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Moukalled N, Dalle IA, Cheikh JE, Ye Y, Malarad F, Mohty M, Bazarbachi A. The emerging role of melflufen and peptide-conjugates in multiple myeloma. Curr Opin Oncol 2024:00001622-990000000-00203. [PMID: 39246181 DOI: 10.1097/cco.0000000000001090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
PURPOSE OF REVIEW The past two decades have witnessed an impressive expansion in the treatment landscape of multiple myeloma, leading to significant improvements in progression-free; as well as overall survival. However, almost all patients still experience multiple relapses during their disease course, with biological and cytogenetic heterogeneity affecting response to subsequent treatments. The purpose of this review is to provide a historical background regarding the role of alkylating agents and an updated data regarding the use of peptide-drug conjugates such as melflufen for patients with multiple myeloma. RECENT FINDINGS The combination of daratumumab-melflufen-dexamethasone evaluated in the LIGHTHOUSE study showed a statistically significant improvement in progression-free survival compared to single-agent daratumumab (not reached vs. 4.9 months respectively; P = 0.0032), with improvement in overall response rate to 59% vs. 30% respectively; P = 0.03. SUMMARY There have been an interest in developing and utilizing peptide-drug conjugates such as melflufen for treatment of patients with multiple myeloma, especially in the relapsed setting given historical results with alkylating agents, the use of which has been limited by dose-related toxicities in a disease that remains largely incurable. Single agent melflufen initially showed promising results especially in specific subgroups of heavily pretreated patients before the decision to suspend all clinical trials evaluating this agent after results from the OCEAN phase 3 trial. Subsequent reported analyses especially for melflufen-based combinations appear promising and suggest a potential use of peptide-drug conjugates provided optimal patient selection, as well as identification of the best companion agent.
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Affiliation(s)
- Nour Moukalled
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Iman Abou Dalle
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jean El Cheikh
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Yishan Ye
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Florent Malarad
- Sorbonne Université, Centre de Recherche Saint-Antoine INSERM UMRs938, Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, Paris, France
| | - Mohamad Mohty
- Sorbonne Université, Centre de Recherche Saint-Antoine INSERM UMRs938, Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, Paris, France
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Tamatam R, Mohammed A. Small molecule anticancer drugs approved during 2021-2022: Synthesis and clinical applications. Eur J Med Chem 2024; 272:116441. [PMID: 38759455 DOI: 10.1016/j.ejmech.2024.116441] [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: 02/29/2024] [Revised: 04/11/2024] [Accepted: 04/19/2024] [Indexed: 05/19/2024]
Abstract
Drugs have structural homology across similar biological targets. Small molecule drugs have the efficacy to target specific molecular targets within the cancer cells with enhanced cell membrane permeability, oral administration, selectivity, and specific affinity. The objective of this review is to highlight the clinical importance and synthetic routes of new small molecule oncology drugs approved by the FDA during the period 2021-2022. These marketed drugs are listed based on the month and year of approval in chronological order. We believed that an in-depth insight into the synthetic approaches for the construction of these chemical entities would enhance the ability to develop new drugs more efficiently.
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Affiliation(s)
- Rekha Tamatam
- Department of Agriculture Science, Faculty of Agro Based Industry, Universiti Malaysia Kelantan, 17600, Jeli, Kelantan, Malaysia
| | - Arifullah Mohammed
- Department of Agriculture Science, Faculty of Agro Based Industry, Universiti Malaysia Kelantan, 17600, Jeli, Kelantan, Malaysia.
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Costa BA, Mouhieddine TH, Ortiz RJ, Richter J. Revisiting the Role of Alkylating Agents in Multiple Myeloma: Up-to-Date Evidence and Future Perspectives. Crit Rev Oncol Hematol 2023; 187:104040. [PMID: 37244325 DOI: 10.1016/j.critrevonc.2023.104040] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/15/2023] [Accepted: 05/23/2023] [Indexed: 05/29/2023] Open
Abstract
From the 1960s to the early 2000s, alkylating agents (e.g., melphalan, cyclophosphamide, and bendamustine) remained a key component of standard therapy for newly-diagnosed or relapsed/refractory multiple myeloma (MM). Later on, their associated toxicities (including second primary malignancies) and the unprecedented efficacy of novel therapies have led clinicians to increasingly consider alkylator-free approaches. Meanwhile, new alkylating agents (e.g., melflufen) and new applications of old alkylators (e.g., lymphodepletion before chimeric antigen receptor T-cell [CAR-T] therapy) have emerged in recent years. Given the expanding use of antigen-directed modalities (e.g., monoclonal antibodies, bispecific antibodies, and CAR-T therapy), this review explores the current and future role of alkylating agents in different treatment settings (e.g., induction, consolidation, stem cell mobilization, pre-transplant conditioning, salvage, bridging, and lymphodepleting chemotherapy) to ellucidate the role of alkylator-based regimens in modern-day MM management.
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Affiliation(s)
- Bruno Almeida Costa
- Department of Medicine, Mount Sinai Morningside and West, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tarek H Mouhieddine
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ricardo J Ortiz
- Department of Medicine, Mount Sinai Morningside and West, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua Richter
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Tannoury M, Garnier D, Susin SA, Bauvois B. Current Status of Novel Agents for the Treatment of B Cell Malignancies: What's Coming Next? Cancers (Basel) 2022; 14:6026. [PMID: 36551511 PMCID: PMC9775488 DOI: 10.3390/cancers14246026] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/29/2022] [Accepted: 12/03/2022] [Indexed: 12/13/2022] Open
Abstract
Resistance to death is one of the hallmarks of human B cell malignancies and often contributes to the lack of a lasting response to today's commonly used treatments. Drug discovery approaches designed to activate the death machinery have generated a large number of inhibitors of anti-apoptotic proteins from the B-cell lymphoma/leukemia 2 family and the B-cell receptor (BCR) signaling pathway. Orally administered small-molecule inhibitors of Bcl-2 protein and BCR partners (e.g., Bruton's tyrosine kinase and phosphatidylinositol-3 kinase) have already been included (as monotherapies or combination therapies) in the standard of care for selected B cell malignancies. Agonistic monoclonal antibodies and their derivatives (antibody-drug conjugates, antibody-radioisotope conjugates, bispecific T cell engagers, and chimeric antigen receptor-modified T cells) targeting tumor-associated antigens (TAAs, such as CD19, CD20, CD22, and CD38) are indicated for treatment (as monotherapies or combination therapies) of patients with B cell tumors. However, given that some patients are either refractory to current therapies or relapse after treatment, novel therapeutic strategies are needed. Here, we review current strategies for managing B cell malignancies, with a focus on the ongoing clinical development of more effective, selective drugs targeting these molecules, as well as other TAAs and signaling proteins. The observed impact of metabolic reprogramming on B cell pathophysiology highlights the promise of targeting metabolic checkpoints in the treatment of these disorders.
