurea, hypomethylating agents (HMA), and allogeneic stem cell transplantation, this latter option remaining the only potentially curative therapy. To date, approved drugs for CMML treatment are HMA, including azacitidine, decitabine, and more recently the oral combination of decitabine and cedazuridine. However, HMA treatment does not meaningfully alter the natural course of this disease. New treatment approaches for improving CMML-associated cytopenias or targeting the CMML malignant clone are emerging. More than 25 therapeutic agents are currently being evaluated in phase 1 or phase 2 clinical trials for CMML and other myeloid malignancies, often in combination with a HMA backbone. Several novel agents, such as sotatercept, ruxolitinib, lenzilumab, and tagraxofusp have shown promising clinical efficacy in CMML. Current evidence supports the idea that effective treatment in CMML will likely require combination therapy targeting multiple pathways, which emphasizes the need for additional new therapeutic options. This review focuses on recent therapeutic advances and innovative treatment strategies in CMML, including global and molecularly targeted approaches. We also discuss what may help to make progress in the design of rationally derived and disease-modifying therapies for CMML.
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Affiliation(s)
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Onyee Chan
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA
| | - Eric Padron
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA
| | - Eric Solary
- INSERM U1287, Gustave Roussy Cancer Campus, Villejuif, France. .,Faculty of Medicine, Université Paris-Sud, Le Kremlin-Bicêtre, France. .,Department of Hematology, Gustave Roussy Cancer Campus, Villejuif, France.
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3
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Thomopoulos TP, Bouhla A, Papageorgiou SG, Pappa V. Chronic myelomonocytic leukemia - a review. Expert Rev Hematol 2020; 14:59-77. [PMID: 33275852 DOI: 10.1080/17474086.2021.1860004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Chronic myelomonocytic leukemia (CMML) is a clonal myeloid neoplasm, denoted by overlapping myelodysplastic and myeloproliferative features, with poor overall survival and high transformation rate to acute myeloid leukemia. AREAS COVERED This review, following a thorough Medline search of pertinent published literature, discusses the diagnostic criteria, the pathogenesis, and the complex genetic landscape of the disease. Prognostication, response criteria, therapeutic management of patients, efficacy of established and novel treatment modalities are thoroughly reviewed. EXPERT OPINION Cytogenetic abnormalities and mutations in genes involved in epigenetic and transcriptional regulation, and cell-signaling are abundant in CMML and implicated in its complex pathogenesis. As presence of these mutations carry a prognostic impact, they are increasingly incorporated in risk-stratification schemes. Novel response criteria have been proposed, considering the unique features of the disease. Although allogeneic hematopoietic stem cell transplantation remains the only treatment with curative intent, it is reserved for a minority of patients; therefore, there is an unmet need for optimizing treatment modalities, such as hypomethylating agents, and introducing novel agents, which could substantially improve survival and quality of life of CMML patients. Clinical trials dedicated specifically to CMML are needed to explore the efficacy and safety of novel treatment modalities.
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Affiliation(s)
- Thomas P Thomopoulos
- 2 Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon" , Athens, Greece
| | - Anthi Bouhla
- 2 Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon" , Athens, Greece
| | - Sotirios G Papageorgiou
- 2 Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon" , Athens, Greece
| | - Vasiliki Pappa
- 2 Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon" , Athens, Greece
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4
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Meng F, Chen X, Yu S, Ren X, Liu Z, Fu R, Li L. Safety and Efficacy of Eltrombopag and Romiplostim in Myelodysplastic Syndromes: A Systematic Review and Meta-Analysis. Front Oncol 2020; 10:582686. [PMID: 33324559 PMCID: PMC7727449 DOI: 10.3389/fonc.2020.582686] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022] Open
Abstract
Background and Aim Many studies indicated that eltrombopag and romiplostim could improve hematopoietic function in patients with myelodysplastic syndromes (MDS), but their toxicity and efficacy were not known. This meta-analysis aimed to investigate the safety and efficacy of eltrombopag and romiplostim in MDS. Methods A full-scale search strategy was used to search relevant published studies in PubMed, Embase, Web of Science, ClinicalTrials.gov and the Cochrane Library until January 2020 using a random-effects model and the pooled risk ratio (RR) with 95% confidence interval as the effect indicator. Statistical analyses were performed using RevMan 5.3. Results This meta-analysis included eight studies comprising 1047 patients. A lower RR of overall response rate (ORR) (RR: 0.65; 95% CI, 0.47–0.9) and grade ≥3 bleeding events (RR: 0.36; 95% CI, 0.36–0.92) were observed after romiplostim and eltrombopag treatment compared with placebo. The pooled RR for the ORR and grade ≥3 bleeding events were 0.58 (95% CI: 0.41–0.83, P = 0.003) and 0.6 (95% CI: 0.37–0.96, P = 0.03) in eltrombopag, respectively. A lower ORR in intermediate- or high-risk MDS (RR: 0.63; 95% CI: 0.45–0.88, P = 0.006) was observed. No difference in mortality, serious adverse events, platelet transfusion, hematologic improvement, and AML transformation was observed. Conclusions Thrombopoietin receptor agonists (TPO-RAs) romiplostim and eltrombopag were effective in reducing bleeding events, especially grade ≥3 bleeding events. However, it might reduce the ORR of MDS, especially in eltrombopag treatment group or high-risk MDS group. Due to the limited treatment of MDS and the poor response to the drug, this may be a selection method for MDS combined with fatal bleeding, although further research is needed to confirm the effectiveness of this approach.
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Affiliation(s)
- Fanqiao Meng
- Hematology Department of Tianjin, Medical University General Hospital, Tianjin, China
| | - Xiuqiong Chen
- Cancer Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shunjie Yu
- Hematology Department of Tianjin, Medical University General Hospital, Tianjin, China
| | - Xiaotong Ren
- Hematology Department of Tianjin, Medical University General Hospital, Tianjin, China
| | - Zhaoyun Liu
- Hematology Department of Tianjin, Medical University General Hospital, Tianjin, China
| | - Rong Fu
- Hematology Department of Tianjin, Medical University General Hospital, Tianjin, China
| | - Lijuan Li
- Hematology Department of Tianjin, Medical University General Hospital, Tianjin, China
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Meng F, Li L, Lu F, Yue J, Liu Z, Zhang W, Fu R. Overexpression of TIGIT in NK and T Cells Contributes to Tumor Immune Escape in Myelodysplastic Syndromes. Front Oncol 2020; 10:1595. [PMID: 32903786 PMCID: PMC7438899 DOI: 10.3389/fonc.2020.01595] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/23/2020] [Indexed: 01/26/2023] Open
Abstract
Objective Targeting immune checkpoints, such as PD-1, represents a promising approach for cancer immunotherapy, achieving long-term disease remission rates in numerous types of cancer. T cell immunoglobulin and ITIM domain (TIGIT) is a checkpoint receptor associated with the antitumor roles of NK and T cells. Notably, the blockade of TIGIT has been revealed as a potential promising approach in cancer immunotherapy. However, the therapeutic potential of blocking TIGIT in myelodysplastic syndrome (MDS) remains unclear and further research is required to reveal their role. Methods Fresh peripheral blood (PB) and bone marrow (BM) were obtained from patients with MDS and healthy donors (HDs) at the Tianjin Medical University General Hospital between January 21 2018 and March 22 2019. The present study investigated the expression levels of TIGIT on NK and T cells using flow cytometry (FCM) and PCR. In addition, other checkpoint receptors, such as CD226 and PD-1, were also investigated. To determine the mechanisms of antitumor immunity, the functions of NK and T cells expressing TIGIT were determined. Results TIGIT was found to be highly expressed on NK and T cells of the PB, where it was involved in disease progression and the immune escape of MDS. The high expression levels of TIGIT were associated with decreased NK and T cell function, and significantly lower secretions of activation factors, such as CD107a, IFN-γ and TNF-α. Notably, blocking TIGIT enhanced the antitumor effects of NK and T cells. Conclusion The results of the present study suggested that targeting TIGIT alone or in combination with PD-1 may be a promising anticancer therapeutic strategy in MDS.
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Affiliation(s)
- Fanqiao Meng
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Lijuan Li
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Fengzhu Lu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Jing Yue
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhaoyun Liu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Wei Zhang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Rong Fu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
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Chandhok NS, Lewis R, Prebet T. Hypomethylating agent based combinations in higher risk myelodysplastic syndrome. Leuk Lymphoma 2020; 61:1012-1027. [PMID: 31814484 DOI: 10.1080/10428194.2019.1697812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
For over a decade the hypomethylating agents (HMA) azacitidine and decitabine have been the mainstay of therapy for myelodysplastic syndrome (MDS). There is a critical need to improve frontline therapy, given that only up to half of high-risk MDS patients will respond to HMA therapy, and responses are short-lived. Currently, a key strategy has been to combine HMAs with other novel agents to improve patient outcomes. While synergy of agents is the goal of combination therapy, combinations often come at the cost of increased side effects that are often intolerable in this vulnerable population. The purpose of this review is to critically examine clinically relevant HMA combinations and discuss the future of MDS management.
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Affiliation(s)
- Namrata S Chandhok
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Russell Lewis
- Smilow Cancer Center at Yale New Haven Hospital, New Haven, CT, USA
| | - Thomas Prebet
- Smilow Cancer Center at Yale New Haven Hospital, New Haven, CT, USA
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Montesinos P, Bergua J, Infante J, Esteve J, Guimaraes JE, Sierra J, Sanz MÁ. Update on management and progress of novel therapeutics for R/R AML: an Iberian expert panel consensus. Ann Hematol 2019; 98:2467-2483. [PMID: 31667544 DOI: 10.1007/s00277-019-03820-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 10/08/2019] [Indexed: 12/19/2022]
Abstract
A significant proportion of adult patients with acute myeloid leukemia (AML) fail to achieve complete remission or will relapse later on after achieving it. Prognosis for relapsed or refractory (R/R) AML patients remains discouraging, with the main curative option still relying on hematopoietic stem cell transplant (HSCT) for those who are eligible. Beyond morphological bone marrow and peripheral blood assessment, evaluation of patient performance status and comorbidities, as well as genetic/molecular characterization, is crucial to make an accurate diagnosis and prognosis, which will be useful to select the most appropriate treatment. Emerging strategies are mainly focusing on the development of immune- and molecular-based approaches. Novel targeted therapies are generally well tolerated, potentially allowing them to be administered alone or in combination with classical chemotherapy agents. Enrolment in clinical trials should be considered first option for R/R AML patients, either as a bridge to HSCT or to benefit from novel therapies that eventually may prolong survival and improve quality of life. An Iberian expert panel has reviewed the recent advances in the management of R/R AML with the aim to develop updated evidence and expert opinion-based recommendations.
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Affiliation(s)
- Pau Montesinos
- Hematology Department, Hospital Universitari I Politècnic La Fe, Av. Fernando Abril Martorell, 106, 46026, Valencia, Spain. .,CIBERONC, Instituto de Salud Carlos III, Madrid, Spain.
