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Nguyen TD, Bordeau BM, Balthasar JP. Mechanisms of ADC Toxicity and Strategies to Increase ADC Tolerability. Cancers (Basel) 2023; 15:713. [PMID: 36765668 PMCID: PMC9913659 DOI: 10.3390/cancers15030713] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/19/2023] [Accepted: 01/19/2023] [Indexed: 01/26/2023] Open
Abstract
Anti-cancer antibody-drug conjugates (ADCs) aim to expand the therapeutic index of traditional chemotherapy by employing the targeting specificity of monoclonal antibodies (mAbs) to increase the efficiency of the delivery of potent cytotoxic agents to malignant cells. In the past three years, the number of ADCs approved by the Food and Drug Administration (FDA) has tripled. Although several ADCs have demonstrated sufficient efficacy and safety to warrant FDA approval, the clinical use of all ADCs leads to substantial toxicity in treated patients, and many ADCs have failed during clinical development due to their unacceptable toxicity profiles. Analysis of the clinical data has demonstrated that dose-limiting toxicities (DLTs) are often shared by different ADCs that deliver the same cytotoxic payload, independent of the antigen that is targeted and/or the type of cancer that is treated. DLTs are commonly associated with cells and tissues that do not express the targeted antigen (i.e., off-target toxicity), and often limit ADC dosage to levels below those required for optimal anti-cancer effects. In this manuscript, we review the fundamental mechanisms contributing to ADC toxicity, we summarize common ADC treatment-related adverse events, and we discuss several approaches to mitigating ADC toxicity.
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Affiliation(s)
- Toan D Nguyen
- Department of Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | - Brandon M Bordeau
- Department of Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | - Joseph P Balthasar
- Department of Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA
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2
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Dhunputh C, Strullu M, Petit A, Merched M, Pasquet M, Azarnoush S, Leverger G, Ducassou S. Single-dose (4.5 mg/m 2 ) gemtuzumab ozogamicin in combination with fludarabine, cytarabine and anthracycline as reinduction therapy in relapsed or refractory paediatric acute myeloid leukaemia. Br J Haematol 2022; 198:373-381. [PMID: 35438187 DOI: 10.1111/bjh.18203] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/02/2022] [Accepted: 04/04/2022] [Indexed: 12/30/2022]
Abstract
Despite major therapeutic improvements, children with relapsed/refractory Acute Myeloid Leukaemia still have poor outcomes and overall survival does not exceed 40%. New treatments are required to improve their outcome; Gemtuzumab ozogamicin (GO), an anti-CD33 immunoconjugate antibody, is a potent cytotoxic agent whose efficacy has been demonstrated mainly in adults. The main objective of this retrospective multicentre study was to assess the outcome of children treated, between February 2008 and August 2019, with GO at a single 4.5 mg/m2 dose, in combination with Fludarabine, Cytarabine and antssshracyclines, in context of a first relapse (n = 26) or refractory disease (n = 3). The remission rate was 83% (24/29 children) and 20 children (69%) were allografted. With a median follow-up of 1.2 years (range: 0.1-8), the overall survival was 49% (CI95% = 33; 72). Most common adverse event was febrile neutropenia with microbiological identification in 55% of cases. Veno-occlusive disease occurred in 6 patients (21%), of which 5 subvened after bone marrow transplantation, and resolved within 2-32 days (median 10.5 days). Administration of GO in combination with FLA-anthracyclines chemotherapy appears to be a good reinduction regimen for relapsed or refractory AML with a good safety profile. These results warrant larger prospective study.
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Affiliation(s)
- Chloé Dhunputh
- Paediatric Haematology Oncology Unit, CHU de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Marion Strullu
- Paediatric Haematology Unit, AP-HP, Hopital Robert Débré, APHP, Paris, France
| | - Arnaud Petit
- Sorbonne Université, Centre de Recherche Saint-Antoine UMR_S938, Paediatric Haematology Oncology Unit, AP-HP, Armand Trousseau Hospital, Paris, France
| | | | - Marlène Pasquet
- Paediatric Haematology Oncology Unit, CHU de Toulouse, France
| | - Saba Azarnoush
- Paediatric Haematology Unit, AP-HP, Hopital Robert Débré, APHP, Paris, France
| | - Guy Leverger
- Sorbonne Université, Centre de Recherche Saint-Antoine UMR_S938, Paediatric Haematology Oncology Unit, AP-HP, Armand Trousseau Hospital, Paris, France
| | - Stéphane Ducassou
- Paediatric Haematology Oncology Unit, CHU de Bordeaux, Université de Bordeaux, Bordeaux, France
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Endo Y, Mohan N, Dokmanovic M, Wu WJ. Mechanisms contributing to ado-trastuzumab emtansine-induced toxicities: a gateway to better understanding of ADC-associated toxicities. Antib Ther 2021; 4:55-59. [PMID: 33937626 DOI: 10.1093/abt/tbab005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/22/2021] [Accepted: 03/11/2021] [Indexed: 01/20/2023] Open
Abstract
In order to improve the safety of novel therapeutic drugs, better understanding of the mechanisms of action is important. Ado-trastuzumab emtansine (also known as T-DM1) is an antibody-drug conjugate (ADC) approved for the treatment of HER2-positive breast cancer. While the treatment with T-DM1 results in significant efficacy in the selected patient population, nonetheless, there are concerns with side effects such as thrombocytopenia and hepatotoxicity. While current understanding of the mechanism of T-DM1-mediated side effects is still incomplete, there have been several reports of HER2-dependent and/or -independent mechanisms that could be associated with the T-DM1-induced adverse events. This review highlights the importance of HER2-independent mechanism of T-DM1 to induce hepatotoxicity, which offers a new insight into a role for CKAP5 in the overall maytansinoid-based ADC (DM1 and DM4)-mediated cytotoxicity. This discovery provides a molecular basis for T-DM1-induced off-target toxicity and opens a new avenue for developing the next generation of ADCs.
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Affiliation(s)
- Yukinori Endo
- Division of Biotechnology Review and Research 1, Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration (FDA), Silver Spring, MD 20993, USA
| | - Nishant Mohan
- Division of Biotechnology Review and Research 1, Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration (FDA), Silver Spring, MD 20993, USA
| | - Milos Dokmanovic
- Division of Biotechnology Review and Research 1, Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration (FDA), Silver Spring, MD 20993, USA
| | - Wen Jin Wu
- Division of Biotechnology Review and Research 1, Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration (FDA), Silver Spring, MD 20993, USA
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4
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Genthon A, Brissot E, Malard F, van de Wyngaert Z, Bonnin A, Banet A, Marjanovic Z, Ikhlef S, Lapusan S, Sestili S, Corre E, Paviglianiti A, Adaeva R, 'Hammedi-Bouzina FM, Labopin M, Dulery R, Mohty M, Legrand O. Gemtuzumab Ozogamicin Combined With Intensive Chemotherapy in Patients With Acute Myeloid Leukemia Relapsing After Allogenic Stem Cell Transplantation. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:791-796. [PMID: 32741743 DOI: 10.1016/j.clml.2020.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/01/2020] [Accepted: 07/02/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND More than one-third of patients with acute myeloid leukemia (AML) will relapse after allogenic hematopoietic cell transplant (allo-HCT). The main challenge is to overcome disease resistance to achieve a new complete remission while avoiding excessive toxicity. Gemtuzumab ozogamicin (GO), a conjugate of calicheamicin linked to the humanized monoclonal anti-CD33 antibody, has been used for refractory or relapsed AML with promising response rates, but liver toxicity of GO has long been considered a limiting factor. PATIENTS AND METHODS We included 18 consecutive patients with AML relapsing after a first allo-HCT and treated with fractioned GO (fGO) and intensive chemotherapy. The median age was 40 years (range, 18-65). RESULTS The overall response rate was 72% (13/18), including 7 complete remissions. No death was attributed to treatment toxicity. The main liver toxicity was transient and consisted of transaminase level elevation and hyperbilirubinemia. No cases of veno-occlusive disease were observed after the GO treatment. From the time of salvage treatment initiation, 1- and 2-year OS rates were 54% (95% confidence interval, 28%-74%) and 42% (95% confidence interval, 19%-63%), respectively. CONCLUSIONS Our study suggests the feasibility, efficacy, and safety of an fGO-based salvage regimen combined with intensive chemotherapy in patients with CD33+ AML in the case of early relapse after an allo-HCT.
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Affiliation(s)
- Alexis Genthon
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France.
| | - Eolia Brissot
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Florent Malard
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Zoe van de Wyngaert
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Agnès Bonnin
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Anne Banet
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Zora Marjanovic
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Souhila Ikhlef
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Simona Lapusan
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Simona Sestili
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Elise Corre
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Annalisa Paviglianiti
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Rosa Adaeva
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Fella M 'Hammedi-Bouzina
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Myriam Labopin
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Rémy Dulery
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Mohamad Mohty
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Ollivier Legrand
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
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5
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Ma H, Sawas A. Combining Biology and Chemistry for a New Take on Chemotherapy: Antibody-Drug Conjugates in Hematologic Malignancies. Curr Hematol Malig Rep 2019; 13:555-569. [PMID: 30362019 DOI: 10.1007/s11899-018-0485-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW This review is about the antibody-drug conjugate (ADC), a form of drug delivery consisting of a monoclonal antibody, linker, and cytotoxic payload. We summarize the history of ADC development, highlighting the three FDA-approved ADCs currently available. RECENT FINDINGS Gemtuzumab ozogamicin is a CD33-targeted ADC linked to calicheamicin. It is approved for CD33+ AML in the first line or the relapsed or refractory (R/R) setting. Brentuximab vedotin is a CD30-targeted ADC bound to MMAE. It is approved for the treatment of certain R/R CD30+ lymphomas. Recently, it has been approved for first line therapy with chemotherapy in advanced HL. Inotuzumab ozogamicin is a CD22-directed ADC attached to calicheamicin indicated for the treatment of adults with R/R B cell precursor ALL. Three ADCs have been approved for the treatment of various hematologic malignancies. We discuss the pertinent human trials that led to FDA approval. We include our perspectives about drug resistance, toxicities, and future development.
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Affiliation(s)
- Helen Ma
- Columbia University Medical Center, New York, NY, 10032, USA
| | - Ahmed Sawas
- Columbia University Medical Center, New York, NY, 10032, USA.
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6
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Abstract
PURPOSE OF REVIEW Bispecific antibodies combine antigen recognition sites from two or more antibodies into a single construct allowing simultaneous binding to multiple targets. Bispecific antibodies exist which can redirect immune effector cells against acute myeloid leukemia (AML) targets. This review will highlight the progress to date and the challenges in developing bispecific antibodies for the treatment of AML. RECENT FINDINGS Currently, a number of bispecific antibody formats including bispecific T cell engagers, dual affinity retargeting proteins, and tandem diabodies are in clinical development for AML. These antibodies target antigens present on AML blasts, including CD33, and the low affinity IL3 receptor, CD123. T cell redirecting bispecific antibodies in early phase clinical trials for AML include AG330, flotetuzumab, JNJ-63709178, and AMV564. Bispecific antibodies represent a promising immunotherapeutic approach for the treatment of cancer. The results of ongoing studies in AML will elucidate the potential for these agents in AML.
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Affiliation(s)
- Daniel G Guy
- Division of Oncology, Washington University School of Medicine, 660 S. Euclid Ave, CB 8007, St. Louis, MO, 63110, USA
| | - Geoffrey L Uy
- Division of Oncology, Washington University School of Medicine, 660 S. Euclid Ave, CB 8007, St. Louis, MO, 63110, USA.
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7
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Leick MB, Maus MV. CAR-T cells beyond CD19, UnCAR-Ted territory. Am J Hematol 2019; 94:S34-S41. [PMID: 30632631 DOI: 10.1002/ajh.25398] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 12/27/2018] [Accepted: 01/08/2019] [Indexed: 01/30/2023]
Abstract
CAR-T cells have made dramatic inroads in targeting CD19-positive B-cell malignancies. This review focuses on application of CAR-T cells in hematologic malignancies beyond targeting CD19, with specific attention to Hodgkin's lymphoma and acute myeloid leukemia.
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Affiliation(s)
- Mark B. Leick
- Cellular Immunotherapy ProgramCancer Center, Massachusetts General Hospital Boston Massachusetts
- Harvard Medical School Boston Massachusetts
| | - Marcela V. Maus
- Cellular Immunotherapy ProgramCancer Center, Massachusetts General Hospital Boston Massachusetts
- Harvard Medical School Boston Massachusetts
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8
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McDonald GB, Freston JW, Boyer JL, DeLeve LD. Liver Complications Following Treatment of Hematologic Malignancy With Anti-CD22-Calicheamicin (Inotuzumab Ozogamicin). Hepatology 2019; 69:831-844. [PMID: 30120894 PMCID: PMC6351187 DOI: 10.1002/hep.30222] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/14/2018] [Indexed: 02/06/2023]
Abstract
Treatment of hematological malignancy with antibody-drug conjugates (ADCs) may cause liver injury. ADCs deliver a toxic moiety into antigen-expressing tumor cells, but may also injure hepatic sinusoids (sinusoidal obstruction syndrome; SOS). We studied patients who received an anti-CD22/calicheamicin conjugate (inotuzumab ozogamicin; InO) to gain insight into mechanisms of sinusoidal injury, given that there are no CD22+ cells in the normal liver, but nonspecific uptake of ADCs by liver sinusoidal endothelial cells (LSECs). Six hundred thirty-eight patients (307 with acute lymphocytic leukemia [ALL], 311 with non-Hodgkin's lymphoma [NHL]) were randomized to either InO or standard chemotherapy (controls). While blinded to treatment assignment, we reviewed all cases with hepatobiliary complications to adjudicate the causes. Frequency of SOS among patients who received InO was 5 of 328 (1.5%), compared to no cases among 310 control patients. Drug-induced liver injury (DILI) developed in 26 (7.9%) InO recipients and 3 (1%) controls. Intrahepatic cholestasis (IHC) was observed in 4.9% of InO recipients and in 5.5% of controls. Subsequent to the randomization study, 113 patients with ALL underwent allogeneic hematopoietic cell transplantation (HCT); frequency of SOS in those previously exposed to InO was 21 of 79 (27%) versus 3 of 34 (9%) in controls. An exploratory multivariate model identified a past history of liver disease and thrombocytopenia before conditioning therapy as dominant risk factors for SOS after transplant. Conclusion: Frequencies of SOS and DILI after inotuzumab ozogamicin treatment were 1.5% and 7.9%, respectively, compared to none and 1% among controls who received standard chemotherapy. These data suggest that ADCs that do not target antigens present in the normal liver have a relatively low frequency of SOS, but a relatively high frequency of DILI.
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9
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Rotolo A, Karadimitris A, Ruella M. Building upon the success of CART19: chimeric antigen receptor T cells for hematologic malignancies. Leuk Lymphoma 2018; 59:2040-2055. [PMID: 29165008 PMCID: PMC6814196 DOI: 10.1080/10428194.2017.1403024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Chimeric antigen receptor T cell (CART) therapy has dramatically changed the therapeutic prospects for B cell malignancies. Over the last decade CD19-redirected CART have demonstrated the ability to induce deep, long-lasting remissions and possibly cure patients with relapsing B cell neoplasms. Such impressive results with CART19 fostered efforts to expand this technology to other incurable malignancies that naturally do not express CD19, such as acute myeloid leukemia (AML), Hodgkin lymphoma (HL) and multiple myeloma (MM). However, to reach this goal, several hurdles have to be overcome, in particular: (i) the apparent lack of suitable targets as effective as CD19; (ii) the immunosuppressive tumor microenvironment; (iii) intra-tumoral heterogeneity and antigen-negative relapses. Therefore, new strategies that allow safer and more potent CART platforms are under development and may provide grounds for new exciting breakthroughs in the field.
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Affiliation(s)
- Antonia Rotolo
- Centre for Haematology, Department of Medicine, Hammersmith Hospital, Imperial College London, London, UK
| | - Anastasios Karadimitris
- Centre for Haematology, Department of Medicine, Hammersmith Hospital, Imperial College London, London, UK
| | - Marco Ruella
- Center for Cellular Immunotherapies, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
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10
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Niktoreh N, Lerius B, Zimmermann M, Gruhn B, Escherich G, Bourquin JP, Dworzak M, Sramkova L, Rossig C, Creutzig U, Reinhardt D, Rasche M. Gemtuzumab ozogamicin in children with relapsed or refractory acute myeloid leukemia: a report by Berlin-Frankfurt-Münster study group. Haematologica 2018; 104:120-127. [PMID: 30093401 PMCID: PMC6312035 DOI: 10.3324/haematol.2018.191841] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 08/03/2018] [Indexed: 12/13/2022] Open
Abstract
Despite intensified salvage treatments, children with relapsed/refractory acute myeloid leukemia (AML) have poor survival. We evaluated gemtuzumab ozogamicin (CD33-targeted drug) used on a compassionate basis in patients diagnosed from 1995 until 2014 within Acute Myeloid Leukemia Berlin-Frankfurt-Münster studies, and identified 76 patients (<18 years) with highly-advanced and pre-treated AML [refractory de novo acute myeloid leukemia (n=10), de novo AML refractory to relapse (1st early: n=41; 1st late: n=10; 2nd or more: n=10), and secondary AML (n=5)]. At doses of 2.5–10 mg/m2, gemtuzumab ozogamicin was administered in 1-4 cycles as single agent (47%), combined with cytarabine (47%), or others (6%). Most common grade 3/4 adverse events were infections or febrile neutropenia (78% of severe adverse events), infusion-related immunological reactions (6%), and gastrointestinal symptoms (5%). Three patients experienced veno-occlusive disease (one fatal due to exacerbation of a pre-existing cardiomyopathy). Sixty-four percent received subsequent hematopoietic stem cell transplantation. Probability of 4-year overall survival was 18±5% in all, 27±7% in patients with and 0% in patients without hematopoietic stem cell transplantation (P<0.0001). Administration of gemtuzumab ozogamicin on a patient-specific, compassionate use basis was frequently considered in our study group and proved to be effective for bridging children with very advanced AML to hematopoietic stem cell transplantation. Uniform prospective studies for these patients are urgently needed.
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Affiliation(s)
- Naghmeh Niktoreh
- Department of Pediatric Hematology and Oncology, University Hospital Essen, Germany
| | - Beate Lerius
- Department of Pediatric Hematology and Oncology, University Hospital Essen, Germany
| | - Martin Zimmermann
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Germany
| | - Bernd Gruhn
- Department of Pediatrics, Jena University Hospital, Germany
| | - Gabriele Escherich
- Department of Pediatric Hematology and Oncology, Eppendorf University Hospital, Hamburg, Germany
| | - Jean-Pierre Bourquin
- Division of Pediatric Hematology/Oncology, University Children's Hospital Zurich, Switzerland
| | - Michael Dworzak
- St. Anna Children's Hospital and Children's Cancer Research Institute, Department of Pediatrics, Medical University of Vienna, Austria
| | - Lucie Sramkova
- Department of Pediatric Hematology and Oncology, 2 Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Claudia Rossig
- University Children's Hospital Münster, Pediatric Hematology and Oncology, Germany
| | - Ursula Creutzig
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Germany
| | - Dirk Reinhardt
- Department of Pediatric Hematology and Oncology, University Hospital Essen, Germany
| | - Mareike Rasche
- Department of Pediatric Hematology and Oncology, University Hospital Essen, Germany
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11
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Abstract
Drug-induced liver injury (DILI) presents unique challenges to the pathologist. It is not only an uncommon reason for liver biopsy, but the pathology of DILI is spread across the entire spectrum of hepatic injury patterns. It is important for the pathologist to suspect DILI when the histological changes are unusual or out of synchronicity with the patient's history. A systematic evaluation approach will yield the most information. It begins with the characterization of the general pattern of injury which, for most cases, will be found in a handful of necroinflammatory and cholestatic patterns. A careful assessment of the severity of injury across the various anatomic compartments will provide information on the probable natural history of the injury. Correlation of liver injury with the patient's medication history and clinical findings will help to narrow the differential diagnosis, particularly when it is recognized that most drugs have a limited range of histological findings and vary in their propensity to cause injury. This review provides an overview of the assessment of the liver biopsy and its use to confirm or exclude particular drugs as contributing to the patient's liver injury.
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Affiliation(s)
- David E Kleiner
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD, USA
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12
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Guffroy M, Falahatpisheh H, Biddle K, Kreeger J, Obert L, Walters K, Goldstein R, Boucher G, Coskran T, Reagan W, Sullivan D, Huang C, Sokolowski S, Giovanelli R, Gerber HP, Finkelstein M, Khan N. Liver Microvascular Injury and Thrombocytopenia of Antibody-Calicheamicin Conjugates in Cynomolgus Monkeys-Mechanism and Monitoring. Clin Cancer Res 2016; 23:1760-1770. [PMID: 27683177 DOI: 10.1158/1078-0432.ccr-16-0939] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 08/17/2016] [Accepted: 09/09/2016] [Indexed: 11/16/2022]
Abstract
Purpose: Adverse reactions reported in patients treated with antibody-calicheamicin conjugates such as gemtuzumab ozogamicin (Mylotarg) and inotuzumab ozogamicin include thrombocytopenia and sinusoidal obstruction syndrome (SOS). The objective of this experimental work was to investigate the mechanism for thrombocytopenia, characterize the liver injury, and identify potential safety biomarkers.Experimental Design: Cynomolgus monkeys were dosed intravenously at 6 mg/m2/dose once every 3 weeks with a nonbinding antibody-calicheamicin conjugate (PF-0259) containing the same linker-payload as gemtuzumab ozogamicin and inotuzumab ozogamicin. Monkeys were necropsied 48 hours after the first administration (day 3) or 3 weeks after the third administration (day 63).Results: PF-0259 induced acute thrombocytopenia (up to 86% platelet reduction) with nadirs on days 3 to 4. There was no indication of effects on megakaryocytes in bone marrow or activation of platelets in peripheral blood. Microscopic evaluation of liver from animals necropsied on day 3 demonstrated midzonal degeneration and loss of sinusoidal endothelial cells (SECs) associated with marked platelet accumulation in sinusoids. Liver histopathology on day 63 showed variable endothelial recovery and progression to a combination of sinusoidal capillarization and sinusoidal dilation/hepatocellular atrophy, consistent with early SOS. Among biomarkers evaluated, there were early and sustained increases in serum hyaluronic acid (HA) that correlated well with serum aspartate aminotransferase and liver microscopic changes, suggesting that HA may be a sensitive diagnostic marker of the liver microvascular injury.Conclusions: These data support the conclusion that target-independent damage to liver SECs may be responsible for acute thrombocytopenia (through platelet sequestration in liver sinusoids) and development of SOS. Clin Cancer Res; 23(7); 1760-70. ©2016 AACR.
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Affiliation(s)
- Magali Guffroy
- Drug Safety Research and Development, Pfizer Inc., Pearl River, New York.
| | - Hadi Falahatpisheh
- Drug Safety Research and Development, Pfizer Inc., Pearl River, New York
| | - Kathleen Biddle
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - John Kreeger
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - Leslie Obert
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - Karen Walters
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - Richard Goldstein
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - Germaine Boucher
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - Timothy Coskran
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - William Reagan
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - Danielle Sullivan
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - Chunli Huang
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - Sharon Sokolowski
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | | | - Hans-Peter Gerber
- Oncology-Rinat Research & Development, Pfizer Inc., Pearl River, New York
| | - Martin Finkelstein
- Drug Safety Research and Development, Pfizer Inc., Pearl River, New York
| | - Nasir Khan
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
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13
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Kell J. The addition of gemtuzumab ozogamicin to chemotherapy in adult patients with acute myeloid leukemia. Expert Rev Anticancer Ther 2016; 16:377-82. [PMID: 26942450 DOI: 10.1586/14737140.2016.1162099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The treatment of acute myeloid leukaemia has remained largely unchanged for the last 30 years since the advent of combination chemotherapy with cytarabine arabinoside and daunorubicin with remission rates around 70% but with long term survival still only around 40% in young adults. Doses of chemotherapy have been pushed to the limit of toxicity. Gemtuzumab ozogamicin allows additional chemotherapy to be delivered to the leukaemic cells without significantly adding to toxicity since the active agent is coupled to a monoclonal anti-CD33 antibody. It was approved by the FDA in 2000 for the treatment of elderly patients with relapsed CD33 positive AML at a dose of 9mg/m(2) on two days two weeks apart. Almost at once, questions were raised about its safety, with a particular liver signal, and it was voluntarily withdrawn from practice in 2010. Many groups have been examining the role of gemtuzumab ozogamicin in combination with chemotherapy, usually at lower doses than originally recommended, with varying degrees of success and toxicity and gemtuzumab ozogamicin is now entering a period of rehabilitation. Currently it is only commercially available in Japan although it is currently also available in the UK Bloodwise AML18 study.
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Affiliation(s)
- Jonathan Kell
- a Department of Haematology , University Hospital of Wales , Cardiff , UK
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14
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Yan H, Endo Y, Shen Y, Rotstein D, Dokmanovic M, Mohan N, Mukhopadhyay P, Gao B, Pacher P, Wu WJ. Ado-Trastuzumab Emtansine Targets Hepatocytes Via Human Epidermal Growth Factor Receptor 2 to Induce Hepatotoxicity. Mol Cancer Ther 2015; 15:480-90. [PMID: 26712117 DOI: 10.1158/1535-7163.mct-15-0580] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 12/04/2015] [Indexed: 11/16/2022]
Abstract
Ado-trastuzumab emtansine (T-DM1) is an antibody-drug conjugate (ADC) approved for the treatment of HER2-positive metastatic breast cancer. It consists of trastuzumab, a humanized mAb directed against HER2, and a microtubule inhibitor, DM1, conjugated to trastuzumab via a thioether linker. Hepatotoxicity is one of the serious adverse events associated with T-DM1 therapy. Mechanisms underlying T-DM1-induced hepatotoxicity remain elusive. Here, we use hepatocytes and mouse models to investigate the mechanisms of T-DM1-induced hepatotoxicity. We show that T-DM1 is internalized upon binding to cell surface HER2 and is colocalized with LAMP1, resulting in DM1-associated cytotoxicity, including disorganized microtubules, nuclear fragmentation/multiple nuclei, and cell growth inhibition. We further demonstrate that T-DM1 treatment significantly increases the serum levels of aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase in mice and induces inflammation and necrosis in liver tissues, and that T-DM1-induced hepatotoxicity is dose dependent. Moreover, the gene expression of TNFα in liver tissues is significantly increased in mice treated with T-DM1 as compared with those treated with trastuzumab or vehicle. We propose that T-DM1-induced upregulation of TNFα enhances the liver injury that may be initially caused by DM1-mediated intracellular damage. Our proposal is underscored by the fact that T-DM1 induces the outer mitochondrial membrane rupture, a typical morphologic change in the mitochondrial-dependent apoptosis, and mitochondrial membrane potential dysfunction. Our work provides mechanistic insights into T-DM1-induced hepatotoxicity, which may yield novel strategies to manage liver injury induced by T-DM1 or other ADCs.
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Affiliation(s)
- Haoheng Yan
- Division of Biotechnology Review and Research I, Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland. Interagency Oncology Task Force Fellowship: Oncology Product Research/Review Fellow, NCI, Bethesda, Maryland
| | - Yukinori Endo
- Division of Biotechnology Review and Research I, Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Yi Shen
- Division of Biotechnology Review and Research I, Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - David Rotstein
- Division of Compliance, Office of Surveillance and Compliance, Center for Veterinary Medicine, U.S. Food and Drug Administration, Derwood, Maryland
| | - Milos Dokmanovic
- Division of Biotechnology Review and Research I, Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Nishant Mohan
- Division of Biotechnology Review and Research I, Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Partha Mukhopadhyay
- Laboratory of Physiologic Studies, National Institute on Alcohol Abuse and Alcoholism, NIH, Bethesda, Maryland
| | - Bin Gao
- Laboratory of Liver Diseases, National Institute on Alcohol Abuse and Alcoholism, NIH, Bethesda, Maryland
| | - Pal Pacher
- Laboratory of Physiologic Studies, National Institute on Alcohol Abuse and Alcoholism, NIH, Bethesda, Maryland
| | - Wen Jin Wu
- Division of Biotechnology Review and Research I, Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland.
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15
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Li X, Xu SN, Qin DB, Tan Y, Gong Q, Chen JP. Effect of adding gemtuzumab ozogamicin to induction chemotherapy for newly diagnosed acute myeloid leukemia: a meta-analysis of prospective randomized phase III trials. Ann Oncol 2015; 25:455-61. [PMID: 24478322 DOI: 10.1093/annonc/mdt566] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Gemtuzumab ozogamicin (GO) is a targeted antineoplastic agent comprised of a recombinant anti-CD33 humanized antibody linked to calicheamicin. Previous trials have showed conflicting results concerning the efficacy and toxicity of adding GO to induction chemotherapy for newly diagnosed acute myeloid leukemia (AML). A systematic review and meta-analysis was conducted to resolve this controversial issue. PATIENTS AND METHODS Summary data from five randomized phase III trials compared adding GO to induction chemotherapy with induction chemotherapy alone for newly diagnosed AML were meta-analyzed. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) for overall survival (OS) and relapse-free survival (RFS), and pooled odds ratios (ORs) and 95% CIs for complete remission (CR) rate, incidences of resistance disease, relapse and toxicity were calculated. RESULTS Data of 3596 patients (1798 GO and 1798 controls) from five randomized phase III trials were analyzed. Compared with induction chemotherapy alone, adding GO significantly prolonged OS (HR 0.93, 95% CI 0.86-1.00, P=0.05) and RFS (HR 0.87, 95% CI 0.79-0.95, P=0.003), decreased the incidences of resistant disease (OR 0.71, 95% CI 0.55-0.93, P=0.01) and relapse (OR 0.75, 95% CI 0.63-0.90, P=0.002), but had no effect on CR rate (OR 1.15, 95% CI 0.91-1.46, P=0.24). Sensitivity analysis yielded similar results. Subgroup analysis identified that cytogenetics might be an influencing factor for the effect of adding GO. In addition, the risks of grade 3-4 nausea/vomiting, diarrhea and liver aspartate transaminase (AST) elevation were increased in GO arm. CONCLUSIONS Adding GO to induction chemotherapy for newly diagnosed AML can significantly prolong OS and RFS, decrease incidences of resistant disease and relapse, but may increase risks of grade 3-4 nausea/vomiting, diarrhea and liver AST elevation.
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Affiliation(s)
- X Li
- Department of Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
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16
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Bornstein GG. Antibody Drug Conjugates: Preclinical Considerations. AAPS JOURNAL 2015; 17:525-34. [PMID: 25724883 DOI: 10.1208/s12248-015-9738-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 02/09/2015] [Indexed: 01/29/2023]
Abstract
The development path for antibody drug conjugates (ADCs) is more complex and challenging than for unmodified antibodies. While many of the preclinical considerations for both unmodified and antibody drug conjugates are shared, special considerations must be taken into account when developing an ADC. Unlike unmodified antibodies, an ADC must preferentially bind to tumor cells, internalize, and traffic to the appropriate intracellular compartment to release the payload. Parameters that can impact the pharmacological properties of this class of therapeutics include the selection of the payload, the type of linker, and the methodology for payload drug conjugation. Despite a plethora of in vitro assays and in vivo models to screen and evaluate ADCs, the challenge remains to develop improved preclinical tools that will be more predictive of clinical outcome. This review will focus on preclinical considerations for clinically validated small molecule ADCs. In addition, the lessons learned from Mylotarg®, the first in class FDA-approved ADC, are highlighted.
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Affiliation(s)
- Gadi G Bornstein
- Centers for Therapeutic Innovation (CTI), Pfizer Inc., 450 East 29th Street, New York, New York, 10016, USA,
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17
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Treatment of CD33-directed chimeric antigen receptor-modified T cells in one patient with relapsed and refractory acute myeloid leukemia. Mol Ther 2014; 23:184-91. [PMID: 25174587 DOI: 10.1038/mt.2014.164] [Citation(s) in RCA: 292] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Accepted: 08/25/2014] [Indexed: 12/20/2022] Open
Abstract
We conducted a clinical trial to assess the feasibility and efficacy of CD33-directed chimeric antigen receptor-modified T cells (CART-33) for the treatment of refractory acute myeloid leukemia (AML). A 41-year-old male patient with AML was enrolled and received a total of 1.12 × 10(9) autologous CART-33 cells, of which ~38% were transduced with CAR. The CART-33 infusion alone induced rigorous chills and fevers; drastic fluctuations of his preexisting pancytopenia; elevated serum cytokine levels, including interleukin (IL)-6, IL-8, tumor necrosis factor-α, and interferon-γ; slight transient hyperbilirubinemia within 2 weeks; a subsequent intermittent moderate fever; and reversed fluctuation of the pancytopenia. A marked decrease of blasts in the bone marrow was observed on examination 2 weeks after therapy, and there was a gradual increase until florid disease progression occurred at 9 weeks after the cell infusion. These observations warrant further research on CART-33 treatment in refractory AML and may spur efforts to extend the CART-33-induced tumor burden to the preparation of other intensive strategies, such as hematopoietic stem cell transplantation. This study is registered at www.ClinicalTrials.gov as NCT01864902.
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18
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The past and future of CD33 as therapeutic target in acute myeloid leukemia. Blood Rev 2014; 28:143-53. [DOI: 10.1016/j.blre.2014.04.001] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 04/11/2014] [Accepted: 04/14/2014] [Indexed: 02/05/2023]
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Abstract
INTRODUCTION Gemtuzumab ozogamicin (GO) is a combination of calicheamicin and a recombinant humanized IgG4 antibody directed against CD33. From 2000 to 2010, it was approved by the FDA for treatment of relapsed, older patients with CD33(+) acute myeloid leukemia (AML). After withdrawal from the market, several trials have provided new evidence on the safety and clinical efficacy of GO. AREAS COVERED In this review, we discuss pharmacological and clinical aspects of GO. GO was found to show benefit in AML patients as adjunct to intensive chemotherapy when it was given in parallel to induction therapy. The benefit was restricted to patients with a favorable- or an intermediate-risk cytogenetic profile. Higher doses of GO above 6 mg/m(2) per administration were associated with increased toxicity without survival benefit, whereas repetitive doses of 3 mg/m(2) resulting in cumulative doses of 9 mg/m(2) were well tolerated. Predictive markers for response to GO other than the cytogenetic profile and P-glycoprotein activity are still missing. EXPERT OPINION GO as adjunct and in parallel to intensive induction chemotherapy does significantly improve survival end points in AML patients with favorable/intermediate-risk cytogenetics. A dose of 3 mg/m(2) per administration appears safer compared with 6 mg/m(2) and even 9 mg/m(2).
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Affiliation(s)
- Felicitas Thol
- Hannover Medical School, Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation , Carl-Neuberg-Str. 1, 30625, Hannover , Germany
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20
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Cowan AJ, Laszlo GS, Estey EH, Walter RB. Antibody-based therapy of acute myeloid leukemia with gemtuzumab ozogamicin. Front Biosci (Landmark Ed) 2013; 18:1311-34. [PMID: 23747885 DOI: 10.2741/4181] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Antibodies have created high expectations for effective yet tolerated therapeutics in acute myeloid leukemia (AML). Hitherto the most exploited target is CD33, a myeloid differentiation antigen found on AML blasts in most patients and, perhaps, leukemic stem cells in some. Treatment efforts have focused on conjugated antibodies, particularly gemtuzumab ozogamicin (GO), an anti-CD33 antibody carrying a toxic calicheamicin-g 1 derivative that, after intracellular hydrolytic release, induces DNA strand breaks, apoptosis, and cell death. Serving as paradigm for this strategy, GO was the first anti-cancer immunoconjugate to obtain regulatory approval in the U.S. While efficacious as monotherapy in acute promyelocytic leukemia (APL), GO alone induces remissions in less than 25-35% of non-APL AML patients. However, emerging data from well controlled trials now indicate that GO improves survival for many non-APL AML patients, supporting the conclusion that CD33 is a clinically relevant target for some disease subsets. It is thus unfortunate that GO has become unavailable in many parts of the world, and the drug's usefulness should be reconsidered and selected patients granted access to this immunoconjugate.
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Affiliation(s)
- Andrew J Cowan
- Hematology/Oncology Fellowship Program, University of Washington, Seattle, WA, USA
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