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Affiliation(s)
| | | | | | - Brigitte Bauvois
- Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Inserm, Cell Death and Drug Resistance in Lymphoproliferative Disorders Team, F-75006 Paris, France
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Ocio EM, Nadeem O, Schjesvold F, Gay F, Touzeau C, Dimopoulos MA, Richardson PG, Mateos MV. Melflufen for the treatment of multiple myeloma. Expert Rev Clin Pharmacol 2022; 15:371-382. [PMID: 35723075 DOI: 10.1080/17512433.2022.2075847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Melphalan flufenamide (melflufen) is a first-in-class peptide-drug conjugate that takes advantage of increased aminopeptidase activity inside tumor cells to rapidly release alkylating agents therein. Melflufen in combination with dexamethasone has been evaluated in multiple clinical trials in patients with relapsed/refractory multiple myeloma (MM). AREAS COVERED This profile covers the unique mechanism of action of melflufen, the preclinical results supporting its activity in cellular models of resistance to chemotherapy, its activity in animal models of MM, and the clinical pharmacokinetics of melflufen. Findings from clinical trials evaluating melflufen, including the pivotal phase II HORIZON study and the phase III OCEAN study, are discussed. EXPERT OPINION Although MM treatment has improved, patients with disease refractory to multiple standard-of-care drug classes face a dismal prognosis. Melflufen demonstrated efficacy and tolerability in select populations, with an initial approval in the United States in patients with ≥ four previous lines of therapy and triple-class-refractory MM. Results from the phase III OCEAN study - currently under discussion with regulatory agencies in the United States and Europe - are more complex and have been put into context herein. Lastly, melflufen provides a proof-of-concept for the utility of the peptide-drug conjugate platform in relapsed/refractory MM.
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Affiliation(s)
- Enrique M Ocio
- Department of Hematology, University Hospital Marqués de Valdecilla (IDIVAL), University of CantabriaUniversity Hospital Marqués de Valdecilla (IDIVAL), University of Cantabria, Santander, Spain
| | - Omar Nadeem
- Harvard Medical School, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Fredrik Schjesvold
- Oslo Myeloma Center, Department of Hematology, Oslo University Hospital, Oslo, Norway
| | - Francesca Gay
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Cyrille Touzeau
- Hematology Department, Centre de Recherche en Cancérologie et Immunologie Nantes-Angers (CRCINA), Institut National de la Santé et de la Recherche Médicale (INSERM), Centre National de la Recherche Scientifique (CNRS), Université d'Angers, Université de Nantes, Nantes, France; Site de Recherche Intégrée sur le Cancer (SIRIC), Imaging and Longitudinal Investigations to Ameliorate Decision-making (ILIAD), Nantes, France; Service d'hématologie Clinique, Centre Hospitalier Universitaire, Place Alexis Ricordeau, Nantes, France
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Paul G Richardson
- Harvard Medical School, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Maria-Victoria Mateos
- Department of Haematology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), Salamanca, Spain
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Flanagan K, Kumari R, Miettinen JJ, Haney SL, Varney ML, Williams JT, Majumder MM, Suvela M, Slipicevic A, Lehmann F, Nupponen NN, Holstein SA, Heckman CA. The Peptide-Drug Conjugate Melflufen Modulates the Unfolded Protein Response of Multiple Myeloma and Amyloidogenic Plasma Cells and Induces Cell Death. Hemasphere 2022; 6:e687. [PMID: 35243210 PMCID: PMC8884539 DOI: 10.1097/hs9.0000000000000687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 01/11/2022] [Indexed: 12/25/2022] Open
Abstract
Immunoglobulin light-chain (AL) amyloidosis is a rare disease caused by clonal plasma cell secretion of misfolded light chains that assemble as toxic amyloid fibrils, depositing in vital organs including the heart and kidneys, causing organ dysfunction. Plasma cell-directed therapeutics are expected to reduce production of toxic light chain by eliminating amyloidogenic cells in bone marrow, thereby diminishing amyloid fibril deposition and providing the potential for organ recovery. Melphalan flufenamide (melflufen) is a first-in-class peptide-drug conjugate that targets aminopeptidases and rapidly releases alkylating agents inside tumor cells. Melflufen is highly lipophilic, permitting rapid uptake by cells, where it is enzymatically hydrolyzed by aminopeptidases, resulting in intracellular accumulation of the alkylating agents, including melphalan. Previous data demonstrating sensitivity of myeloma cells to melflufen suggest that the drug might be useful in AL amyloidosis. We describe the effects of melflufen on amyloidogenic plasma cells in vitro and ex vivo, demonstrating enhanced cytotoxic effects in comparison to melphalan, as well as novel mechanisms of action through the unfolded protein response (UPR) pathway. These findings provide evidence that melflufen-mediated cytotoxicity extends to amyloidogenic plasma cells, and support the rationale for the evaluation of melflufen in patients with AL amyloidosis.
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Affiliation(s)
| | - Romika Kumari
- Institute for Molecular Medicine Finland - FIMM, HiLIFE – Helsinki Institute of Life Science, iCAN Digital Precision Cancer Medicine Flagship, University of Helsinki, Finland
| | - Juho J. Miettinen
- Institute for Molecular Medicine Finland - FIMM, HiLIFE – Helsinki Institute of Life Science, iCAN Digital Precision Cancer Medicine Flagship, University of Helsinki, Finland
| | - Staci L. Haney
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Michelle L. Varney
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jacob T. Williams
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Muntasir M. Majumder
- Institute for Molecular Medicine Finland - FIMM, HiLIFE – Helsinki Institute of Life Science, iCAN Digital Precision Cancer Medicine Flagship, University of Helsinki, Finland
| | - Minna Suvela
- Institute for Molecular Medicine Finland - FIMM, HiLIFE – Helsinki Institute of Life Science, iCAN Digital Precision Cancer Medicine Flagship, University of Helsinki, Finland
| | | | | | | | - Sarah A. Holstein
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Caroline A. Heckman
- Institute for Molecular Medicine Finland - FIMM, HiLIFE – Helsinki Institute of Life Science, iCAN Digital Precision Cancer Medicine Flagship, University of Helsinki, Finland
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Verhulst E, Garnier D, De Meester I, Bauvois B. Validating Cell Surface Proteases as Drug Targets for Cancer Therapy: What Do We Know, and Where Do We Go? Cancers (Basel) 2022; 14:624. [PMID: 35158891 PMCID: PMC8833564 DOI: 10.3390/cancers14030624] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 02/06/2023] Open
Abstract
Cell surface proteases (also known as ectoproteases) are transmembrane and membrane-bound enzymes involved in various physiological and pathological processes. Several members, most notably dipeptidyl peptidase 4 (DPP4/CD26) and its related family member fibroblast activation protein (FAP), aminopeptidase N (APN/CD13), a disintegrin and metalloprotease 17 (ADAM17/TACE), and matrix metalloproteinases (MMPs) MMP2 and MMP9, are often overexpressed in cancers and have been associated with tumour dysfunction. With multifaceted actions, these ectoproteases have been validated as therapeutic targets for cancer. Numerous inhibitors have been developed to target these enzymes, attempting to control their enzymatic activity. Even though clinical trials with these compounds did not show the expected results in most cases, the field of ectoprotease inhibitors is growing. This review summarizes the current knowledge on this subject and highlights the recent development of more effective and selective drugs targeting ectoproteases among which small molecular weight inhibitors, peptide conjugates, prodrugs, or monoclonal antibodies (mAbs) and derivatives. These promising avenues have the potential to deliver novel therapeutic strategies in the treatment of cancers.
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Affiliation(s)
- Emile Verhulst
- Laboratory of Medical Biochemistry, Department of Pharmaceutical Sciences, University of Antwerp, 2000 Antwerp, Belgium; (E.V.); (I.D.M.)
| | - Delphine Garnier
- Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Cell Death and Drug Resistance in Lymphoproliferative Disorders Team, F-75006 Paris, France;
| | - Ingrid De Meester
- Laboratory of Medical Biochemistry, Department of Pharmaceutical Sciences, University of Antwerp, 2000 Antwerp, Belgium; (E.V.); (I.D.M.)
| | - Brigitte Bauvois
- Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Cell Death and Drug Resistance in Lymphoproliferative Disorders Team, F-75006 Paris, France;
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Morabito F, Tripepi G, Martino EA, Vigna E, Mendicino F, Morabito L, Todoerti K, Al-Janazreh H, D'Arrigo G, Canale FA, Cutrona G, Neri A, Martino M, Gentile M. Spotlight on Melphalan Flufenamide: An Up-and-Coming Therapy for the Treatment of Myeloma. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:2969-2978. [PMID: 34262262 PMCID: PMC8275138 DOI: 10.2147/dddt.s295215] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/22/2021] [Indexed: 01/08/2023]
Abstract
Despite recent therapeutic advances, multiple myeloma (MM) patients experience relapses as they become resistant to various classes and combinations of treatment. Melphalan (L-PAM) is an ageless drug. However, its use in the autologous stem cell transplantation (ASCT) setting and the innovative quadruplet regimen as well as daratumumab, bortezomib, and prednisone make this old drug current yet. Melflufen is a peptide-conjugated alkylator belonging to a novel class of compounds, representing an overcoming of L-PAM in terms of mechanism of action and effectiveness. The improved melflufen cytotoxicity is related to aminopeptidase activity, notably present in normal and neoplastic cells and remarkably heavily overexpressed in MM cells. Upon entering a cell, melflufen is cleaved by aminopeptidases, ultimately releasing the L-PAM payload and eliciting further the inflow and cleavage of the conjugated peptide. This virtuous loop persists until all extracellular melflufen has been utilized. The aminopeptidase-driven accumulation results in a 50-fold increase in L-PAM cell enrichment as compared with free alkylator. This condition produces selective cytotoxicity, increased on-target cell potency, and decreased off-target cell toxicity, ultimately overcoming resistance pathways triggered by previous treatments, including alkylators. Due to its distinct mechanism of action, melflufen plus dexamethasone as a doublet, and in combination with other novel drugs, has the potential to be beneficial for a broad range of patients with relapsed/refractory (RR) MM in third- or even in second-line therapy. The safety profile of melflufen has been consistent across studies, and no new safety concerns have been identified when melflufen was administered in doublet and triplet combinations. Based on growing clinical evidence, melflufen could be not only a good addition in the fight against RRMM but also a drug with a very favorable tolerability profile.
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Affiliation(s)
- Fortunato Morabito
- Biotechnology Research Unit, AO of Cosenza, Cosenza, Italy.,Hematology and Bone Marrow Transplant Unit, Hemato-Oncology Department, Augusta Victoria Hospital, East Jerusalem, Israel
| | - Giovanni Tripepi
- HCNR-IBIM, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension of Reggio Calabria, Reggio, Calabria, Italy
| | | | | | | | - Lucio Morabito
- Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Katia Todoerti
- Hematology, Fondazione Cà Granda IRCCS Policlinico, Milan, Italy
| | - Hamdi Al-Janazreh
- Hematology and Bone Marrow Transplant Unit, Hemato-Oncology Department, Augusta Victoria Hospital, East Jerusalem, Israel
| | - Graziella D'Arrigo
- HCNR-IBIM, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension of Reggio Calabria, Reggio, Calabria, Italy
| | - Filippo Antonio Canale
- Stem Cell Transplant Program, Clinical Section, Department of Hemato-Oncology and Radiotherapy, Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | | | - Antonino Neri
- Hematology, Fondazione Cà Granda IRCCS Policlinico, Milan, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Massimo Martino
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
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Abstract
Melphalan flufenamide (melflufen, Pepaxto®) is a peptide conjugated alkylating drug developed by Oncopeptides for the treatment of multiple myeloma (MM) and amyloid light-chain amyloidosis. It is an ethyl ester of a lipophilic dipeptide consisting of melphalan and para-fluoro-L-phenylalanine. Due to its lipophilicity, melphalan flufenamide is rapidly transported across the cell membrane and almost immediately hydrolyzed by aminopeptidases in the cytoplasm to yield more hydrophilic alkylating molecules, such as melphalan and desethyl-melflufen. Like other nitrogen mustard drugs, melphalan flufenamide exerts antitumor activity through DNA crosslinking. In February 2021, melphalan flufenamide, in combination with dexamethasone, received its first approval in the USA for the treatment of adults with relapsed or refractory (r/r) MM who have received at least four prior lines of therapy and whose disease is refractory to at least one proteasome inhibitor (PI), one immunomodulatory agent, and one CD38-directed monoclonal antibody. A multinational clinical study of melphalan flufenamide in amyloid light-chain amyloidosis is underway across several countries, and preclinical studies for various haematological and solid cancers are underway. This article summarizes the milestones in the development of melphalan flufenamide leading to this first approval.
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Treatment of Multiple Myeloma and the Role of Melphalan in the Era of Modern Therapies-Current Research and Clinical Approaches. J Clin Med 2021; 10:jcm10091841. [PMID: 33922721 PMCID: PMC8123041 DOI: 10.3390/jcm10091841] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/01/2021] [Accepted: 04/16/2021] [Indexed: 12/18/2022] Open
Abstract
Multiple myeloma (MM) accounts for 10% of all hematological malignancies, and it is the second most common hematological neoplasm for which chemotherapy is an important pharmacological treatment. High dose melphalan followed by autologous stem cell transplantation remains the standard of treatment for transplant-eligible patients with MM. In this review, we describe aspects of the pharmacokinetics and pharmacodynamics of melphalan therapy and related compounds. In addition, we describe the use of melphalan in innovative therapies for the treatment of MM, including the development of drug carriers to reduce systemic toxicity, combination therapy to improve the effectiveness of cancer therapy, and the chemical modification of the melphalan molecule to improve antitumor activity.
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Holstein SA, Hillengass J, McCarthy PL. Melflufen: A Next-Generation Nitrogen Mustard. J Clin Oncol 2021; 39:836-839. [PMID: 33439689 DOI: 10.1200/jco.20.03326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Sarah A Holstein
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Jens Hillengass
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Philip L McCarthy
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
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12
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Up-regulation of multidrug resistance protein MDR1/ABCB1 in carfilzomib-resistant multiple myeloma differentially affects efficacy of anti-myeloma drugs. Leuk Res 2020; 101:106499. [PMID: 33422770 DOI: 10.1016/j.leukres.2020.106499] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/16/2020] [Accepted: 12/24/2020] [Indexed: 11/23/2022]
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Oriol A, Larocca A, Leleu X, Hajek R, Hassoun H, Rodríguez-Otero P, Paner A, Schjesvold FH, Gullbo J, Richardson PG. Melflufen for relapsed and refractory multiple myeloma. Expert Opin Investig Drugs 2020; 29:1069-1078. [PMID: 32924646 DOI: 10.1080/13543784.2020.1808884] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The overall survival of patients with multiple myeloma has improved with the advent of novel agents; however, multiple myeloma remains incurable. Combinations of standard-of-care agents such as immunomodulators, proteasome inhibitors, and anti-CD38 monoclonal antibodies are increasingly used in earlier lines of therapy. Patients with disease that is refractory to multiple novel agents represent a population with high unmet medical need and for whom therapies with new mechanisms of action could be beneficial. Melphalan flufenamide (melflufen) has demonstrated encouraging activity in patients with relapsed and refractory multiple myeloma. AREAS COVERED This review provides an overview of the mechanism of action of melflufen, a first-in-class peptide-drug conjugate that targets aminopeptidases and rapidly delivers alkylating agents into tumor cells. It reviews key Phase I and II clinical trial data for melflufen in combination with dexamethasone as well as in triplet combinations with daratumumab or bortezomib. The safety profile of melflufen, which is characterized primarily by clinically manageable hematologic adverse events, is described. EXPERT OPINION Melflufen has potential to fill a gap in the myeloma treatment landscape by providing a new mechanism of action with clinically meaningful efficacy and a favorable safety profile in patients refractory to multiple novel agents.
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Affiliation(s)
- Albert Oriol
- Institut Josep Carreras and Institut Català d'Oncologia, Hospital Germans Trias I Pujol , Badalona, Spain
| | - Alessandra Larocca
- Azienda Ospedaliero-Universitaria Città Della Salute E Della Scienza Di Torino, University of Torino , Torino, Italy
| | - Xavier Leleu
- Department of Hematology, Hôpital De La Milétrie, CHU De Poitiers , Poitiers, France
| | - Roman Hajek
- Department of Hemato-Oncology, University of Ostrava and Faculty of Medicine, University of Ostrava , Ostrava, Czech Republic
| | - Hani Hassoun
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center , New York, NY, USA
| | | | - Agne Paner
- Division of Hematology, Oncology and Stem Cell Transplant, Rush University Medical Center , Chicago, IL, USA
| | - Fredrik H Schjesvold
- Oslo Myeloma Center, Oslo University Hospital and K.G. Jebsen Centre for B-Cell Malignancies, University of Oslo , Oslo, Norway
| | - Joachim Gullbo
- Department of Medical Sciences, Division of Clinical Pharmacology, Uppsala University , Uppsala, Sweden
| | - Paul G Richardson
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School , Boston, MA, USA
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Mateos MV, Bladé J, Bringhen S, Ocio EM, Efebera Y, Pour L, Gay F, Sonneveld P, Gullbo J, Richardson PG. Melflufen: A Peptide-Drug Conjugate for the Treatment of Multiple Myeloma. J Clin Med 2020; 9:E3120. [PMID: 32992506 PMCID: PMC7601491 DOI: 10.3390/jcm9103120] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/15/2020] [Accepted: 09/23/2020] [Indexed: 02/06/2023] Open
Abstract
Despite the availability of new therapies that have led to improved outcomes for patients with multiple myeloma, most patients will eventually relapse. With triplet and even quadruplet combination therapies becoming standard in the first and second line, many patients will have few treatment options after second-line treatment. Melflufen (melphalan flufenamide) is a first-in-class peptide-drug conjugate (PDC) that targets aminopeptidases and rapidly releases alkylating agents into tumor cells. Once inside the tumor cells, melflufen is hydrolyzed by peptidases to release alkylator molecules, which become entrapped. Melflufen showed anti-myeloma activity in myeloma cells that were resistant to bortezomib and the alkylator melphalan. In early phase studies (O-12-M1 and HORIZON [OP-106]), melflufen plus dexamethasone has demonstrated encouraging clinical activity and a manageable safety profile in heavily pretreated patients with relapsed/refractory multiple myeloma, including those with triple-class refractory disease and extramedullary disease. The Phase III OCEAN study (OP-104) is further evaluating melflufen plus dexamethasone in patients with relapsed/refractory multiple myeloma. The safety profile of melflufen is characterized primarily by clinically manageable hematologic adverse events. Melflufen, with its novel mechanism of action, has the potential to provide clinically meaningful benefits to patients with relapsed/refractory multiple myeloma, including those with high unmet needs.
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Affiliation(s)
| | - Joan Bladé
- Hematology Department, Institut d’Investigacions Biomèdiques August Pi I Sunyer, Hospital Clinic, 08036 Barcelona, Spain;
| | - Sara Bringhen
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Torino, Italy; (S.B.); (F.G.)
| | - Enrique M Ocio
- University Hospital Marqués de Valdecilla (IDIVAL), University of Cantabria, 39008 Santander, Spain;
| | - Yvonne Efebera
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA;
| | - Luděk Pour
- Department of Internal Medicine, Hematology and Oncology, University Hospital Brno, 62500 Brno, Czech Republic;
| | - Francesca Gay
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Torino, Italy; (S.B.); (F.G.)
| | - Pieter Sonneveld
- Erasmus MC Cancer Institute, 3075 EA Rotterdam, The Netherlands;
| | - Joachim Gullbo
- Department of Medical Sciences, Division of Clinical Pharmacology, Uppsala University, 751 85 Uppsala, Sweden;
| | - Paul G. Richardson
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
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15
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Byrgazov K, Anderson C, Salzer B, Bozsaky E, Larsson R, Gullbo J, Lehner M, Lehmann F, Slipicevic A, Kager L, Fryknäs M, Taschner-Mandl S. Targeting aggressive osteosarcoma with a peptidase-enhanced cytotoxic melphalan flufenamide. Ther Adv Med Oncol 2020; 12:1758835920937891. [PMID: 32774473 PMCID: PMC7391428 DOI: 10.1177/1758835920937891] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/22/2020] [Indexed: 12/28/2022] Open
Abstract
Background: Low survival rates in metastatic high-grade osteosarcoma (HGOS) have remained stagnant for the last three decades. This study aims to investigate the role of aminopeptidase N (ANPEP) in HGOS progression and its targeting with a novel lipophilic peptidase-enhanced cytotoxic compound melphalan flufenamide (melflufen) in HGOS. Methods: Meta-analysis of publicly available gene expression datasets was performed to determine the impact of ANPEP gene expression on metastasis-free survival of HGOS patients. The efficacy of standard-of-care anti-neoplastic drugs and a lipophilic peptidase-enhanced cytotoxic conjugate melflufen was investigated in patient-derived HGOS ex vivo models and cell lines. The kinetics of apoptosis and necrosis induced by melflufen and doxorubicin were compared. Anti-neoplastic effects of melflufen were investigated in vivo. Results: Elevated ANPEP expression in diagnostic biopsies of HGOS patients was found to significantly reduce metastasis-free survival. In drug sensitivity assays, melflufen has shown an anti-proliferative effect in HGOS ex vivo samples and cell lines, including those resistant to methotrexate, etoposide, doxorubicin, and PARP inhibitors. Further, HGOS cells treated with melflufen displayed a rapid induction of apoptosis and this sensitivity correlated with high expression of ANPEP. In combination treatments, melflufen demonstrated synergy with doxorubicin in killing HGOS cells. Finally, Melflufen displayed anti-tumor growth and anti-metastatic effects in vivo. Conclusion: This study may pave the way for use of melflufen as an adjuvant to doxorubicin in improving the therapeutic efficacy for the treatment of metastatic HGOS.
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Affiliation(s)
| | - Claes Anderson
- Department of Medical Sciences, Division of Cancer Pharmacology and Computational Medicine, Uppsala University, Uppsala, Sweden
| | - Benjamin Salzer
- St. Anna Children's Cancer Research Institute (CCRI), Vienna, Austria
| | - Eva Bozsaky
- St. Anna Children's Cancer Research Institute (CCRI), Vienna, Austria
| | - Rolf Larsson
- Department of Medical Sciences, Division of Cancer Pharmacology and Computational Medicine, Uppsala University, Uppsala, Sweden
| | | | - Manfred Lehner
- St. Anna Children's Cancer Research Institute (CCRI), Vienna, Austria
| | | | | | - Leo Kager
- Department of Pediatrics, St. Anna Children's Hospital, Medical University of Vienna and Children's Cancer Research Institute (CCRI), Vienna, Austria
| | - Mårten Fryknäs
- Department of Medical Sciences, Division of Cancer Pharmacology and Computational Medicine, Uppsala University, Uppsala, Sweden
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16
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Richardson PG, Bringhen S, Voorhees P, Plesner T, Mellqvist UH, Reeves B, Paba-Prada C, Zubair H, Byrne C, Chauhan D, Anderson K, Nordström E, Harmenberg J, Palumbo A, Sonneveld P. Melflufen plus dexamethasone in relapsed and refractory multiple myeloma (O-12-M1): a multicentre, international, open-label, phase 1–2 study. LANCET HAEMATOLOGY 2020; 7:e395-e407. [DOI: 10.1016/s2352-3026(20)30044-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/06/2020] [Accepted: 02/11/2020] [Indexed: 10/24/2022]
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17
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Schjesvold F, Robak P, Pour L, Aschan J, Sonneveld P. OCEAN: a randomized Phase III study of melflufen + dexamethasone to treat relapsed refractory multiple myeloma. Future Oncol 2020; 16:631-641. [PMID: 32141766 DOI: 10.2217/fon-2020-0024] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Melflufen is a novel peptide-drug conjugate that rapidly delivers a cytotoxic payload into tumor cells. It has emerged as a potential new multiple myeloma treatment, particularly for late-stage forms of the disease. Here we describe the rationale and design of OCEAN (NCT03151811), a randomized, head-to-head, superiority, open-label, global, Phase III study evaluating the efficacy and safety of melflufen + dexamethasone versus pomalidomide + dexamethasone. Eligible patients with relapsed refractory multiple myeloma have received 2-4 previous treatments and are refractory to both lenalidomide and their last treatment. Patients are excluded if they have previously received pomalidomide. The primary endpoint is progression-free survival, and key secondary endpoints include overall response rate, duration of response and overall survival.
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Affiliation(s)
- Fredrik Schjesvold
- Oslo Myeloma Center, Oslo University Hospital & KG Jebsen Center for B Cell Malignancies, University of Oslo, Oslo, Norway
| | | | - Ludek Pour
- University Hospital of Masaryk, Brno, Czech Republic
| | | | - Pieter Sonneveld
- Erasmus MC Cancer Institute & Erasmus University of Rotterdam, Rotterdam, The Netherlands
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18
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Stratmann J, van Kann E, Rummelt C, Koschade S, Röllig C, Lübbert M, Schaich M, Parmentier S, Sebastian M, Chromik J, Becker von Rose A, Ballo O, Steffen B, Serve H, Brandts C, Shaid S. Low-dose melphalan in elderly patients with relapsed or refractory acute myeloid leukemia: A well-tolerated and effective treatment after hypomethylating-agent failure. Leuk Res 2019; 85:106192. [PMID: 31445469 DOI: 10.1016/j.leukres.2019.106192] [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: 03/28/2019] [Revised: 06/14/2019] [Accepted: 07/14/2019] [Indexed: 12/17/2022]
Abstract
Relapsed or refractory (R/R) disease remains challenging in acute myeloid leukemia (AML), especially in elderly patients not considered eligible for intensive treatment options. We retrospectively evaluated the safety and efficacy of low-dose melphalan (LD-Mel) in a multicenter analysis in patients over 65 years with R/R AML, who previously had received ≥1 non-curative treatment line. The study included 31 patients (median age 77 years) with 1-4 previous treatment lines. Three patients (9.7%) achieved a complete remission. Two patients (6.5%) achieved a partial remission, nine patients (29.0%) had disease stabilization with reduction of peripheral or bone marrow blast burden, resulting in an overall response rate of 16.1% and 45.2% achieved clinical benefit. Responders showed a significantly longer median overall survival than non-responders (16.3 vs. 2.3 months, p < 0.001). Multivariate analysis identified complex karyotype as the only risk factor associated with inferior survival (p < 0.001), whereas prior treatment with hypomethylating agents (HMAs) in 25 of 31 patients was associated with superior OS, regardless of prior response to HMAs (p = 0.03). LD-Mel was well tolerated, with mild myelosuppressive side effects. Conclusively, LD-Mel is an effective treatment option in elderly patients with R/R AML, particularly after HMA therapy and in the absence of a complex karyotype.
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Affiliation(s)
- Jan Stratmann
- Department of Medicine, Hematology/Oncology, Goethe University, Frankfurt, Frankfurt am Main, Germany.
| | - Elisabeth van Kann
- Department of Medicine, Hematology/Oncology, Goethe University, Frankfurt, Frankfurt am Main, Germany
| | - Christoph Rummelt
- Department of Hematology, Oncology and Stem Cell Transplantation, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Sebastian Koschade
- Department of Medicine, Hematology/Oncology, Goethe University, Frankfurt, Frankfurt am Main, Germany; German Cancer Consortium (DKTK), Frankfurt, Germany
| | - Christoph Röllig
- Department of Hematology, Carl Gustav Carus University of Dresden, Dresden, Germany
| | - Michael Lübbert
- Department of Hematology, Oncology and Stem Cell Transplantation, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany; German Cancer Consortium (DKTK), Freiburg, Germany
| | - Markus Schaich
- Department of Hematology and Oncology, Rems-Murr-Klinikum Winnenden, Germany
| | - Stefani Parmentier
- Department of Hematology and Oncology, Rems-Murr-Klinikum Winnenden, Germany
| | - Martin Sebastian
- Department of Medicine, Hematology/Oncology, Goethe University, Frankfurt, Frankfurt am Main, Germany
| | - Joerg Chromik
- Department of Medicine, Hematology/Oncology, Goethe University, Frankfurt, Frankfurt am Main, Germany
| | - Aaron Becker von Rose
- Department of Medicine, Hematology/Oncology, Goethe University, Frankfurt, Frankfurt am Main, Germany
| | - Olivier Ballo
- Department of Medicine, Hematology/Oncology, Goethe University, Frankfurt, Frankfurt am Main, Germany
| | - Björn Steffen
- Department of Medicine, Hematology/Oncology, Goethe University, Frankfurt, Frankfurt am Main, Germany
| | - Hubert Serve
- Department of Medicine, Hematology/Oncology, Goethe University, Frankfurt, Frankfurt am Main, Germany; German Cancer Consortium (DKTK), Frankfurt, Germany
| | - Christian Brandts
- Department of Medicine, Hematology/Oncology, Goethe University, Frankfurt, Frankfurt am Main, Germany; German Cancer Consortium (DKTK), Frankfurt, Germany
| | - Shabnam Shaid
- Department of Medicine, Hematology/Oncology, Goethe University, Frankfurt, Frankfurt am Main, Germany; German Cancer Consortium (DKTK), Frankfurt, Germany
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19
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Cotton H, Bäckström B, Fritzson I, Lehmann F, Monemi T, Oltner V, Sölver E, Wahlström N, Wennerberg J. Development of a Safe Process for Manufacturing of the Potent Anticancer Agent Melflufen Hydrochloride. Org Process Res Dev 2019. [DOI: 10.1021/acs.oprd.9b00116] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Hanna Cotton
- Magle Chemoswed, Agneslundsvägen 27, SE, 212 15 Malmö, Sweden
| | | | - Ingela Fritzson
- Magle Chemoswed, Agneslundsvägen 27, SE, 212 15 Malmö, Sweden
| | - Fredrik Lehmann
- Recipharm OT Chemistry, Virdings Allé 32 B, 754 50 Uppsala, Sweden
| | - Taraneh Monemi
- Magle Chemoswed, Agneslundsvägen 27, SE, 212 15 Malmö, Sweden
| | - Viveca Oltner
- Magle Chemoswed, Agneslundsvägen 27, SE, 212 15 Malmö, Sweden
| | - Ellen Sölver
- Magle Chemoswed, Agneslundsvägen 27, SE, 212 15 Malmö, Sweden
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20
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Laubach JP, Liu CJ, Raje NS, Yee AJ, Armand P, Schlossman RL, Rosenblatt J, Hedlund J, Martin M, Reynolds C, Shain KH, Zackon I, Stampleman L, Henrick P, Rivotto B, Hornburg KTV, Dumke HJ, Chuma S, Savell A, Handisides DR, Kroll S, Anderson KC, Richardson PG, Ghobrial IM. A Phase I/II Study of Evofosfamide, A Hypoxia-activated Prodrug with or without Bortezomib in Subjects with Relapsed/Refractory Multiple Myeloma. Clin Cancer Res 2018; 25:478-486. [PMID: 30279233 DOI: 10.1158/1078-0432.ccr-18-1325] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 08/12/2018] [Accepted: 09/26/2018] [Indexed: 01/07/2023]
Abstract
PURPOSE The presence of hypoxia in the diseased bone marrow presents a new therapeutic target for multiple myeloma. Evofosfamide (formerly TH-302) is a 2-nitroimidazole prodrug of the DNA alkylator, bromo-isophosphoramide mustard, which is selectively activated under hypoxia. This trial was designed as a phase I/II study investigating evofosfamide in combination with dexamethasone, and in combination with bortezomib and dexamethasone in relapsed/refractory multiple myeloma. PATIENTS AND METHODS Fifty-nine patients initiated therapy, 31 received the combination of evofosfamide and dexamethasone, and 28 received the combination of evofosfamide, bortezomib, and dexamethasone. Patients were heavily pretreated with a median number of prior therapies of 7 (range: 2-15). All had previously received bortezomib and immunomodulators. The MTD, treatment toxicity, and efficacy were determined. RESULTS The MTD was established at 340 mg/m2 evofosfamide + dexamethasone with dose-limiting mucositis at higher doses. For the combination of evofosfamide, bortezomib, and dexamethasone, no patient had a dose-limiting toxicity (DLT) and the recommended phase II dose was established at 340 mg/m2. The most common ≥grade 3 adverse events (AE) were thrombocytopenia (25 patients), anemia (24 patients), neutropenia (15 patients), and leukopenia (9 patients). Skin toxicity was reported in 42 (71%) patients. Responses included 1 very good partial response (VGPR), 3 partial response (PR), 2 minor response (MR), 20 stable disease (SD), and 4 progressive disease (PD) for evofosfamide + dexamethasone and 1 complete response (CR), 2 PR, 1 MR, 18 SD, and 5 PD for evofosfamide + bortezomib + dexamethasone. Disease stabilization was observed in over 80% and this was reflective of the prolonged overall survival of 11.2 months. CONCLUSIONS Evofosfamide can be administered at 340 mg/m2 twice a week with or without bortezomib. Clinical activity has been noted in patients with heavily pretreated relapsed refractory multiple myeloma.
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Affiliation(s)
- Jacob P Laubach
- Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Blood Cancer Research Partnership (BCRP), Boston, Massachusetts
| | - Chia-Jen Liu
- Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Noopur S Raje
- Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew J Yee
- Massachusetts General Hospital, Boston, Massachusetts
| | - Philippe Armand
- Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Blood Cancer Research Partnership (BCRP), Boston, Massachusetts
| | - Robert L Schlossman
- Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Blood Cancer Research Partnership (BCRP), Boston, Massachusetts
| | - Jacalyn Rosenblatt
- Blood Cancer Research Partnership (BCRP), Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jacquelyn Hedlund
- Blood Cancer Research Partnership (BCRP), Boston, Massachusetts.,Maine Center For Cancer Medicine, Scarborough, Maine
| | - Michael Martin
- Blood Cancer Research Partnership (BCRP), Boston, Massachusetts.,The West Clinic, Memphis, Tennessee
| | - Craig Reynolds
- Blood Cancer Research Partnership (BCRP), Boston, Massachusetts.,Ocala Oncology Center, Ocala, Florida
| | | | - Ira Zackon
- Blood Cancer Research Partnership (BCRP), Boston, Massachusetts.,New York Oncology Hematology, Albany, New York
| | - Laura Stampleman
- Blood Cancer Research Partnership (BCRP), Boston, Massachusetts.,Pacific Cancer Care, Salinas, California
| | - Patrick Henrick
- Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Blood Cancer Research Partnership (BCRP), Boston, Massachusetts
| | - Bradley Rivotto
- Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Kalvis T V Hornburg
- Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Henry J Dumke
- Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Stacey Chuma
- Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Blood Cancer Research Partnership (BCRP), Boston, Massachusetts
| | - Alexandra Savell
- Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Blood Cancer Research Partnership (BCRP), Boston, Massachusetts
| | | | - Stew Kroll
- Threshold Pharmaceuticals, South San Francisco, California
| | - Kenneth C Anderson
- Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Blood Cancer Research Partnership (BCRP), Boston, Massachusetts
| | - Paul G Richardson
- Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts. .,Blood Cancer Research Partnership (BCRP), Boston, Massachusetts
| | - Irene M Ghobrial
- Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts. .,Blood Cancer Research Partnership (BCRP), Boston, Massachusetts
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21
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Therapeutic journery of nitrogen mustard as alkylating anticancer agents: Historic to future perspectives. Eur J Med Chem 2018; 151:401-433. [DOI: 10.1016/j.ejmech.2018.04.001] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/30/2018] [Accepted: 04/01/2018] [Indexed: 12/17/2022]
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22
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Strese S, Hassan SB, Velander E, Haglund C, Höglund M, Larsson R, Gullbo J. In vitro and in vivo anti-leukemic activity of the peptidase-potentiated alkylator melflufen in acute myeloid leukemia. Oncotarget 2018; 8:6341-6352. [PMID: 27974676 PMCID: PMC5351636 DOI: 10.18632/oncotarget.13856] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 11/06/2016] [Indexed: 01/09/2023] Open
Abstract
The novel aminopeptidase potentiated alkylating agent melflufen, was evaluated for activity in acute myeloid leukemia in a range of in vitro models, as well as in a patient derived xenograft study. All tested AML cell lines were highly sensitive to melflufen while melphalan was considerably less potent. In the HL-60 cell line model, synergy was observed for the combination of melflufen and cytarabine, an interaction that appeared sequence dependent with increased synergy when melflufen was added before cytarabine. Also, in primary cultures of AML cells from patients melflufen was highly active, while normal PBMC cultures appeared less sensitive, indicating a 7-fold in vitro therapeutic index. Melphalan, on the other hand, was only 2-fold more potent in the AML patient samples compared with PBMCs. Melflufen was equally active against non-malignant, immature CD34+ progenitor cells and a more differentiated CD34+ derived cell population (GM14), whereas the stem cell like cells were less sensitive to melphalan. Finally, melflufen treatment showed significant anti-leukemia activity and increased survival in a patient derived xenograft of AML in mice. In conclusion, melflufen demonstrates high and significant preclinical activity in AML and further clinical evaluation seem warranted in this disease.
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Affiliation(s)
- Sara Strese
- Department of Medical Sciences, Division of Cancer Pharmacology and Computational Medicine, Uppsala University, Uppsala, Sweden
| | - Saadia Bashir Hassan
- Department of Medical Sciences, Division of Cancer Pharmacology and Computational Medicine, Uppsala University, Uppsala, Sweden
| | - Ebba Velander
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Caroline Haglund
- Department of Medical Sciences, Division of Cancer Pharmacology and Computational Medicine, Uppsala University, Uppsala, Sweden
| | - Martin Höglund
- Department of Medical Sciences, Division of Hematology, Uppsala University, Uppsala, Sweden
| | - Rolf Larsson
- Department of Medical Sciences, Division of Cancer Pharmacology and Computational Medicine, Uppsala University, Uppsala, Sweden
| | - Joachim Gullbo
- Department of Medical Sciences, Division of Cancer Pharmacology and Computational Medicine, Uppsala University, Uppsala, Sweden.,Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
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23
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Carlier C, Strese S, Viktorsson K, Velander E, Nygren P, Uustalu M, Juntti T, Lewensohn R, Larsson R, Spira J, De Vlieghere E, Ceelen WP, Gullbo J. Preclinical activity of melflufen (J1) in ovarian cancer. Oncotarget 2018; 7:59322-59335. [PMID: 27528037 PMCID: PMC5312315 DOI: 10.18632/oncotarget.11163] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 07/19/2016] [Indexed: 12/12/2022] Open
Abstract
Ovarian cancer carries a significant mortality. Since symptoms tend to be minimal, the disease is often diagnosed when peritoneal metastases are already present. The standard of care in advanced ovarian cancer consists of platinum-based chemotherapy combined with cytoreductive surgery. Unfortunately, even after optimal cytoreduction and adjuvant chemotherapy, most patients with stage III disease will develop a recurrence. Intraperitoneal administration of chemotherapy is an alternative treatment for patients with localized disease. The pharmacological and physiochemical properties of melflufen, a peptidase potentiated alkylator, raised the hypothesis that this drug could be useful in ovarian cancer and particularily against peritoneal carcinomatosis. In this study the preclinical effects of melflufen were investigated in different ovarian cancer models. Melflufen was active against ovarian cancer cell lines, primary cultures of patient-derived ovarian cancer cells, and inhibited the growth of subcutaneous A2780 ovarian cancer xenografts alone and when combined with gemcitabine or liposomal doxorubicin when administered intravenously. In addition, an intra- and subperitoneal xenograft model showed activity of intraperitoneal administered melflufen for peritoneal carcinomatosis, with minimal side effects and modest systemic exposure. In conclusion, results from this study support further investigations of melflufen for the treatment of peritoneal carcinomatosis from ovarian cancer, both for intravenous and intraperitoneal administration.
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Affiliation(s)
- Charlotte Carlier
- Department of Surgery, Laboratory of Experimental Surgery, Ghent University, Ghent, Belgium
| | - Sara Strese
- Department of Medical Sciences, Division of Cancer Pharmacology and Computational Medicine, Uppsala University, Uppsala, Sweden
| | - Kristina Viktorsson
- Department of Oncology and Pathology, Karolinska Biomics Center, Karolinska Institutet, Stockholm, Sweden
| | - Ebba Velander
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Peter Nygren
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | | | - Therese Juntti
- Department of Oncology and Pathology, Karolinska Biomics Center, Karolinska Institutet, Stockholm, Sweden.,Oncopeptides AB, Stockholm, Sweden
| | - Rolf Lewensohn
- Department of Oncology and Pathology, Karolinska Biomics Center, Karolinska Institutet, Stockholm, Sweden
| | - Rolf Larsson
- Department of Medical Sciences, Division of Cancer Pharmacology and Computational Medicine, Uppsala University, Uppsala, Sweden
| | - Jack Spira
- Present address: InSpira Medical AB, Tyresö, Sweden
| | - Elly De Vlieghere
- Radiation Oncology and Experimental Cancer Research, Laboratory of Experimental Cancer Research, Ghent University, Ghent, Belgium
| | - Wim P Ceelen
- Department of Surgery, Laboratory of Experimental Surgery, Ghent University, Ghent, Belgium
| | - Joachim Gullbo
- Department of Medical Sciences, Division of Cancer Pharmacology and Computational Medicine, Uppsala University, Uppsala, Sweden.,Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
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24
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Wickström M, Nygren P, Larsson R, Harmenberg J, Lindberg J, Sjöberg P, Jerling M, Lehmann F, Richardson P, Anderson K, Chauhan D, Gullbo J. Melflufen - a peptidase-potentiated alkylating agent in clinical trials. Oncotarget 2017; 8:66641-66655. [PMID: 29029544 PMCID: PMC5630444 DOI: 10.18632/oncotarget.18420] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 04/17/2017] [Indexed: 12/02/2022] Open
Abstract
Aminopeptidases like aminopeptidase N (APN, also known as CD13) play an important role not only in normal cellular functioning but also in the development of cancer, including processes like tumor cell invasion, differentiation, proliferation, apoptosis, motility, and angiogenesis. An increased expression of APN has been described in several types of human malignancies, especially those characterized by fast-growing and aggressive phenotypes, suggesting APN as a potential therapeutic target. Melphalan flufenamide ethyl ester (melflufen, previously denoted J1) is a peptidase-potentiated alkylating agent. Melflufen readily penetrates membranes and an equilibrium is rapidly achieved, followed by enzymatic cleavage in aminopeptidase positive cells, which results in trapping of less lipophilic metabolites. This targeting effect results in very high intracellular concentrations of its metabolite melphalan and subsequent apoptotic cell death. This results in a potency increase (melflufen vs melphalan) ranging from 10- to several 100-fold in different in vitro models. Melflufen triggers a rapid, robust, and an irreversible DNA damage which may account for its ability to overcome melphalan-resistance in multiple myeloma cells. Furthermore, anti-angiogenic properties of melflufen have been described. Consequently, it is hypothesized that melflufen could provide better efficacy but no more toxicity than what is achieved with melphalan, an assumption so far supported by experiences from hollow fiber and xenograft studies in rodents as well as by clinical data from patients with solid tumors and multiple myeloma. This review summarizes the current preclinical and clinical knowledge of melflufen.
