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Tien FM, Hou HA. CEBPA mutations in acute myeloid leukemia: implications in risk stratification and treatment. Int J Hematol 2024:10.1007/s12185-024-03773-5. [PMID: 38671183 DOI: 10.1007/s12185-024-03773-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/02/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024]
Abstract
Mutations in CCAAT enhancer binding protein α (CEBPA) occur in approximately 10% of patients with de novo acute myeloid leukemia (AML). Emerging evidence supports that in-frame mutations in the basic leucine zipper domain of CEBPA (CEBPAbZIP-inf) confer a survival benefit, and CEBPAbZIP-inf replaced CEBPA double mutations (CEBPAdm) as a unique entity in the 2022 World Health Organization (WHO-2022) classification and International Consensus Classification (ICC). However, challenges remain in daily clinical practice since more than 30% patients with CEBPAbZIP-inf die of AML despite intensive treatment. This review aims to provide a comprehensive summary of the heterogeneities observed in AML with CEBPAdm and CEBPAbZIP-inf, and will discuss the prognostic implications of concurrent mutations and novel mechanistic targets that may inform future drug development. The ultimate goal is to optimize clinical management and to provide precision medicine for this category of patients.
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Affiliation(s)
- Feng-Ming Tien
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hsin-An Hou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
- Division of General Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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Georgi JA, Stasik S, Kramer M, Meggendorfer M, Röllig C, Haferlach T, Valk P, Linch D, Herold T, Duployez N, Taube F, Middeke JM, Platzbecker U, Serve H, Baldus CD, Muller-Tidow C, Haferlach C, Koch S, Berdel WE, Woermann BJ, Krug U, Braess J, Hiddemann W, Spiekermann K, Boertjes EL, Hills RK, Burnett A, Ehninger G, Metzeler K, Rothenberg-Thurley M, Dufour A, Dombret H, Pautas C, Preudhomme C, Fenwarth L, Bornhäuser M, Gale R, Thiede C. Prognostic impact of CEBPA mutational subgroups in adult AML. Leukemia 2024; 38:281-290. [PMID: 38228680 PMCID: PMC10844079 DOI: 10.1038/s41375-024-02140-x] [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: 10/30/2023] [Revised: 12/28/2023] [Accepted: 01/05/2024] [Indexed: 01/18/2024]
Abstract
Despite recent refinements in the diagnostic and prognostic assessment of CEBPA mutations in AML, several questions remain open, i.e. implications of different types of basic region leucin zipper (bZIP) mutations, the role of co-mutations and the allelic state. Using pooled primary data analysis on 1010 CEBPA-mutant adult AML patients, a comparison was performed taking into account the type of mutation (bZIP: either typical in-frame insertion/deletion (InDel) mutations (bZIPInDel), frameshift InDel or nonsense mutations inducing translational stop (bZIPSTOP) or single base-pair missense alterations (bZIPms), and transcription activation domain (TAD) mutations) and the allelic state (single (smCEBPA) vs. double mutant (dmCEBPA)). Only bZIPInDel patients had significantly higher rates of complete remission and longer relapse free and overall survival (OS) compared with all other CEBPA-mutant subgroups. Moreover, co-mutations in bZIPInDel patients (e.g. GATA2, FLT3, WT1 as well as ELN2022 adverse risk aberrations) had no independent impact on OS, whereas in non-bZIPInDel patients, grouping according to ELN2022 recommendations added significant prognostic information. In conclusion, these results demonstrate bZIPInDel mutations to be the major independent determinant of outcome in CEBPA-mutant AML, thereby refining current classifications according to WHO (including all dmCEBPA and smCEBPA bZIP) as well as ELN2022 and ICC recommendations (including CEBPA bZIPms).
