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Parmar K, Kundu R, Maiti A, Ball S. Updates in biology, classification, and management of acute myeloid leukemia with antecedent hematologic disorder and therapy related acute myeloid leukemia. Leuk Res 2024; 144:107546. [PMID: 38986173 DOI: 10.1016/j.leukres.2024.107546] [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: 01/20/2024] [Revised: 06/03/2024] [Accepted: 06/21/2024] [Indexed: 07/12/2024]
Abstract
Acute myeloid leukemia with antecedent hematologic disorder (AHD-AML) and therapy related AML (t-AML) constitute a heterogenous disease with inferior outcomes. It is often characterized by high-risk cytogenetic and molecular alterations associated with AHD or prior cancer therapy. Historically, the standard of care treatment has been intensive induction with "7 + 3", with an improved overall response rate and survival with CPX-351. Results from large registry-based studies suggested that allogeneic hematopoietic stem cell transplant is preferable to consolidation chemotherapy alone for achieving long-term survival in patients with AHD-AML. Prevalence of high-risk genetic features and advanced age and comorbidities in patients make AHD-AML and t-AML clinically challenging subgroups to treat with intensive approaches. Recent reports on less intensive treatment options, particularly the hypomethylating agent-venetoclax combination, have shown encouraging response rates in these patients. However, emerging resistance mechanisms compromise duration of response and overall survival. Several novel agents targeting apoptotic machinery, signaling pathways, and immune checkpoints are under clinical investigation, with an aim to truly improve overall outcomes in this subgroup. We reviewed updates in biology, classification, and clinical data comparing safety and efficacy of intensive and less intensive treatment options, and summarized ongoing studies with promising novel therapies in AHD-AML and t-AML.
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Affiliation(s)
- Kanak Parmar
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Rupayan Kundu
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Abhishek Maiti
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Somedeb Ball
- Division of Hematology and Oncology, Vanderbilt University School of Medicine and Vanderbilt-Ingram Cancer Center, Nashville, TN, USA.
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Kovecses O, Mercier FE, McKeague M. Nucleic acid therapeutics as differentiation agents for myeloid leukemias. Leukemia 2024; 38:1441-1454. [PMID: 38424137 PMCID: PMC11216999 DOI: 10.1038/s41375-024-02191-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 02/15/2024] [Accepted: 02/19/2024] [Indexed: 03/02/2024]
Abstract
Differentiation therapy has proven to be a success story for patients with acute promyelocytic leukemia. However, the remaining subtypes of acute myeloid leukemia (AML) are treated with cytotoxic chemotherapies that have limited efficacy and a high likelihood of resistance. As differentiation arrest is a hallmark of AML, there is increased interest in developing differentiation-inducing agents to enhance disease-free survival. Here, we provide a comprehensive review of current reports and future avenues of nucleic acid therapeutics for AML, focusing on the use of targeted nucleic acid drugs to promote differentiation. Specifically, we compare and discuss the precision of small interfering RNA, small activating RNA, antisense oligonucleotides, and aptamers to modulate gene expression patterns that drive leukemic cell differentiation. We delve into preclinical and clinical studies that demonstrate the efficacy of nucleic acid-based differentiation therapies to induce leukemic cell maturation and reduce disease burden. By directly influencing the expression of key genes involved in myeloid maturation, nucleic acid therapeutics hold the potential to induce the differentiation of leukemic cells towards a more mature and less aggressive phenotype. Furthermore, we discuss the most critical challenges associated with developing nucleic acid therapeutics for myeloid malignancies. By introducing the progress in the field and identifying future opportunities, we aim to highlight the power of nucleic acid therapeutics in reshaping the landscape of myeloid leukemia treatment.
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MESH Headings
- Humans
- Cell Differentiation/drug effects
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Nucleic Acids/therapeutic use
- Animals
- Leukemia, Myeloid/drug therapy
- Leukemia, Myeloid/genetics
- Leukemia, Myeloid/pathology
- RNA, Small Interfering/genetics
- RNA, Small Interfering/therapeutic use
- Oligonucleotides, Antisense/therapeutic use
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Affiliation(s)
- Olivia Kovecses
- Department of Pharmacology and Therapeutics, McGill University, Montreal, H3G 1Y6, QC, Canada
| | - François E Mercier
- Division of Hematology and Experimental Medicine, Department of Medicine, McGill University, Montreal, H3T 1E2, QC, Canada
| | - Maureen McKeague
- Department of Pharmacology and Therapeutics, McGill University, Montreal, H3G 1Y6, QC, Canada.
- Department of Chemistry, McGill University, Montreal, H3A 0B8, QC, Canada.
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Kargbo RB. Redefining Cancer Therapy: Toward BCL-XL/BCL-2 Dual Inhibitors with Diminished Platelet Toxicity. ACS Med Chem Lett 2023; 14:1156-1158. [PMID: 37736185 PMCID: PMC10510493 DOI: 10.1021/acsmedchemlett.3c00357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Indexed: 09/23/2023] Open
Abstract
This Patent Highlight focuses on the development of Bcl-xL/Bcl-2 dual inhibitors with minimized platelet toxicity to improve cancer treatment strategies. Acknowledging the critical role of antiapoptotic Bcl-2 family proteins in cancer pathogenesis, the paper reviews various inhibitors, notably venetoclax. Despite its success, resistance due to Bcl-xL upregulation prompted interest in dual inhibitors like ABT-263. However, their use often incurs platelet toxicity. Hence, this Patent Highlight showcases the synthesis of new compounds that could maintain potent antitumor effects while preserving platelet viability. This novel approach could redefine cancer therapy, offering more effective treatment for Bcl-2-driven cancers.
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Fedorov K, Maiti A, Konopleva M. Targeting FLT3 Mutation in Acute Myeloid Leukemia: Current Strategies and Future Directions. Cancers (Basel) 2023; 15:cancers15082312. [PMID: 37190240 DOI: 10.3390/cancers15082312] [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: 03/01/2023] [Revised: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 05/17/2023] Open
Abstract
FLT3 mutations are present in 30% of newly diagnosed patients with acute myeloid leukemia. Two broad categories of FLT3 mutations are ITD and TKD, with the former having substantial clinical significance. Patients with FLT3-ITD mutation present with a higher disease burden and have inferior overall survival, due to high relapse rates after achieving remission. The development of targeted therapies with FLT3 inhibitors over the past decade has substantially improved clinical outcomes. Currently, two FLT3 inhibitors are approved for use in patients with acute myeloid leukemia: midostaurin in the frontline setting, in combination with intensive chemotherapy; and gilteritinib as monotherapy in the relapsed refractory setting. The addition of FLT3 inhibitors to hypomethylating agents and venetoclax offers superior responses in several completed and ongoing studies, with encouraging preliminary data. However, responses to FLT3 inhibitors are of limited duration due to the emergence of resistance. A protective environment within the bone marrow makes eradication of FLT3mut leukemic cells difficult, while prior exposure to FLT3 inhibitors leads to the development of alternative FLT3 mutations as well as activating mutations in downstream signaling, promoting resistance to currently available therapies. Multiple novel therapeutic strategies are under investigation, including BCL-2, menin, and MERTK inhibitors, as well as FLT3-directed BiTEs and CAR-T therapy.
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Affiliation(s)
- Kateryna Fedorov
- Department of Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Abhishek Maiti
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Marina Konopleva
- Department of Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA
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Akiyama H, Carter BZ, Andreeff M, Ishizawa J. Molecular Mechanisms of Ferroptosis and Updates of Ferroptosis Studies in Cancers and Leukemia. Cells 2023; 12:1128. [PMID: 37190037 PMCID: PMC10136912 DOI: 10.3390/cells12081128] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/04/2023] [Accepted: 04/07/2023] [Indexed: 05/17/2023] Open
Abstract
Ferroptosis is a mode of cell death regulated by iron-dependent lipid peroxidation. Growing evidence suggests ferroptosis induction as a novel anti-cancer modality that could potentially overcome therapy resistance in cancers. The molecular mechanisms involved in the regulation of ferroptosis are complex and highly dependent on context. Therefore, a comprehensive understanding of its execution and protection machinery in each tumor type is necessary for the implementation of this unique cell death mode to target individual cancers. Since most of the current evidence for ferroptosis regulation mechanisms is based on solid cancer studies, the knowledge of ferroptosis with regard to leukemia is largely lacking. In this review, we summarize the current understanding of ferroptosis-regulating mechanisms with respect to the metabolism of phospholipids and iron as well as major anti-oxidative pathways that protect cells from ferroptosis. We also highlight the diverse impact of p53, a master regulator of cell death and cellular metabolic processes, on the regulation of ferroptosis. Lastly, we discuss recent ferroptosis studies in leukemia and provide a future perspective for the development of promising anti-leukemia therapies implementing ferroptosis induction.