| | - Juan Bergua
- Division of Hematology/Oncology, Hospital San Pedro Alcántara, Cáceres, Spain
| | - Joana Infante
- Serviço de Hematologia e Transplantação de Medula Óssea, Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, Lisbon, Portugal
| | - Jordi Esteve
- Department of Hematology, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - José Eduardo Guimaraes
- Serviço de Hematologia Clínica, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Jordi Sierra
- Hematology Department, Hospital de la Santa Creu i Sant Pau, IIB Sant Pau and Jose Carreras Leukemia Research Institutes, Autonomous University of Barcelona, Barcelona, Spain
| | - Miguel Ángel Sanz
- Hematology Department, Hospital Universitari I Politècnic La Fe, Av. Fernando Abril Martorell, 106, 46026, Valencia, Spain
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8
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Bewersdorf JP, Stahl M, Zeidan AM. One plus one does not always equal two, especially with regard to hypomethylating agents: the question of synergy of azacitidine and lenalidomide for treatment of relapsed acute myeloid leukemia and myelodysplastic syndromes post allogeneic hematopoietic stem cell transplant. Expert Rev Hematol 2019; 12:575-578. [PMID: 31225770 DOI: 10.1080/17474086.2019.1635005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Key paper evaluation: Craddock C, et al. Combination Lenalidomide and Azacitidine: A Novel Salvage Therapy in Patients Who Relapse After Allogeneic Stem-Cell Transplantation for Acute Myeloid Leukemia. J Clin Oncol. 2019; 37: 580-8. Allogeneic hematopoietic stem cell transplant (allo-HSCT) is the only potentially curative treatment for acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS). However, most patients relapse after allo-HSCT and treatment options are limited. Craddock et al. reported recently in the Journal of Clinical Oncology results from a small phase Ib study combining azacitidine (AZA) and lenalidomide (LEN) for treatment of 29 patients (24 AML and 5 MDS patients) who relapsed after allo-HSCT. Overall response rate was 24%. Patients who received ≥3 cycles of treatment had a higher response rate and responders had a better survival compared to non-responders (27 months vs. 10 months; p = 0.004). Combination treatment was well tolerated with three cases of graft-versus-host disease. While this study suggests a potential synergistic effect of LEN + AZA combination therapy, many questions remain. Efficacy and safety should be confirmed in larger, ideally randomized, studies. Further research on mechanism of action of this combination, comparison with other treatment combinations (e.g. AZA + venetoclax) and use during other disease stages are needed.
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Affiliation(s)
- Jan Philipp Bewersdorf
- a Department of Internal Medicine, Section of Hematology, Yale School of Medicine , New Haven , CT , USA
| | - Maximilian Stahl
- b Leukemia Service, Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Amer M Zeidan
- a Department of Internal Medicine, Section of Hematology, Yale School of Medicine , New Haven , CT , USA.,c Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University , New Haven , CT , USA
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9
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Zeidan AM, Shallis RM, Wang R, Davidoff A, Ma X. Epidemiology of myelodysplastic syndromes: Why characterizing the beast is a prerequisite to taming it. Blood Rev 2019; 34:1-15. [DOI: 10.1016/j.blre.2018.09.001] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 09/01/2018] [Accepted: 09/17/2018] [Indexed: 02/08/2023]
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10
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Ungerstedt JS. Epigenetic Modifiers in Myeloid Malignancies: The Role of Histone Deacetylase Inhibitors. Int J Mol Sci 2018; 19:ijms19103091. [PMID: 30304859 PMCID: PMC6212943 DOI: 10.3390/ijms19103091] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 10/01/2018] [Accepted: 10/05/2018] [Indexed: 01/18/2023] Open
Abstract
Myeloid hematological malignancies are clonal bone marrow neoplasms, comprising of acute myeloid leukemia (AML), the myelodysplastic syndromes (MDS), chronic myelomonocytic leukemia (CMML), the myeloproliferative neoplasms (MPN) and systemic mastocytosis (SM). The field of epigenetic regulation of normal and malignant hematopoiesis is rapidly growing. In recent years, heterozygous somatic mutations in genes encoding epigenetic regulators have been found in all subtypes of myeloid malignancies, supporting the rationale for treatment with epigenetic modifiers. Histone deacetylase inhibitors (HDACi) are epigenetic modifiers that, in vitro, have been shown to induce growth arrest, apoptotic or autophagic cell death, and terminal differentiation of myeloid tumor cells. These effects were observed both at the bulk tumor level and in the most immature CD34+38− cell compartments containing the leukemic stem cells. Thus, there is a strong rationale supporting HDACi therapy in myeloid malignancies. However, despite initial promising results in phase I trials, HDACi in monotherapy as well as in combination with other drugs, have failed to improve responses or survival. This review provides an overview of the rationale for HDACi in myeloid malignancies, clinical results and speculations on why clinical trials have thus far not met the expectations, and how this may be improved in the future.
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Affiliation(s)
- Johanna S Ungerstedt
- Department of Medicine, Huddinge, Karolinska Institutet, and Hematology Center, and Karolinska University Hospital, S-141 86 Stockholm, Sweden.
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Kubasch AS, Platzbecker U. Beyond the Edge of Hypomethylating Agents: Novel Combination Strategies for Older Adults with Advanced MDS and AML. Cancers (Basel) 2018; 10:E158. [PMID: 29795051 PMCID: PMC6025349 DOI: 10.3390/cancers10060158] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 05/19/2018] [Accepted: 05/21/2018] [Indexed: 12/14/2022] Open
Abstract
Higher-risk myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) of the elderly exhibit several commonalities, including first line treatment with hypomethylating agents (HMA) like azacitidine (AZA) or decitabine (DAC). Until today, response to treatment occurs in less than 50 percent of patients, and is often short-lived. Moreover, patients failing HMA have a dismal prognosis. Current developments include combinations of HMA with novel drugs targeting epigenetic or immunomodulatory pathways. Other efforts focus on the prevention of resistance to HMA using checkpoint inhibitors to enhance immune attack. This review focuses on recent advances in the field of HMA-based front-line therapies in elderly patients with myeloid diseases.
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Affiliation(s)
- Anne Sophie Kubasch
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany.
| | - Uwe Platzbecker
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany.
- National Center for Tumor Diseases (NCT), University Hospital Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany.
- German Cancer Consortium (DKTK), 01307 Dresden, Germany.
- German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany.
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12
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Abstract
Acute myeloid leukemia (AML) is one of the best studied malignancies, and significant progress has been made in understanding the clinical implications of its disease biology. Unfortunately, drug development has not kept pace, as the '7+3' induction regimen remains the standard of care for patients fit for intensive therapy 40 years after its first use. Temporal improvements in overall survival were mostly confined to younger patients and driven by improvements in supportive care and use of hematopoietic stem cell transplantation. Multiple forms of novel therapy are currently in clinical trials and are attempting to bring bench discoveries to the bedside to benefit patients. These novel therapies include improved chemotherapeutic agents, targeted molecular inhibitors, cell cycle regulators, pro-apoptotic agents, epigenetic modifiers, and metabolic therapies. Immunotherapies in the form of vaccines; naked, conjugated and bispecific monoclonal antibodies; cell-based therapy; and immune checkpoint inhibitors are also being evaluated in an effort to replicate the success seen in other malignancies. Herein, we review the scientific basis of these novel therapeutic approaches, summarize the currently available evidence, and look into the future of AML therapy by highlighting key clinical studies and the challenges the field continues to face.
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13
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Zeidan AM, Stahl M, Sekeres MA, Steensma DP, Komrokji RS, Gore SD. A call for action: Increasing enrollment of untreated patients with higher-risk myelodysplastic syndromes in first-line clinical trials. Cancer 2017; 123:3662-3672. [DOI: 10.1002/cncr.30903] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 05/22/2017] [Accepted: 06/12/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Amer M. Zeidan
- Department of Hematology, Department of Internal Medicine, Yale Comprehensive Cancer Center; Yale University School of Medicine; New Haven Connecticut
| | - Maximilian Stahl
- Department of Hematology, Department of Internal Medicine, Yale Comprehensive Cancer Center; Yale University School of Medicine; New Haven Connecticut
| | | | - David P. Steensma
- Dana-Farber Cancer Institute; Harvard Medical School; Boston Massachusetts
| | - Rami S. Komrokji
- H. Lee Moffitt Cancer Center and Research Institute; Tampa Florida
| | - Steven D. Gore
- Department of Hematology, Department of Internal Medicine, Yale Comprehensive Cancer Center; Yale University School of Medicine; New Haven Connecticut
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14
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Gbolahan OB, Zeidan AM, Stahl M, Abu Zaid M, Farag S, Paczesny S, Konig H. Immunotherapeutic Concepts to Target Acute Myeloid Leukemia: Focusing on the Role of Monoclonal Antibodies, Hypomethylating Agents and the Leukemic Microenvironment. Int J Mol Sci 2017; 18:E1660. [PMID: 28758974 PMCID: PMC5578050 DOI: 10.3390/ijms18081660] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 07/22/2017] [Accepted: 07/24/2017] [Indexed: 12/20/2022] Open
Abstract
Intensive chemotherapeutic protocols and allogeneic stem cell transplantation continue to represent the mainstay of acute myeloid leukemia (AML) treatment. Although this approach leads to remissions in the majority of patients, long-term disease control remains unsatisfactory as mirrored by overall survival rates of approximately 30%. The reason for this poor outcome is, in part, due to various toxicities associated with traditional AML therapy and the limited ability of most patients to tolerate such treatment. More effective and less toxic therapies therefore represent an unmet need in the management of AML, a disease for which therapeutic progress has been traditionally slow when compared to other cancers. Several studies have shown that leukemic blasts elicit immune responses that could be exploited for the development of novel treatment concepts. To this end, early phase studies of immune-based therapies in AML have delivered encouraging results and demonstrated safety and feasibility. In this review, we discuss opportunities for immunotherapeutic interventions to enhance the potential to achieve a cure in AML, thereby focusing on the role of monoclonal antibodies, hypomethylating agents and the leukemic microenvironment.
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Affiliation(s)
- Olumide Babajide Gbolahan
- Department of Medicine, Division of Hematology/Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Amer M Zeidan
- Department of Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT 06510, USA.
| | - Maximilian Stahl
- Department of Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT 06510, USA.
| | - Mohammad Abu Zaid
- Department of Medicine, Bone Marrow and Stem Cell Transplantation, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Sherif Farag
- Department of Medicine, Bone Marrow and Stem Cell Transplantation, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Sophie Paczesny
- Wells Center for Pediatric Research, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Heiko Konig
- Department of Medicine, Division of Hematology/Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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Stahl M, Zeidan AM. Management of lower-risk myelodysplastic syndromes without del5q: current approach and future trends. Expert Rev Hematol 2017; 10:345-364. [PMID: 28277851 DOI: 10.1080/17474086.2017.1297704] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Myelodysplastic syndromes (MDS) are characterized by progressive bone marrow failure manifesting as blood cytopenia and a variable risk of progression into acute myeloid leukemia. MDS is heterogeneous in biology and clinical behavior. MDS are generally divided into lower-risk (LR) and higher-risk (HR) MDS. Goals of care in HR-MDS focus on changing the natural history of the disease, whereas in LR-MDS symptom control and quality of life are the main goals. Areas covered: We review the epidemiology, tools of risk assessment, and the available therapeutic modalities for LR-MDS. We discuss the use of erythropoiesis stimulating agents (ESAs), immunosuppressive therapy (IST), lenalidomide and the hypomethylating agents (HMAs). We also discuss the predictors of response, combination treatment modalities, and management of iron overload. Lastly, we overview the most promising investigational agents for LR-MDS. Expert commentary: It remains unclear how to best incorporate a wealth of new genetic and epigenetic prognostic markers into risk assessment tools especially for LR-MDS patients. Only a subset of patients respond to current treatment modalities and most responders eventually lose their response. Once standard therapeutic options fail, management becomes more challenging. Combination-based approaches have been largely unsuccessful. Among the most promising investigational are the TPO agonists, TGF- β pathway inhibitors, telomerase inhibitors, and the splicing modifiers.
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Affiliation(s)
- Maximilian Stahl
- a Section of Hematology, Department of Internal Medicine, Section of Hematology, Yale University and the Yale Comprehensive Cancer Center , Yale University School of Medicine , New Haven , CT , USA
| | - Amer M Zeidan
- a Section of Hematology, Department of Internal Medicine, Section of Hematology, Yale University and the Yale Comprehensive Cancer Center , Yale University School of Medicine , New Haven , CT , USA
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