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Affiliation(s)
- Julia-Annabell Georgi
- Medizinische Klinik und Poliklinik 1, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Sebastian Stasik
- Medizinische Klinik und Poliklinik 1, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | | | | | - Christoph Röllig
- Medizinische Klinik und Poliklinik 1, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | | | - Peter Valk
- Erasmus University Medical Center, Rotterdam, Netherlands
| | - David Linch
- Department of Haematology, UCL Cancer Institute, London, UK
| | - Tobias Herold
- Laboratory for Leukemia Diagnostics, Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Nicolas Duployez
- Institut de Recherche contre le Cancer de Lille, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Franziska Taube
- Medizinische Klinik und Poliklinik 1, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jan Moritz Middeke
- Medizinische Klinik und Poliklinik 1, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Uwe Platzbecker
- Klinik und Poliklinik fur Hämatologie, Zelltherapie und Hämostaseologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Hubert Serve
- Medizinische Klinik 2, Universitätsklinikum Frankfurt, Frankfurt am Main, Germany
| | - Claudia D Baldus
- Klinik für Innere Medizin II, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Carsten Muller-Tidow
- Klinik für Hämatologie, Onkologie und Rheumatologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | | | - Sarah Koch
- MLL Münchner Leukämielabor GmbH, Munich, Germany
| | - Wolfgang E Berdel
- Department of Medicine A, University Hospital Münster, Münster, Germany
| | | | - Utz Krug
- Department of Medicine 3, Klinikum Leverkusen, Leverkusen, Germany
| | - Jan Braess
- Department of Oncology and Hematology, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Wolfgang Hiddemann
- Department of Medicine III, University Hospital LMU Munich, Munich, Germany
| | | | | | - Robert K Hills
- Nuffield Department of Population Health, Oxford University, Oxford, UK
| | - Alan Burnett
- Department of Haematology, Cardiff University, University Hospital of Wales, Cardiff, UK
| | | | - Klaus Metzeler
- Klinik und Poliklinik fur Hämatologie, Zelltherapie und Hämostaseologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | | | - Annika Dufour
- Department of Medicine III, University Hospital LMU Munich, Munich, Germany
| | - Hervé Dombret
- Hôpital Saint-Louis (AP-HP), EA 3518, Université de Paris, Paris, France
| | - Cecile Pautas
- Service d'Hématologie et de thérapie cellulaire, Hôpital Henri Mondor, Créteil, France
| | - Claude Preudhomme
- Institut de Recherche contre le Cancer de Lille, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Laurene Fenwarth
- Institut de Recherche contre le Cancer de Lille, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Martin Bornhäuser
- Medizinische Klinik und Poliklinik 1, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Nationales Zentrum für Tumorerkrankungen (NCT), Dresden, Germany
| | - Rosemary Gale
- Department of Haematology, UCL Cancer Institute, London, UK
| | - Christian Thiede
- Medizinische Klinik und Poliklinik 1, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
- AgenDix GmbH, Dresden, Germany.
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Tecik M, Adan A. Therapeutic Targeting of FLT3 in Acute Myeloid Leukemia: Current Status and Novel Approaches. Onco Targets Ther 2022; 15:1449-1478. [PMID: 36474506 PMCID: PMC9719701 DOI: 10.2147/ott.s384293] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/19/2022] [Indexed: 08/13/2023] Open
Abstract
FMS-like tyrosine kinase 3 (FLT3) is mutated in approximately 30% of acute myeloid leukemia (AML) patients. The presence of FLT3-ITD (internal tandem duplication, 20-25%) mutation and, to a lesser extent, FLT3-TKD (tyrosine kinase domain, 5-10%) mutation is associated with poorer diagnosis and therapy response since the leukemic cells become hyperproliferative and resistant to apoptosis after continuous activation of FLT3 signaling. Targeting FLT3 has been the focus of many pre-clinical and clinical studies. Hence, many small-molecule FLT3 inhibitors (FLT3is) have been developed, some of which are approved such as midostaurin and gilteritinib to be used in different clinical settings, either in combination with chemotherapy or alone. However, many questions regarding the best treatment strategy remain to be answered. On the other hand, various FLT3-dependent and -independent resistance mechanisms could be evolved during FLT3i therapy which limit their clinical impact. Therefore, identifying molecular mechanisms of resistance and developing novel strategies to overcome this obstacle is a current interest in the field. In this review, recent studies of approved FLT3i and knowledge about major resistance mechanisms of clinically approved FLT3i's will be discussed together with novel treatment approaches such as designing novel FLT3i and dual FLT3i and combination strategies including approved FLT3i plus small-molecule agents targeting altered molecules in the resistant cells to abrogate resistance. Moreover, how to choose an appropriate FLT3i for the patients will be summarized based on what is currently known from available clinical data. In addition, strategies beyond FLT3i's including immunotherapeutics, small-molecule FLT3 degraders, and flavonoids will be summarized to highlight potential alternatives in FLT3-mutated AML therapy.
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Affiliation(s)
- Melisa Tecik
- Bioengineering Program, Graduate School of Engineering and Science, Abdullah Gul University, Kayseri, Turkey
| | - Aysun Adan
- Department of Molecular Biology and Genetics, Faculty of Life and Natural Sciences, Abdullah Gul University, Kayseri, Turkey
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