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Kayton ML, Weiss AR, Xue W, Binitie O, Hayes Dixon A, Randall RL, Sorger JI, Hawkins DS, Spunt SL, Wang D, Million L, Terezakis S, Choy E, Okuno SH, Venkatramani R, Chen YL, Scharschmidt TJ. Neoadjuvant pazopanib in nonrhabdomyosarcoma soft tissue sarcomas (ARST1321): A report of major wound complications from the Children's Oncology Group and NRG Oncology. J Surg Oncol 2023; 127:871-881. [PMID: 36779385 PMCID: PMC10121189 DOI: 10.1002/jso.27205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 01/05/2023] [Accepted: 01/15/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND AND OBJECTIVES The impact upon wound healing of targeted molecular therapies, when incorporated into neoadjuvant therapy of soft tissue sarcoma, is largely unknown. Here, we describe wound complications following addition of pazopanib, a tyrosine kinase inhibitor (TKI), to neoadjuvant radiotherapy (RT) +/- chemotherapy for soft tissue sarcoma. METHODS Wound complications were evaluated on dose-finding and randomized arms of ARST1321, a phase II/III study incorporating neoadjuvant RT, +/- pazopanib, +/- ifosfamide/doxorubicin (ID) for sarcoma therapy. RESULTS Of 85 evaluable patients, 35 (41%) experienced postoperative wound complications. Most (57%) were grade III. Randomization to pazopanib + RT + ID carried a 50% wound complication rate (17/34, with 47% grade III), compared to 22% (5/23) with ID + RT alone. In nonchemotherapy study arms, pazopanib + RT resulted in a 59% wound complication rate versus 25% for those receiving RT alone. Grade III wound complications occurred among 26% (15/58) of all patients receiving pazopanib. Wound complications occurred a median of 35 days postoperatively. Some occurred following diagnostic biopsies and at remote surgical sites. CONCLUSION The addition of pazopanib to neoadjuvant chemotherapy and RT resulted in a higher wound complication rate following therapy of soft tissue sarcoma. The rate of grade III complications remained comparable to that reported in contemporary literature.
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Affiliation(s)
- Mark L Kayton
- Department of Surgery, K. Hovnanian Children's Hospital at Jersey Shore University Medical Center, Hackensack-Meridian Health Network, Neptune, New Jersey, USA
| | - Aaron R Weiss
- Department of Pediatrics, Maine Medical Center, Portland, Maine, USA
| | - Wei Xue
- Department of Biostatistics, University of Florida, Gainesville, Florida, USA
| | - Odion Binitie
- Department of Sarcoma, Moffitt Cancer Center, Tampa, Florida, USA
| | - Andrea Hayes Dixon
- Department of Surgery, Howard University, Washington, District of Columbia, USA
| | - R Lor Randall
- Department of Orthopaedic Surgery, University of California Davis, Sacramento, California, USA
| | - Joel I Sorger
- Department of Orthopedic Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Douglas S Hawkins
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington, USA
| | - Sheri L Spunt
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Dian Wang
- Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois, USA
| | - Lynn Million
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Stephanie Terezakis
- Department of Radiation Oncology, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Edwin Choy
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Scott H Okuno
- Department of Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rajkumar Venkatramani
- Department of Pediatrics, Texas Children's Cancer Center, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Yen-Lin Chen
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thomas J Scharschmidt
- Department of Orthopaedics, James Cancer Hospital and Nationwide Children's Hospital, Columbus, Ohio, USA
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2
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Fleuren EDG, Vlenterie M, van der Graaf WTA. Recent advances on anti-angiogenic multi-receptor tyrosine kinase inhibitors in osteosarcoma and Ewing sarcoma. Front Oncol 2023; 13:1013359. [PMID: 36994209 PMCID: PMC10040783 DOI: 10.3389/fonc.2023.1013359] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 02/06/2023] [Indexed: 03/16/2023] Open
Abstract
Osteosarcoma (OS) and Ewing sarcoma (ES) are the two most common types of primary bone cancer that predominantly affect the young. Despite aggressive multimodal treatment, survival has not improved significantly over the past four decades. Clinical efficacy has historically been observed for some mono-Receptor Tyrosine Kinase (RTK) inhibitors, albeit in small subsets of OS and ES patients. Clinical efficacy in larger groups of OS or ES patients was reported recently with several newer generation multi-RTK inhibitors. All these inhibitors combine a strong anti-angiogenic (VEGFRs) component with simultaneous inhibition of other key RTKs implicated in OS and ES progression (PDGFR, FGFR, KIT and/or MET). However, despite interesting clinical data, none of these agents have obtained a registration for these indications and are thus difficult to implement in routine OS and ES patient care. It is at present also unclear which of these drugs, with largely overlapping molecular inhibition profiles, would work best for which patient or subtype, and treatment resistance almost uniformly occurs. Here, we provide a critical assessment and systemic comparison on the clinical outcomes to the six most tested drugs in this field in OS and ES to date, including pazopanib, sorafenib, regorafenib, anlotinib, lenvatinib and cabozantinib. We pay special attention to clinical response evaluations in bone sarcomas and provide drug comparisons, including drug-related toxicity, to put these drugs into context for OS and ES patients, and describe how future trials utilizing anti-angiogenic multi-RTK targeted drugs could be designed to ultimately improve response rates and decrease toxicity.
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Affiliation(s)
- Emmy D. G. Fleuren
- Children’s Cancer Institute, Lowy Cancer Research Centre, UNSW Sydney, Sydney, NSW, Australia
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
- Centre for Childhood Cancer Research, UNSW Sydney, Sydney, NSW, Australia
- *Correspondence: Emmy D. G. Fleuren,
| | - Myrella Vlenterie
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Winette T. A. van der Graaf
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
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Abstract
The nitrogen mustards are powerful cytotoxic and lymphoablative agents and have been used for more than 60 years. They are employed in the treatment of cancers, sarcomas, and hematologic malignancies. Cyclophosphamide, the most versatile of the nitrogen mustards, also has a place in stem cell transplantation and the therapy of autoimmune diseases. Adverse effects caused by the nitrogen mustards on the central nervous system, kidney, heart, bladder, and gonads remain important issues. Advances in analytical techniques have facilitated the investigation of the pharmacokinetics of the nitrogen mustards, especially the oxazaphosphorines, which are prodrugs requiring metabolic activation. Enzymes involved in the metabolism of cyclophosphamide and ifosfamide are very polymorphic, but a greater understanding of the pharmacogenomic influences on their activity has not yet translated into a personalized medicine approach. In addition to damaging DNA, the nitrogen mustards can act through other mechanisms, such as antiangiogenesis and immunomodulation. The immunomodulatory properties of cyclophosphamide are an area of current exploration. In particular, cyclophosphamide decreases the number and activity of regulatory T cells, and the interaction between cyclophosphamide and the intestinal microbiome is now recognized as an important factor. New derivatives of the nitrogen mustards continue to be assessed. Oxazaphosphorine analogs have been synthesized in attempts to both improve efficacy and reduce toxicity, with varying degrees of success. Combinations of the nitrogen mustards with monoclonal antibodies and small-molecule targeted agents are being evaluated. SIGNIFICANCE STATEMENT: The nitrogen mustards are important, well-established therapeutic agents that are used to treat a variety of diseases. Their role is continuing to evolve.
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Affiliation(s)
- Martin S Highley
- Plymouth Oncology Centre, Derriford Hospital, and Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom (M.S.H.); Department of Animal Physiology and Neurobiology (B.L.) and Laboratory for Experimental Oncology (E.A.D.B.), University of Leuven, Leuven, