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Pollard JA, Alonzo TA, Gerbing R, Brown P, Fox E, Choi J, Fisher B, Hirsch B, Kahwash S, Getz K, Levine J, Brodersen LE, Loken MR, Raimondi S, Tarlock K, Wood A, Sung L, Kolb EA, Gamis A, Meshinchi S, Aplenc R. Sorafenib in Combination With Standard Chemotherapy for Children With High Allelic Ratio FLT3/ITD+ Acute Myeloid Leukemia: A Report From the Children's Oncology Group Protocol AAML1031. J Clin Oncol 2022; 40:2023-2035. [PMID: 35349331 PMCID: PMC9197362 DOI: 10.1200/jco.21.01612] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/05/2022] [Accepted: 02/03/2022] [Indexed: 01/17/2023] Open
Abstract
PURPOSE High allelic ratio (HAR) FLT3/ITD (AR > 0.4) mutations confer poor prognosis in pediatric acute myeloid leukemia (AML). COG AAML1031 studied the feasibility and efficacy of adding sorafenib, a multikinase tyrosine kinase inhibitor to standard chemotherapy and as single-agent maintenance therapy in this population. MATERIALS AND METHODS Patients were treated in three cohorts. The initial safety phase defined the maximum tolerated dose of sorafenib starting in induction 2. Cohorts 2 and 3 added sorafenib in induction and as single-agent maintenance. Clinical outcome analysis was limited to n = 72 patients in cohorts 2/3 and compared with n = 76 HAR FLT3/ITD+ AML patients who received identical chemotherapy without sorafenib. Sorafenib pharmacokinetics and plasma inhibitory activity were measured in a subset of patients. RESULTS The maximum tolerated dose of sorafenib was 200 mg/m2 once daily; dose-limiting toxicities included rash (n = 2; 1 grade 3 and 1 grade 2), grade 2 hand-foot syndrome, and grade 3 fever. Pharmacokinetics/plasma inhibitory activity data demonstrated that measured plasma concentrations were sufficient to inhibit phosphorylated FLT3. Although outcomes were superior with sorafenib in cohorts 2 and 3, patients treated with sorafenib also underwent hematopoietic stem-cell transplant more frequently than the comparator population. Multivariable analysis that accounted for both hematopoietic stem-cell transplant and favorable co-occurring mutations confirmed sorafenib's benefit. Specifically, risk of an event was approximately two-fold higher in HAR FLT3/ITD+ patients who did not receive sorafenib (event-free survival from study entry: hazard ratio [HR] 2.37, 95% CI, 1.45 to 3.88, P < .001, disease-free survival from complete remission: HR 2.28, 95% CI, 1.08 to 4.82, P = .032, relapse risk from complete remission: HR 3.03, 95% CI 1.31 to 7.04, P = .010). CONCLUSION Sorafenib can be safely added to conventional AML chemotherapy and may improve outcomes in pediatric HAR FLT3/ITD+ AML.
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Affiliation(s)
- Jessica A. Pollard
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Todd A. Alonzo
- University of Southern California Keck School of Medicine, Los Angeles, CA
| | | | - Patrick Brown
- Johns Hopkins Kimmel Comprehensive Cancer Center, Baltimore, MD
| | | | - John Choi
- University of Alabama, Birmingham AL
| | - Brian Fisher
- Children's Hospital of Philadelphia, Philadelphia, PA
| | | | | | - Kelly Getz
- University of Pennsylvania, Department of Epidemiology, Biostatistics and Informatics, Philadelphia, PA
| | | | | | | | | | - Katherine Tarlock
- Fred Hutchinson Cancer Research Center, Seattle, WA
- Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Andrew Wood
- University of Auckland, Auckland, New Zealand
| | | | | | - Alan Gamis
- Children's Mercy Hospital and Clinics, Kansas City, MO
| | - Soheil Meshinchi
- Fred Hutchinson Cancer Research Center, Seattle, WA
- Seattle Children's Hospital, University of Washington, Seattle, WA
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2
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Chen Z, Han C, Wang X, He Y, Liang T, Mo S, Li X, Zhu G, Su H, Ye X, Lv Z, Shang L, Wen Z, Peng M, Peng T. Graft versus host disease after liver transplantation following radiotherapy for the treatment of hepatocellular carcinoma: A case report and literature review. SAGE Open Med Case Rep 2022; 10:2050313X221101747. [PMID: 35646373 PMCID: PMC9136437 DOI: 10.1177/2050313x221101747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 04/27/2022] [Indexed: 11/16/2022] Open
Abstract
Graft versus host disease after solid organ transplantation is very rare. This article reports a case of graft versus host disease after liver transplantation following targeted therapy and radiotherapy for the treatment of hepatocellular carcinoma. The patient developed a symptomatic skin rash and pancytopenia 13 days after surgery, which was confirmed as graft versus host disease after liver transplantation by histopathology and fluorescence in situ hybridization. Early diagnosis of graft versus host disease after solid organ transplantation is difficult and often delayed due to nonspecific manifestations that overlap with other diseases. Currently, the treatment of graft versus host disease after liver transplantation occurs by either strengthening the immune suppression or weakening the immune suppression; however, there is no unified standard treatment strategy. We found that in addition to age, gender, and human leukocyte antigen type, preoperative radiotherapy is a likely risk factor for graft versus host disease after liver transplantation.
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Affiliation(s)
- Zijun Chen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Chuangye Han
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiangkun Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yongfei He
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Tianyi Liang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shutian Mo
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xuan Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Guangzhi Zhu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Hao Su
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xinping Ye
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zili Lv
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Liming Shang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zhang Wen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Minhao Peng
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Tao Peng
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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3
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FLT3-inhibitor therapy for prevention and treatment of relapse after allogeneic hematopoietic cell transplantation. Int J Hematol 2022; 116:341-350. [PMID: 35460465 PMCID: PMC9392688 DOI: 10.1007/s12185-022-03352-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 02/05/2023]
Abstract
The curative potential of allogeneic hematopoietic cell transplantation (allo-HCT) for acute myeloid leukemia (AML) relies on the graft-versus-leukemia (GVL)-effect. Relapse after allo-HCT occurs in a considerable proportion of patients, and has a dismal prognosis with very limited curative potential, especially for patients with FLT-ITD-mutated AML. Since the first description of sorafenib for treatment of FLT3-ITD-mutated AML, several clinical trials have tried to determine the efficacy of FLT3 inhibitors for preventing and treating AML relapse after allo-HSCT, but many questions regarding differences among compounds and mechanisms of action remain unanswered. This review provides an overview on the established and evolving use of FLT3 inhibitors to prevent or treat relapse of AML in the context of allo-HCT, focusing on the recently discovered immunogenic potential of some FLT3 inhibitors and addressing the possible mechanisms of leukemia drug-escape.
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4
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Bazarbachi A, Bug G, Baron F, Brissot E, Ciceri F, Dalle IA, Döhner H, Esteve J, Floisand Y, Giebel S, Gilleece M, Gorin NC, Jabbour E, Aljurf M, Kantarjian H, Kharfan-Dabaja M, Labopin M, Lanza F, Malard F, Peric Z, Prebet T, Ravandi F, Ruggeri A, Sanz J, Schmid C, Shouval R, Spyridonidis A, Versluis J, Vey N, Savani BN, Nagler A, Mohty M. Clinical practice recommendation on hematopoietic stem cell transplantation for acute myeloid leukemia patients with FLT3-internal tandem duplication: a position statement from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation. Haematologica 2020; 105:1507-1516. [PMID: 32241850 PMCID: PMC7271578 DOI: 10.3324/haematol.2019.243410] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/19/2020] [Indexed: 12/13/2022] Open
Abstract
The FMS-like tyrosine kinase 3 (FLT3) gene is mutated in 25-30% of patients with acute myeloid leukemia (AML). Because of the poor prognosis associated with FLT3-internal tandem duplication mutated AML, allogeneic hematopoietic stem-cell transplantation (SCT) was commonly performed in first complete remission. Remarkable progress has been made in frontline treatments with the incorporation of FLT3 inhibitors and the development of highly sensitive minimal/measurable residual disease assays. Similarly, recent progress in allogeneic hematopoietic SCT includes improvement of transplant techniques, the use of haploidentical donors in patients lacking an HLA matched donor, and the introduction of FLT3 inhibitors as post-transplant maintenance therapy. Nevertheless, current transplant strategies vary between centers and differ in terms of transplant indications based on the internal tandem duplication allelic ratio and concomitant nucleophos-min-1 mutation, as well as in terms of post-transplant maintenance/consolidation. This review generated by international leukemia or transplant experts, mostly from the European Society for Blood and Marrow Transplantation, attempts to develop a position statement on best approaches for allogeneic hematopoietic SCT for AML with FLT3-internal tandem duplication including indications for and modalities of such transplants and on the potential optimization of post-transplant maintenance with FLT inhibitors.
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Affiliation(s)
- Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Department of Anatomy, Cell Biology, and Physiological Sciences, American University of Beirut, Beirut, Lebanon
| | - Gesine Bug
- Department of Medicine 2, Hematology and Oncology, University Hospital, Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | - Eolia Brissot
- Sorbonne Universités, UPMC University of Paris 06, INSERM, Centre de Recherche Saint-Antoine (CRSA), Hematology Department, AP-HP, Saint Antoine Hospital, Paris, France
| | - Fabio Ciceri
- Vita-Salute San Raffaele University of Milan, Milan, ItalyHematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Iman Abou Dalle
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hartmut Döhner
- Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany
| | - Jordi Esteve
- Hematology Department, Hospital Clínic of Barcelona, IDIBAPS, University of Barcelona, Barcellona, Spain
| | - Yngvar Floisand
- Department of Hematology, Oslo University Hospital - Rikshospitalet, Oslo, Norway
- Center for Cancer Cell Reprogramming, Institute for Cancer Research, Oslo University Hospital, Montebello, Oslo, Norway
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Oncohematology, Maria Sklodowska-Curie Institute - Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Maria Gilleece
- Department of Haematology, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Norbert-Claude Gorin
- Department of Hematology and Cell Therapy, European Society for Blood and Marrow Transplantation, Paris Office, Hopital Saint-Antoine, Paris, France
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mahmoud Aljurf
- Department of Hematology King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mohamed Kharfan-Dabaja
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapies Program, Mayo Clinic, Jacksonville, FL, USA
| | - Myriam Labopin
- Acute Leukemia Working Party, Paris Study Office, European Society for Blood and Marrow Transplantation, Paris, France
- Sorbonne Universités, UPMC University of Paris 06, INSERM, Centre de Recherche Saint-Antoine (CRSA), Hematology Department, AP-HP, Saint Antoine Hospital, Paris, France
| | | | - Florent Malard
- Sorbonne Universités, UPMC University of Paris 06, INSERM, Centre de Recherche Saint-Antoine (CRSA), Hematology Department, AP-HP, Saint Antoine Hospital, Paris, France
| | - Zinaida Peric
- University Hospital Center Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Thomas Prebet
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Annalisa Ruggeri
- Department of Pediatric Hematology and Oncology, IRCCS Bambino Gesù Children's Hospital, Roma, ItalyEurocord, Hôpital Saint Louis, Paris, France
| | - Jaime Sanz
- Hematology Department, Hospital Universitari i Politecnic La Fe. Instituto de Investigación Sanitaria La Fe, Valencia, CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Christoph Schmid
- Department of Hematology and Oncology, Augsburg University Hospital, Augsburg, Germany
| | - Roni Shouval
- Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Jurjen Versluis
- Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Norbert Vey
- Department of Hematology, Institut Paoli-Calmettes, Marseille, France
| | - Bipin N Savani
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arnon Nagler
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Israel
| | - Mohamad Mohty
- Sorbonne Universités, UPMC University of Paris 06, INSERM, Centre de Recherche Saint-Antoine (CRSA), Hematology Department, AP-HP, Saint Antoine Hospital, Paris, France
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5
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Bazarbachi A, Labopin M, Battipaglia G, Djabali A, Forcade E, Arcese W, Socié G, Blaise D, Halter J, Gerull S, Cornelissen JJ, Chevallier P, Maertens J, Schaap N, El-Cheikh J, Esteve J, Nagler A, Mohty M. Allogeneic Stem Cell Transplantation for FLT3-Mutated Acute Myeloid Leukemia: In vivo T-Cell Depletion and Posttransplant Sorafenib Maintenance Improve Survival. A Retrospective Acute Leukemia Working Party-European Society for Blood and Marrow Transplant Study. Clin Hematol Int 2019; 1:58-74. [PMID: 34595412 PMCID: PMC8432385 DOI: 10.2991/chi.d.190310.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 02/20/2019] [Indexed: 12/23/2022] Open
Abstract
Acute myeloid leukemia (AML) with FLT3-mutation carries a poor prognosis, and allogeneic stem cell transplantation (allo-SCT) is recommended at first complete remission (CR1). We assessed 462 adults (median age 50 years) with FLT3-mutated AML allografted between 2010 and 2015 from a matched related (40%), unrelated (49%), or haploidentical donor (11%). The median follow-up of alive patients was 39 months. Day-100 acute graft versus host disease (GVHD) grades II–IV and III–IV were encountered in 26% and 9%, whereas the 2-year incidence of chronic and extensive chronic GVHD were 34% and 16%, respectively. The 2-year incidences of relapse and nonrelapse mortality were 34% and 15%, respectively. The 2-year leukemia-free survival, overall survival (OS), and GVHD relapse-free survival (GRFS) were 51%, 59%, and 38%, respectively. In multivariate analysis, NPM1-mutation, transplantation in CR1, in vivo T-cell depletion, and posttransplant sorafenib improved OS, whereas more than one induction (late CR1) negatively affected OS. Similarly, NPM1-mutation, a haploidentical donor, T-cell depletion, and sorafenib maintenance improved GRFS, whereas late CR1 or persistent disease negatively affected it. In conclusion, FLT3-mutated AML remains a challenge even following allo-SCT. In vivo T-cell depletion and posttransplant sorafenib significantly improve OS and GRFS, and may be considered as standard of care.
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Affiliation(s)
- Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.,Department of Anatomy, Cell Biology, and Physiological Sciences, American University of Beirut, Beirut, Lebanon
| | | | - Giorgia Battipaglia
- Department of hematology and cellular therapy Hopital Saint Antoine, Paris, France.,Department of hematology and cellular therapy, Hopital Saint Antoine, Université Pierre & Marie Curie, INSERM, UMRs 938, Paris, France
| | | | - Edouard Forcade
- Department of Hematology, CHU Bordeaux Hôpital Haut-leveque, Pessac, France
| | - William Arcese
- Department of Stem cell transplant, Tor Vergata University of Rome, Rome, Italy
| | - Gerard Socié
- Department of Hematology-bone marrow transplant, Hopital Saint Louis, Paris, France
| | - Didier Blaise
- Department of Hematology, programme de Transplantation & Therapie Cellulaire, Centre de Recherche en Cancérologie de Marseille, Institut Paoli Calmettes, Marseille, France
| | - Joerg Halter
- Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Sabine Gerull
- Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Jan J Cornelissen
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Johan Maertens
- Department of Hematology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Nicolaas Schaap
- Department of Hematology, Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Jean El-Cheikh
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jordi Esteve
- Hematology Department, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - Arnon Nagler
- Department of Hematology, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Mohamad Mohty
- Department of hematology and cellular therapy Hopital Saint Antoine, Paris, France.,Department of hematology and cellular therapy, Hopital Saint Antoine, Université Pierre & Marie Curie, INSERM, UMRs 938, Paris, France
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6
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Bazarbachi A, Labopin M, Battipaglia G, Djabali A, Passweg J, Socié G, Forcade E, Blaise D, Chevallier P, Orvain C, Cornelissen JJ, Arcese W, Chantepie S, Hashaishi K, El Cheikh J, Medinger M, Esteve J, Nagler A, Mohty M. Sorafenib improves survival of FLT3-mutated acute myeloid leukemia in relapse after allogeneic stem cell transplantation: a report of the EBMT Acute Leukemia Working Party. Haematologica 2019; 104:e398-e401. [PMID: 30792203 DOI: 10.3324/haematol.2018.211615] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon .,Department of Cell Biology, Anatomy and Physiological Sciences, American University of Beirut, Beirut, Lebanon
| | - Myriam Labopin
- Acute Leukemia Working Party of EBMT, Paris, France.,Hematology Department, Hôpital Saint Antoine, Service d'Hématologie et Thérapie Cellulaire, Paris, France.,Hôpital Saint Antoine, Université Pierre and Marie Curie, INSERM, UMRs 938, Paris, France
| | - Giorgia Battipaglia
- Hematology Department, Hôpital Saint Antoine, Service d'Hématologie et Thérapie Cellulaire, Paris, France.,Hematology Department, Federico II University of Naples, Naples, Italy
| | - Azedine Djabali
- Acute Leukemia Working Party of EBMT, Paris, France.,Hematology Department, Hôpital Saint Antoine, Service d'Hématologie et Thérapie Cellulaire, Paris, France
| | | | - Gerard Socié
- Hôpital Saint Louis, Department of Hematology - BMT, Paris, France
| | | | - Didier Blaise
- Programme de Transplantation and Therapie Cellulaire, Centre de Recherche en Cancérologie de Marseille, Institut Paoli Calmettes, Marseille, France
| | | | | | | | - William Arcese
- Tor Vergata University of Rome, Stem Cell Transplant Unit, Policlinico Universitario Tor Vergata, Rome, Italy
| | | | | | - Jean El Cheikh
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | | | - Jordi Esteve
- Acute Leukemia Working Party of EBMT, Paris, France.,Hematology Department, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - Arnon Nagler
- Acute Leukemia Working Party of EBMT, Paris, France.,Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Mohamad Mohty
- Acute Leukemia Working Party of EBMT, Paris, France.,Hematology Department, Hôpital Saint Antoine, Service d'Hématologie et Thérapie Cellulaire, Paris, France.,Hôpital Saint Antoine, Université Pierre and Marie Curie, INSERM, UMRs 938, Paris, France
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7
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Battipaglia G, Ruggeri A, Massoud R, El Cheikh J, Jestin M, Antar A, Ahmed SO, Rasheed W, Shaheen M, Belhocine R, Brissot E, Dulery R, Eder S, Giannotti F, Isnard F, Lapusan S, Rubio MT, Vekhoff A, Aljurf M, Legrand O, Mohty M, Bazarbachi A. Efficacy and feasibility of sorafenib as a maintenance agent after allogeneic hematopoietic stem cell transplantation for Fms-like tyrosine kinase 3-mutated acute myeloid leukemia. Cancer 2017; 123:2867-2874. [PMID: 28387928 DOI: 10.1002/cncr.30680] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 02/02/2017] [Accepted: 02/09/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Sorafenib has shown encouraging results in patients with Fms-like tyrosine kinase 3 (FLT3)-positive acute myeloid leukemia. Its role after allogeneic stem cell transplantation (HSCT) has been reported in a few cases with encouraging results. METHODS The authors describe the use of sorafenib as a maintenance agent after HSCT in 27 patients with FLT3-positive acute myeloid leukemia. RESULTS The median age of the patients was 46 years (range, 15-57 years). Sorafenib was introduced at a median of 70 days (range, 29-337 days) after HSCT. The median treatment duration was 8.4 months (range, 0.2-46 months). Eleven patients experienced treatment toxicities, mainly of grade 1 to 2 (graded according to the National Cancer Institute Common Toxicity Criteria [version 4.0]). Dose reduction or withdrawal was required in 4 patients and 4 patients, respectively. The persistence of toxicity prompted treatment withdrawal in 1 patient. Clinical improvement followed dose modifications. Thirteen patients experienced chronic graft-versus-host disease (limited in 9 patients and extensive in 4 patients), resulting in dose reduction in 5 patients followed by withdrawal in 1 of these individuals. At a median follow-up of 18 months (range, 4-48 months), 25 patients were alive (all of whom were in complete molecular remission) and 18 were still receiving treatment, with 1-year overall survival and progression-free survival rates of 92% ± 6% and 92% ± 5%, respectively. CONCLUSIONS Sorafenib treatment after HSCT appears to be feasible and highly effective with dose individualization according to patient tolerability. Further analysis is needed to evaluate the immunomodulating role of sorafenib after HSCT. The data from the current support prospective controlled trials of sorafenib after HSCT. Cancer 2017;123:2867-74. © 2017 American Cancer Society.
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Affiliation(s)
- Giorgia Battipaglia
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France.,Department of Hematology and Marrow Transplantation, Federico II University, Naples, Italy
| | - Annalisa Ruggeri
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Radwan Massoud
- Bone Marrow Transplantation Program, Department of Internal Medicine, American Universit6y of Beirut Medical Center, Beirut, Lebanon
| | - Jean El Cheikh
- Bone Marrow Transplantation Program, Department of Internal Medicine, American Universit6y of Beirut Medical Center, Beirut, Lebanon
| | - Matthieu Jestin
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Ahmad Antar
- Bone Marrow Transplantation Program, Department of Internal Medicine, American Universit6y of Beirut Medical Center, Beirut, Lebanon
| | - Syed Osman Ahmed
- Adult Hematology/HSCT Section, Oncology Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Walid Rasheed
- Adult Hematology/HSCT Section, Oncology Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Marwan Shaheen
- Adult Hematology/HSCT Section, Oncology Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ramdane Belhocine
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Eolia Brissot
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Remy Dulery
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Sandra Eder
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Federica Giannotti
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Francoise Isnard
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Simona Lapusan
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Marie-Therese Rubio
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Anne Vekhoff
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Mahmoud Aljurf
- Adult Hematology/HSCT Section, Oncology Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ollivier Legrand
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Mohamad Mohty
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France.,Hospital Saint-Antoine, Paris University UPMC, Paris, France.,INSERM, Paris, France
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American Universit6y of Beirut Medical Center, Beirut, Lebanon.,Department of Cell Biology, Anatomy and Physiological Sciences, American University of Beirut, Beirut, Lebanon
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8
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Abstract
Myelodysplastic syndrome (MDS) is a heterogeneous, clonal stem cell disorder of the blood and marrow typically diagnosed based on the presence of persistent cytopenia(s), dysplastic cells, and genetic markers. Common issues that arise in the clinical management include difficulty confirming MDS diagnosis, lack of a standard approach with novel agents in MDS, and few prospective long-term, randomized controlled MDS clinical studies to guide allogeneic blood and marrow transplant. With the recent genetic characterization of MDS, certain aspects of these issues will be better addressed by integrating genetic data into clinical study design and clinical practice.
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Affiliation(s)
- Kim-Hien T Dao
- Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Mail Code: UHN73C, 3181 South West Sam Jackson Park Road, Portland, OR 97239, USA.
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9
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Rautenberg C, Nachtkamp K, Dienst A, Schmidt PV, Heyn C, Kondakci M, Germing U, Haas R, Kobbe G, Schroeder T. Sorafenib and azacitidine as salvage therapy for relapse of FLT3-ITD mutated AML after allo-SCT. Eur J Haematol 2017; 98:348-354. [DOI: 10.1111/ejh.12832] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Christina Rautenberg
- Department of Hematology, Oncology and Clinical Immunology; Medical Faculty; University of Duesseldorf; Duesseldorf Germany
| | - Kathrin Nachtkamp
- Department of Hematology, Oncology and Clinical Immunology; Medical Faculty; University of Duesseldorf; Duesseldorf Germany
| | - Ariane Dienst
- Department of Hematology, Oncology and Clinical Immunology; Medical Faculty; University of Duesseldorf; Duesseldorf Germany
| | - Pia Verena Schmidt
- Department of Hematology, Oncology and Clinical Immunology; Medical Faculty; University of Duesseldorf; Duesseldorf Germany
| | - Claudia Heyn
- Department of Hematology, Oncology and Clinical Immunology; Medical Faculty; University of Duesseldorf; Duesseldorf Germany
| | - Mustafa Kondakci
- Department of Hematology, Oncology and Clinical Immunology; Medical Faculty; University of Duesseldorf; Duesseldorf Germany
| | - Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology; Medical Faculty; University of Duesseldorf; Duesseldorf Germany
| | - Rainer Haas
- Department of Hematology, Oncology and Clinical Immunology; Medical Faculty; University of Duesseldorf; Duesseldorf Germany
| | - Guido Kobbe
- Department of Hematology, Oncology and Clinical Immunology; Medical Faculty; University of Duesseldorf; Duesseldorf Germany
| | - Thomas Schroeder
- Department of Hematology, Oncology and Clinical Immunology; Medical Faculty; University of Duesseldorf; Duesseldorf Germany
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10
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Lee CJ, Shiraz P, Muffly L. Pharmacologic maintenance strategies following allogeneic hematopoietic cell transplantation for acute myeloid leukemia. Leuk Lymphoma 2016; 58:516-527. [PMID: 27685315 DOI: 10.1080/10428194.2016.1205744] [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: 10/21/2022]
Abstract
The use of pharmacologic agents to maintain remission following allogeneic hematopoietic cell transplantation (HCT) is a topic of increasing interest and exploration for patients with high-risk acute myeloid leukemia (AML). This review details published and ongoing studies focused on post-transplant pharmacologic maintenance for AML. While early phase studies have demonstrated the safety and tolerability of various maintenance approaches following HCT, the results of several ongoing randomized prospective studies will be required to determine the clinical efficacy needed to expand this approach from experimental to standard of care.
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Affiliation(s)
- Catherine J Lee
- a Huntsman Cancer Institute, University of Utah, Blood and Marrow Transplantation Program , Salt Lake City , UT , USA
| | - Parveen Shiraz
- b Division of Blood and Marrow Transplantation , Stanford University , Stanford , CA , USA
| | - Lori Muffly
- b Division of Blood and Marrow Transplantation , Stanford University , Stanford , CA , USA
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11
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Addition of sorafenib versus placebo to standard therapy in patients aged 60 years or younger with newly diagnosed acute myeloid leukaemia (SORAML): a multicentre, phase 2, randomised controlled trial. Lancet Oncol 2015; 16:1691-9. [DOI: 10.1016/s1470-2045(15)00362-9] [Citation(s) in RCA: 276] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 09/20/2015] [Accepted: 09/23/2015] [Indexed: 01/07/2023]
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12
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De Freitas T, Marktel S, Piemontese S, Carrabba MG, Tresoldi C, Messina C, Lupo Stanghellini MT, Assanelli A, Corti C, Bernardi M, Peccatori J, Vago L, Ciceri F. High rate of hematological responses to sorafenib in FLT3-ITD acute myeloid leukemia relapsed after allogeneic hematopoietic stem cell transplantation. Eur J Haematol 2015; 96:629-36. [DOI: 10.1111/ejh.12647] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Tiago De Freitas
- Unit of Hematology and Bone Marrow Transplantation; IRCCS San Raffaele Scientific Institute; Milan Italy
| | - Sarah Marktel
- Unit of Hematology and Bone Marrow Transplantation; IRCCS San Raffaele Scientific Institute; Milan Italy
| | - Simona Piemontese
- Unit of Hematology and Bone Marrow Transplantation; IRCCS San Raffaele Scientific Institute; Milan Italy
| | - Matteo G. Carrabba
- Unit of Hematology and Bone Marrow Transplantation; IRCCS San Raffaele Scientific Institute; Milan Italy
| | - Cristina Tresoldi
- Molecular Hematology Laboratory; IRCCS San Raffaele Scientific Institute; Milan Italy
| | - Carlo Messina
- Unit of Hematology and Bone Marrow Transplantation; IRCCS San Raffaele Scientific Institute; Milan Italy
| | | | - Andrea Assanelli
- Unit of Hematology and Bone Marrow Transplantation; IRCCS San Raffaele Scientific Institute; Milan Italy
| | - Consuelo Corti
- Unit of Hematology and Bone Marrow Transplantation; IRCCS San Raffaele Scientific Institute; Milan Italy
| | - Massimo Bernardi
- Unit of Hematology and Bone Marrow Transplantation; IRCCS San Raffaele Scientific Institute; Milan Italy
| | - Jacopo Peccatori
- Unit of Hematology and Bone Marrow Transplantation; IRCCS San Raffaele Scientific Institute; Milan Italy
| | - Luca Vago
- Unit of Hematology and Bone Marrow Transplantation; IRCCS San Raffaele Scientific Institute; Milan Italy
- Unit of Immunogenetics; Leukemia Genomics and Immunobiology; IRCCS San Raffaele Scientific Institute; Milan Italy
| | - Fabio Ciceri
- Unit of Hematology and Bone Marrow Transplantation; IRCCS San Raffaele Scientific Institute; Milan Italy
- Vita-Salute San Raffaele University; Milan Italy
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13
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Fathi AT, Chen YB. Treatment of relapse of acute myeloid leukemia after allogeneic hematopoietic stem cell transplantation. Curr Hematol Malig Rep 2015; 9:186-92. [PMID: 24643311 DOI: 10.1007/s11899-014-0209-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Disease relapse remains a major cause of mortality for patients with acute myeloid leukemia (AML) undergoing allogeneic hematopoietic stem cell transplantation (HSCT). Historically, patients who experience disease relapse after HSCT have a dismal prognosis with very few long-term survivors. There is no standard treatment for patients in this situation given the variability in patient characteristics, disease biology, complications such as graft-vs.-host disease (GVHD) and infections, donor availability, and patient choice. Here, we discuss the current options for treatment of relapsed AML after HSCT including conventional chemotherapy, novel agents, donor leukocyte infusion, second allogeneic HSCT, and emerging therapies.
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Affiliation(s)
- Amir T Fathi
- Center for Leukemia, Massachusetts General Hospital, Zero Emerson Place, Suite 118, Boston, MA, 02114, USA,
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14
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Abstract
Despite the enormously important and gratifying advances in cancer treatment outcomes for children with cancer, cancer remains the biggest cause of death from disease in children. Because the etiology and biology of cancers that occur in children differ dramatically from those that occur in adults, the immediate extrapolation of efficacy and safety of new cancer drugs to childhood cancer indications is not possible. We discuss factors that will play key roles in guiding pediatric oncologists as they select lines of research to pursue in their quest for more effective treatments for children with cancer.
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Sorafenib Maintenance Appears Safe and Improves Clinical Outcomes in FLT3-ITD Acute Myeloid Leukemia After Allogeneic Hematopoietic Cell Transplantation. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2014; 15:298-302. [PMID: 25550214 DOI: 10.1016/j.clml.2014.12.005] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 11/17/2014] [Accepted: 12/06/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND The FMS-like tyrosine kinase 3 internal tandem duplication (FLT3-ITD) gene is one of the most frequently observed genetic alterations in acute myeloid leukemia (AML), with an incidence of about 20% to 30%. FLT3-ITD is significantly associated with a poor outcome, and offering an allogeneic hematopoietic cell transplantation (allo-HCT) is recommended for patients harboring this mutation. Sorafenib is a tyrosine kinase inhibitor active against RAF, VEGF, and FLT3-ITD. It has been used in an off-label fashion in FLT3-ITD AML. PATIENTS AND METHODS We retrospectively assessed the successful use of sorafenib after allo-HCT in patients with FLT3-ITD AML. Six FLT3-ITD AML patients received sorafenib as posttransplantation maintenance therapy (n = 5) or as salvage therapy after a post-allo-HCT relapse (n = 1) and continued afterward. RESULTS One patient developed myocardial infarction 100 days after initiation of sorafenib. Interestingly, skin graft versus host disease (grade II) was observed in 5 of 6 patients and generally occurred within few days after initiation of sorafenib, but it responded promptly to corticosteroid therapy in all patients. All 6 patients were alive and in complete remission at a median follow-up of 16 months (range, 10-29 months) since first induction and at a median follow-up of 12 months (range, 4-20 months) since initiation of sorafenib. Remarkably, the disease of all patients was in molecular remission. CONCLUSION Sorafenib appears to be an effective maintenance therapy after allo-HCT in FLT3-ITD AML, with achievement of durable complete responses. This suggests an immunomodulatory effect of sorafenib in the posttransplantation setting and warrants a broader clinical evaluation of the use of maintenance sorafenib in FLT3-ITD AML.
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Chen YB, Li S, Lane AA, Connolly C, Del Rio C, Valles B, Curtis M, Ballen K, Cutler C, Dey BR, El-Jawahri A, Fathi AT, Ho VT, Joyce A, McAfee S, Rudek M, Rajkhowa T, Verselis S, Antin JH, Spitzer TR, Levis M, Soiffer R. Phase I trial of maintenance sorafenib after allogeneic hematopoietic stem cell transplantation for fms-like tyrosine kinase 3 internal tandem duplication acute myeloid leukemia. Biol Blood Marrow Transplant 2014; 20:2042-8. [PMID: 25239228 PMCID: PMC4253683 DOI: 10.1016/j.bbmt.2014.09.007] [Citation(s) in RCA: 191] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 09/10/2014] [Indexed: 01/19/2023]
Abstract
The fms-like tyrosine kinase 3 internal tandem duplication (FLT3-ITD) mutation is associated with a high relapse rate for patients with acute myeloid leukemia (AML) even after allogeneic hematopoietic stem cell transplantation (HSCT). Sorafenib is a tyrosine kinase inhibitor, which inhibits the FLT3 tyrosine kinase and has shown encouraging activity in FLT3-ITD AML. We conducted a phase I trial of maintenance sorafenib after HSCT in patients with FLT3-ITD AML (ClinicalTrials.govNCT01398501). Patients received a variety of conditioning regimens and graft sources. A dose escalation 3 + 3 cohort design was used to define the maximum tolerated dose (MTD), with an additional 10 patients treated at the MTD. Sorafenib was initiated between days 45 and 120 after HSCT and continued for 12 28-day cycles. Twenty-two patients were enrolled (status at HSCT: first complete remission [CR1], n = 16; second complete remission [CR2], n = 3; refractory, n = 3). The MTD was established at 400 mg twice daily with 1 dose-limiting toxicity (DLT) observed (pericardial effusion). Two patients died of transplantation-related causes, both unrelated to sorafenib. Two patients stopped sorafenib after relapse and 5 stopped because of attributable toxicities after the DLT period. Median follow-up for surviving patients is 16.7 months after HSCT (range, 8.1 to 35.0). There was 1 case of grade II acute graft-versus-host disease (GVHD) after starting sorafenib and the 12-month cumulative incidence of chronic GVHD was 38% (90% confidence interval [CI], 21% to 56%). For all patients, 1-year progression-free survival (PFS) was 85% (90% CI, 66% to 94%) and 1-year overall survival (OS) was 95% (90% CI, 79% to 99%) after HSCT. For patients in CR1/CR2 before HSCT (n = 19), 1-year PFS was 95% (90% CI, 76% to 99%) and 1-year OS was 100%, with only 1 patient who relapsed. Sorafenib is safe after HSCT for FLT3-ITD AML and merits further investigation for the prevention of relapse.
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Affiliation(s)
- Yi-Bin Chen
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts.
| | - Shuli Li
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Andrew A Lane
- Division of Hematologic Malignancies, Dana-Farber Cancer Center, Boston, Massachusetts
| | - Christine Connolly
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Candice Del Rio
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Betsy Valles
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Morgan Curtis
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Karen Ballen
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Corey Cutler
- Division of Hematologic Malignancies, Dana-Farber Cancer Center, Boston, Massachusetts
| | - Bimalangshu R Dey
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Areej El-Jawahri
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Amir T Fathi
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Vincent T Ho
- Division of Hematologic Malignancies, Dana-Farber Cancer Center, Boston, Massachusetts
| | - Amy Joyce
- Division of Hematologic Malignancies, Dana-Farber Cancer Center, Boston, Massachusetts
| | - Steven McAfee
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Michelle Rudek
- Division of Hematologic Malignancies, Dana-Farber Cancer Center, Boston, Massachusetts
| | - Trivikram Rajkhowa
- Division of Hematologic Malignancies, Dana-Farber Cancer Center, Boston, Massachusetts
| | - Sigitas Verselis
- Division of Hematologic Malignancies, Dana-Farber Cancer Center, Boston, Massachusetts
| | - Joseph H Antin
- Division of Hematologic Malignancies, Dana-Farber Cancer Center, Boston, Massachusetts
| | - Thomas R Spitzer
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Mark Levis
- Sidney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Robert Soiffer
- Division of Hematologic Malignancies, Dana-Farber Cancer Center, Boston, Massachusetts
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17
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Annesley CE, Brown P. The Biology and Targeting of FLT3 in Pediatric Leukemia. Front Oncol 2014; 4:263. [PMID: 25295230 PMCID: PMC4172015 DOI: 10.3389/fonc.2014.00263] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 09/08/2014] [Indexed: 12/22/2022] Open
Abstract
Despite remarkable improvement in treatment outcomes in pediatric leukemia over the past several decades, the prognosis for high-risk groups of acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL), as well as for relapsed leukemia, remains poor. Intensification of chemotherapy regimens for those at highest risk has improved success rates, but at the cost of significantly increased morbidity and long-term adverse effects. With the success of imatinib in Philadelphia-chromosome-positive leukemia and all-trans retinoic acid in acute promyelocytic leukemia, the quest to find additional molecularly targeted therapies has generated much excitement over recent years. Another such possible target in pediatric acute leukemia is FMS-like tyrosine kinase 3 (FLT3). FLT3 aberrations are among the most frequently identified transforming events in AML, and have significant clinical implications in both high-risk pediatric AML and in certain high-risk groups of pediatric ALL. Therefore, the successful targeting of FLT3 has tremendous potential to improve outcomes in these subsets of patients. This article will give an overview of the molecular function and signaling of the FLT3 receptor, as well as its pathogenic role in leukemia. We review the discovery of targeting FLT3, discuss currently available FLT3 inhibitors in pediatric leukemia and results of clinical trials to date, and finally, consider the future promise and challenges of FLT3 inhibitor therapy.
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Affiliation(s)
- Colleen E. Annesley
- Oncology and Pediatrics, The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Patrick Brown
- Oncology and Pediatrics, The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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18
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Schnittger S, Haferlach C, Kern W, Haferlach T. Analysis for loss of heterozygosity on chromosome arm 13q by STR analysis or SNP sequencing can replace analysis of FLT3-ITD to detect patients with prognostically adverse AML. Genes Chromosomes Cancer 2014; 53:1008-17. [PMID: 25183446 DOI: 10.1002/gcc.22210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 07/30/2014] [Accepted: 07/30/2014] [Indexed: 11/08/2022] Open
Abstract
We aimed at developing novel assays for Loss of Heterozygosity (LOH) detection on 13q as a substitute for FLT3-ITD analysis to identify acute myeloid leukemia (AML) patients with high risk of shorter survival. To this aim, we first analyzed a selected cohort of 185 patients with (n = 138) or without (n = 47) FLT3-ITD by short tandem repeat (STR) analysis for 13q LOH. In 46 of 138 FLT3-ITD positive cases, a FLT3-ITD/FLT3wt ratio of ≥ 1 was measured indicating LOH. Applying analysis with a combination of five different STR markers, a threshold of an STR allelic ratio of >65% allows the identification of LOH in 40/46 (87%) samples. Survival analysis revealed significantly inferior outcome in patients with LOH as detected by STR analysis (event free survival (EFS): no LOH: 13.3 months versus LOH: 4.5 months, p < 0.001; overall survival (OS): no LOH: 35.8 months versus LOH: 9.7 months, p = 0.001). In multivariate Cox regression analysis, 13q LOH was found to be an independent adverse parameter for EFS and OS (p = 0.003 and p < 0.001, respectively) besides age and white blood cell count. Thus, the prognostic impact of 13q LOH is nearly identical to the one of FLT3-ITD/FLT3wt load of ≥ 1 and thus is a feasible alternative to identify respective patients with high risk AML. In a second approach, a cohort of 91 patients was subjected to a proof-of-principle study of applying single nucleotide polymorphism analysis by next generation amplicon sequencing for detection of LOH. 53/91 cases had LOH and 50 were identified with this new method resulting in a positive detection rate of 94.3%.
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Song G, Valdez BC, Li Y, Liu Y, Champlin RE, Andersson BS. Synergistic cytotoxicity of sorafenib with busulfan and nucleoside analogs in human FMS-like tyrosine kinase 3 internal tandem duplications-positive acute myeloid leukemia cells. Biol Blood Marrow Transplant 2014; 20:1687-95. [PMID: 25111583 DOI: 10.1016/j.bbmt.2014.08.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 08/04/2014] [Indexed: 01/28/2023]
Abstract
Clofarabine (Clo), fludarabine (Flu), and busulfan (Bu) are used in pretransplantation conditioning therapy for patients with myeloid leukemia. To further improve their efficacy in FMS-like tyrosine kinase 3 internal tandem duplications (FLT3-ITD)-positive acute myeloid leukemia (AML), we investigated their synergism with sorafenib (Sor). Exposure of FLT3-ITD-positive MV-4-11 and MOLM 13 cells to Bu+Clo+Flu+Sor resulted in synergistic cytotoxicity; no such synergism was observed in the FLT3-wild type THP-1 and KBM3/Bu250(6) cell lines. The drug synergism in MV-4-11 cells could be attributed to activation of DNA damage response, histone 3 modifications, inhibition of prosurvival kinases, and activation of apoptosis. Further, the phosphorylation of kinases, including FLT3, MAPK kinase (MEK), and AKT, was inhibited. The FLT3-ITD substrate STAT5 and its target gene PIM 2 product decreased when cells were exposed to Sor alone, Bu+Clo+Flu, and Bu+Clo+Flu+Sor. The level of the proapoptotic protein p53 upregulated modulator of apoptosis (PUMA) increased, whereas the level of prosurvival protein MCL-1 decreased when cells were exposed to Bu+Clo+Flu+Sor. The interactions of PUMA with MCL-1 and/or BCL-2 were enhanced when cells were exposed to Bu+Clo+Flu or Bu+Clo+Flu+Sor. The changes in the level of these proteins, which are involved in mitochondrial control of apoptosis, correlate with changes in mitochondrial membrane potential. Bu+Clo+Flu+Sor decreased mitochondrial membrane potential by 60% and caused leakage of cytochrome c, second mitochondria-derived activator of caspases (SMAC)/direct IAP Binding protein with low pI (DIABLO), and AIF from the mitochondria to the cytoplasm, caspase activation, and cell death, suggesting the activation of apoptosis. Analogous, synergistic cytotoxicity in response to Bu, Clo, Flu, and Sor was observed in mononuclear cells isolated from FLT3-ITD-positive AML patients. Although our previous studies were aimed at standardizing the conditioning regimen, the new findings suggest that patients with abnormal expression of FLT3 might further benefit from individualizing treatment through the addition of Sor to Bu+Clo+Flu, thereby providing personalized pretransplantation therapy.
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Affiliation(s)
- Guiyun Song
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Benigno C Valdez
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yang Li
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yan Liu
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Borje S Andersson
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, Texas.
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Abstract
The high rate of negative clinical trials and failed drug development programs calls into question the use of preclinical testing as currently practiced. An important issue for the in vitro testing of agents that have advanced into the clinic is the use of clinically irrelevant concentrations in reports making claims for anticancer activity, as illustrated by publications for sorafenib, vorinostat, and metformin. For sorafenib, high protein binding leads to a dichotomy between concentrations active in the 10% serum conditions commonly used for in vitro testing and concentrations active in plasma. Failure to recognize this distinction leads to inappropriate claims of activity for sorafenib based on the micromolar concentrations commonly used for in vitro testing in low serum conditions. For vorinostat and metformin, results using in vitro concentrations higher than those achievable in patients are reported despite the availability of publications describing human pharmacokinetic data for each agent. We encourage journal editors and reviewers to pay greater attention to clinically relevant concentrations when considering reports that include in vitro testing of agents for which human pharmacokinetic data are available. Steps taken to more carefully scrutinize activity claims based on in vitro results can help direct researchers away from clinically irrelevant lines of research and toward lines of research that are more likely to lead to positive clinical trials and to improved treatments for patients with cancer.
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Affiliation(s)
- Malcolm A Smith
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, Maryland 20892, USA.
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21
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Zhao X, Tian C, Puszyk WM, Ogunwobi OO, Cao M, Wang T, Cabrera R, Nelson DR, Liu C. OPA1 downregulation is involved in sorafenib-induced apoptosis in hepatocellular carcinoma. J Transl Med 2013; 93:8-19. [DOI: doi10.1038/labinvest.2012.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
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22
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Zhao X, Tian C, Puszyk WM, Ogunwobi OO, Cao M, Wang T, Cabrera R, Nelson DR, Liu C. OPA1 downregulation is involved in sorafenib-induced apoptosis in hepatocellular carcinoma. J Transl Med 2013; 93:8-19. [PMID: 23108376 PMCID: PMC3860369 DOI: 10.1038/labinvest.2012.144] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Sorafenib has been used to treat advanced hepatocellular carcinoma (HCC), but the underlying molecular mechanisms remain controversial and why some patients do not respond to this therapy is poorly understood. In this study, we show that sorafenib triggers cell growth inhibition and apoptosis in HCC cells by directly targeting the mitochondria. Treatment with sorafenib induces rapid mitochondrial fragmentation, which is associated with the deregulation of mitochondria fusion-related protein optic atrophy 1 (OPA1). Exposure of cells or isolated mitochondria to sorafenib substantially induces cytochrome c release. Our data indicate that siRNA-mediated OPA1 knockdown significantly sensitizes HCC cells to sorafenib-induced apoptosis. Furthermore, sorafenib has no apparent apoptotic toxicity to normal human primary hepatocytes. Sorafenib inhibits HCC xenograft tumor growth in vivo and murine xenograft tumor tissue analysis reveals mitochondria fusion protein. OPA1 expression levels are strongly downregulated by sorafenib treatment. Western blotting evaluation of patient HCC with matched non-tumor tissue samples demonstrates that OPA1 expression is decreased in up to 40% of HCC patients. Taken together, we have shown that sorafenib suppresses the tumorigenesis of HCC through the induction of mitochondrial injury via OPA1. Our results provide new insights into the pathogenesis of HCC and suggest that OPA1 is a novel therapeutic target in patients with HCC.
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Affiliation(s)
- Xiangxuan Zhao
- Departments of Pathology, Immunology, and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Changhai Tian
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, USA
| | - William M Puszyk
- Departments of Pathology, Immunology, and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Olorunseun O Ogunwobi
- Departments of Pathology, Immunology, and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Mengde Cao
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Ton Wang
- Departments of Pathology, Immunology, and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Roniel Cabrera
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - David R Nelson
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Chen Liu
- Departments of Pathology, Immunology, and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
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23
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Watt TC, Cooper T. Sorafenib as treatment for relapsed or refractory pediatric acute myelogenous leukemia. Pediatr Blood Cancer 2012; 59:756-7. [PMID: 22052552 DOI: 10.1002/pbc.23394] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 09/21/2011] [Indexed: 11/09/2022]
Abstract
The prognosis for children with acute myelogenous leukemia (AML) has improved with overall survival rates of up to 65% [Pui et al. J Clin Oncol 2011; 29: 551-565]. However, the cure rate for AML lags behind that of acute lymphoblastic leukemia. Advances in AML leukemogenesis are leading to refined risk stratification. FMS like tyrosine kinase 3 (FLT3) mutations are independently associated with a poor prognosis. Newer kinase inhibitors, including sorafenib, have shown promise in adult studies. We report three pediatric patients with relapsed AML who achieved a sustained remission with sorafenib. Further trials are necessary to understand the role of sorafenib in pediatric AML.
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Affiliation(s)
- Tanya C Watt
- Department of Pediatrics, Division of Hematology/Oncology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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24
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Metzelder SK, Schroeder T, Finck A, Scholl S, Fey M, Götze K, Linn YC, Kröger M, Reiter A, Salih HR, Heinicke T, Stuhlmann R, Müller L, Giagounidis A, Meyer RG, Brugger W, Vöhringer M, Dreger P, Mori M, Basara N, Schäfer-Eckart K, Schultheis B, Baldus C, Neubauer A, Burchert A. High activity of sorafenib in FLT3-ITD-positive acute myeloid leukemia synergizes with allo-immune effects to induce sustained responses. Leukemia 2012; 26:2353-9. [PMID: 22504140 DOI: 10.1038/leu.2012.105] [Citation(s) in RCA: 191] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Preliminary evidence suggests that the multikinase inhibitor sorafenib has clinical activity in FLT3-ITD-positive (FLT3-ITD) acute myeloid leukemia (AML). However, the quality and sustainability of achievable remissions and clinical variables that influence the outcome of sorafenib monotherapy are largely undefined. To address these questions, we evaluated sorafenib monotherapy in 65 FLT3-ITD AML patients treated at 23 centers. All but two patients had relapsed or were chemotherapy-refractory after a median of three prior chemotherapy cycles. Twenty-nine patients (45%) had undergone prior allogeneic stem cell transplantation (allo-SCT). The documented best responses were: hematological remission in 24 patients (37%), bone marrow remission in 5 patients (8%), complete remission (with and without normalization of peripheral blood counts) in 15 patients (23%) and molecular remission with undetectable FLT3-ITD mRNA in 10 patients (15%), respectively. Seventeen of the patients without prior allo-SCT (47%) developed sorafenib resistance after a median treatment duration of 136 days (range, 56-270 days). In contrast, allo-SCT patients developed sorafenib resistance less frequently (38%) and significantly later (197 days, range 38-225 days; P=0.03). Sustained remissions were seen exclusively in the allo-SCT cohort. Thus, sorafenib monotherapy has significant activity in FLT3-ITD AML and may synergize with allogeneic immune effects to induce durable remissions.
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Affiliation(s)
- S K Metzelder
- Philipps Universität Marburg, Universitätsklinikum Gießen und Marburg, Standort Marburg, Klinik für Hämatologie, Onkologie und Immunologie, Marburg, Germany
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25
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Sorafenib treatment of FLT3-ITD(+) acute myeloid leukemia: favorable initial outcome and mechanisms of subsequent nonresponsiveness associated with the emergence of a D835 mutation. Blood 2012; 119:5133-43. [PMID: 22368270 DOI: 10.1182/blood-2011-06-363960] [Citation(s) in RCA: 232] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Internal tandem duplication (ITD) of the fms-related tyrosine kinase-3 (FLT3) gene occurs in 30% of acute myeloid leukemias (AMLs) and confers a poor prognosis. Thirteen relapsed or chemo-refractory FLT3-ITD(+) AML patients were treated with sorafenib (200-400 mg twice daily). Twelve patients showed clearance or near clearance of bone marrow myeloblasts after 27 (range 21-84) days with evidence of differentiation of leukemia cells. The sorafenib response was lost in most patients after 72 (range 54-287) days but the FLT3 and downstream effectors remained suppressed. Gene expression profiling showed that leukemia cells that have become sorafenib resistant expressed several genes including ALDH1A1, JAK3, and MMP15, whose functions were unknown in AML. Nonobese diabetic/severe combined immunodeficiency mice transplanted with leukemia cells from patients before and during sorafenib resistance recapitulated the clinical results. Both ITD and tyrosine kinase domain mutations at D835 were identified in leukemia initiating cells (LICs) from samples before sorafenib treatment. LICs bearing the D835 mutant have expanded during sorafenib treatment and dominated during the subsequent clinical resistance. These results suggest that sorafenib have selected more aggressive sorafenib-resistant subclones carrying both FLT3-ITD and D835 mutations, and might provide important leads to further improvement of treatment outcome with FLT3 inhibitors.
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26
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Sharma M, Ravandi F, Bayraktar UD, Chiattone A, Bashir Q, Giralt S, Chen J, Qazilbash M, Kebriaei P, Konopleva M, Andreeff M, Cortes J, McCue D, Kantarjian H, Champlin RE, de Lima M. Treatment of FLT3-ITD-positive acute myeloid leukemia relapsing after allogeneic stem cell transplantation with sorafenib. Biol Blood Marrow Transplant 2011; 17:1874-7. [PMID: 21767516 DOI: 10.1016/j.bbmt.2011.07.011] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2011] [Accepted: 07/10/2011] [Indexed: 10/17/2022]
Abstract
Patients with acute myeloid leukemia (AML) and internal tandem duplication of FMS-like tyrosine kinase receptor-3 gene (FLT3-ITD) mutation have poor prognoses and are often treated with allogeneic hematopoietic stem cell transplantation (HSCT). Sorafenib, an inhibitor of multiple kinases including FLT3, has shown promising activity in FLT3-ITD-positive AML. We treated 16 patients with FLT3-ITD-positive AML who relapsed after HSCT with sorafenib alone (n = 8) or in combination with cytotoxic chemotherapy (n = 8). The number of circulating blasts decreased in 80% of cases, but none of the patients achieved complete remission (CR); 3 achieved partial remission. Two patients were bridged to a second transplantation but both relapsed within 3 months of the transplantation. Median overall survival (OS) was 83 days, with none surviving more than a year. Sorafenib is not effective in the treatment of FLT3-ITD-positive AML relapsing after HSCT. Preventive strategies after HSCT may be more suitable for these high-risk patients.
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Affiliation(s)
- Manish Sharma
- Department of Stem Cell Transplantation, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030-4009, USA
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27
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Abstract
FLT3 inhibition has been a goal of acute myeloid leukemia (AML) therapy since FLT3 mutations were discovered to have a role in AML. Several FLT3 inhibitors have been developed in the last several years, beginning with less potent, less selective agents. The newer FLT3 inhibitors appear to be more potent in vivo and have shown more promise than the older agents in monotherapy trials.
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Affiliation(s)
- Mark J Levis
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD 21287, USA.
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