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Affiliation(s)
| | | | | | - Jo Ishizawa
- Section of Molecular Hematology and Therapy, Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (H.A.); (B.Z.C.); (M.A.)
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Garciaz S, Miller T, Collette Y, Vey N. Targeting regulated cell death pathways in acute myeloid leukemia. CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2023; 6:151-168. [PMID: 37065864 PMCID: PMC10099605 DOI: 10.20517/cdr.2022.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 01/24/2023] [Accepted: 03/01/2023] [Indexed: 03/17/2023]
Abstract
The use of the BCL2 inhibitor venetoclax has transformed the management of patients with acute myeloid leukemia (AML) who are ineligible for intensive chemotherapy. By triggering intrinsic apoptosis, the drug is an excellent illustration of how our greater understanding of molecular cell death pathways can be translated into the clinic. Nevertheless, most venetoclax-treated patients will relapse, suggesting the need to target additional regulated cell death pathways. To highlight advances in this strategy, we review the recognized regulated cell death pathways, including apoptosis, necroptosis, ferroptosis and autophagy. Next, we detail the therapeutic opportunities to trigger regulated cell death in AML. Finally, we describe the main drug discovery challenges for regulated cell death inducers and their translation into clinical trials. A better knowledge of the molecular pathways regulating cell death represents a promising strategy to develop new drugs to cure resistant or refractory AML patients, particularly those resistant to intrinsic apoptosis.
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Affiliation(s)
- Sylvain Garciaz
- Hematology Department, Integrative Structural and Chemical Biology, Aix-Marseille Université, Inserm U1068, CNRS UMR7258, Institut Paoli-Calmettes, Centre de Recherche en Cancérologie de Marseille (CRCM), Marseille 13009, France
| | - Thomas Miller
- Integrative Structural and Chemical Biology, Aix-Marseille Université, Inserm U1068, CNRS UMR7258, Institut Paoli-Calmettes, Centre de Recherche en Cancérologie de Marseille (CRCM), Marseille 13009, France
| | - Yves Collette
- Integrative Structural and Chemical Biology, Aix-Marseille Université, Inserm U1068, CNRS UMR7258, Institut Paoli-Calmettes, Centre de Recherche en Cancérologie de Marseille (CRCM), Marseille 13009, France
| | - Norbert Vey
- Hematology Department, Aix-Marseille Université, Inserm U1068, CNRS UMR7258, Institut Paoli-Calmettes, Centre de Recherche en Cancérologie de Marseille (CRCM), Marseille 13009, France
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Gandhi A, Andrick B, Darling J, Truong T, Signorelli J. Oral Antineoplastics in Acute Myeloid Leukemia: A Comprehensive Review. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e1033-e1049. [PMID: 36192350 DOI: 10.1016/j.clml.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 01/26/2023]
Abstract
AML is a biologically and clinically heterogeneous disease that is associated with poor overall long-term survival. The expanding knowledge of genomic landscape in AML as well as advancements in molecular and chemical biology over the pathway in AML. After 40 years of stagnancy, the recent approval of numerous novel oral anti-leukemic agents for the treatment of AML has changed both the armamentarium of medications and treatment paradigms. These agents have unique clinical considerations in terms of administration, adverse effects, and monitoring parameters which may differ from clinician's historical expectations. Understanding the data, indication and clinical considerations for such novel oral anti-leukemic agents is paramount for clinicians caring patients with AML.
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Affiliation(s)
- Arpita Gandhi
- Assistant Director, Hematology/Oncology Clinical Pharmacy Specialist, Emory Healthcare, Atlanta, GA.
| | - Benjamin Andrick
- Assistant Professor, Clinical Research, Center for Pharmacy Innovations and Outcomes, Geisinger Health, Hematology/Oncology Pharmacy, Danville, PA
| | - Julianne Darling
- Manger of Education, National Community Oncology Dispensing Association, Inc., Cazenovia, NY
| | - Tuyet Truong
- Northeastern University School of Pharmacy, Boston, MA
| | - Jessie Signorelli
- Clinical Pharmacist Specialist, Hematology, Massachusetts General Hospital, Boston, MA
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