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Affiliation(s)
- Malin Wickström
- Department of Medical Sciences, Division of Clinical Pharmacology, Uppsala University, Uppsala SE, Sweden.,Department of Women's and Children's Health, Childhood Cancer Research Unit, Karolinska Institutet, Stockholm, Sweden
| | - Peter Nygren
- Department of Medical Sciences, Division of Clinical Pharmacology, Uppsala University, Uppsala SE, Sweden.,Department of Immunology, Genetics and Pathology, Uppsala University, SE-75185, Uppsala, Sweden
| | - Rolf Larsson
- Department of Medical Sciences, Division of Clinical Pharmacology, Uppsala University, Uppsala SE, Sweden
| | | | - Jakob Lindberg
- Oncopeptides AB, Västra Trädgårdsgatan 15, Stockholm, Sweden
| | - Per Sjöberg
- Oncopeptides AB, Västra Trädgårdsgatan 15, Stockholm, Sweden
| | - Markus Jerling
- Oncopeptides AB, Västra Trädgårdsgatan 15, Stockholm, Sweden
| | | | - Paul Richardson
- Department of Medical Oncology, The LeBow Institute for Myeloma Therapeutics and Jerome Lipper Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Kenneth Anderson
- Department of Medical Oncology, The LeBow Institute for Myeloma Therapeutics and Jerome Lipper Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Dharminder Chauhan
- Department of Medical Oncology, The LeBow Institute for Myeloma Therapeutics and Jerome Lipper Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Joachim Gullbo
- Department of Medical Sciences, Division of Clinical Pharmacology, Uppsala University, Uppsala SE, Sweden.,Department of Immunology, Genetics and Pathology, Uppsala University, SE-75185, Uppsala, Sweden
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Viktorsson K, Shah CH, Juntti T, Hååg P, Zielinska-Chomej K, Sierakowiak A, Holmsten K, Tu J, Spira J, Kanter L, Lewensohn R, Ullén A. Melphalan-flufenamide is cytotoxic and potentiates treatment with chemotherapy and the Src inhibitor dasatinib in urothelial carcinoma. Mol Oncol 2016; 10:719-34. [PMID: 26827254 PMCID: PMC5423156 DOI: 10.1016/j.molonc.2015.12.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 12/23/2015] [Accepted: 12/23/2015] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Chemotherapy options in advanced urothelial carcinoma (UC) remain limited. Here we evaluated the peptide-based alkylating agent melphalan-flufenamide (mel-flufen) for UC. METHODS UC cell lines J82, RT4, TCCsup and 5637 were treated with mel-flufen, alone or combined with cisplatin, gemcitabine, dasatinib or bestatin. Cell viability (MTT assay), intracellular drug accumulation (liquid chromatography) apoptosis induction (apoptotic cell nuclei morphology, western blot analysis of PARP-1/caspase-9 cleavage and Bak/Bax activation) were evaluated. Kinome alterations were characterized by PathScan array and phospho-Src validated by western blotting. Aminopeptidase N (ANPEP) expression was evaluated in UC clinical specimens in relation to patient outcome. RESULTS In J82, RT4, TCCsup and 5637 UC cells, mel-flufen amplified the intracellular loading of melphalan in part via aminopeptidase N (ANPEP), resulting in increased cytotoxicity compared to melphalan alone. Mel-flufen induced apoptosis seen as activation of Bak/Bax, cleavage of caspase-9/PARP-1 and induction of apoptotic cell nuclei morphology. Combining mel-flufen with cisplatin or gemcitabine in J82 cells resulted in additive cytotoxic effects and for gemcitabine also increased apoptosis induction. Profiling of mel-flufen-induced kinome alterations in J82 cells revealed that mel-flufen alone did not inhibit Src phosphorylation. Accordingly, the Src inhibitor dasatinib sensitized for mel-flufen cytotoxicity. Immunohistochemical analysis of the putative mel-flufen biomarker ANPEP demonstrated prominent expression levels in tumours from 82 of 83 cystectomy patients. Significantly longer median overall survival was found in patients with high ANPEP expression (P = 0.02). CONCLUSION Mel-flufen alone or in combination with cisplatin, gemcitabine or Src inhibition holds promise as a novel treatment for UC.
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Affiliation(s)
- Kristina Viktorsson
- Karolinska Institutet, Department of Oncology-Pathology, Karolinska Biomics Center, SE-171 76, Stockholm, Sweden.
| | - Carl-Henrik Shah
- Karolinska Institutet, Department of Oncology-Pathology, Karolinska Biomics Center, SE-171 76, Stockholm, Sweden; Department of Oncology, Radiumhemmet, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Therese Juntti
- Karolinska Institutet, Department of Oncology-Pathology, Karolinska Biomics Center, SE-171 76, Stockholm, Sweden
| | - Petra Hååg
- Karolinska Institutet, Department of Oncology-Pathology, Karolinska Biomics Center, SE-171 76, Stockholm, Sweden
| | - Katarzyna Zielinska-Chomej
- Karolinska Institutet, Department of Oncology-Pathology, Karolinska Biomics Center, SE-171 76, Stockholm, Sweden
| | - Adam Sierakowiak
- Karolinska Institutet, Department of Oncology-Pathology, Karolinska Biomics Center, SE-171 76, Stockholm, Sweden
| | - Karin Holmsten
- Karolinska Institutet, Department of Oncology-Pathology, Karolinska Biomics Center, SE-171 76, Stockholm, Sweden; Department of Oncology, Radiumhemmet, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Jessica Tu
- Karolinska Institutet, Department of Oncology-Pathology, Karolinska Biomics Center, SE-171 76, Stockholm, Sweden
| | - Jack Spira
- InSpira Medical AB, SE-135 53 Tyresö, Sweden
| | - Lena Kanter
- Karolinska Institutet, Department of Oncology-Pathology, Karolinska Biomics Center, SE-171 76, Stockholm, Sweden
| | - Rolf Lewensohn
- Karolinska Institutet, Department of Oncology-Pathology, Karolinska Biomics Center, SE-171 76, Stockholm, Sweden; Department of Oncology, Radiumhemmet, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Anders Ullén
- Karolinska Institutet, Department of Oncology-Pathology, Karolinska Biomics Center, SE-171 76, Stockholm, Sweden; Department of Oncology, Radiumhemmet, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
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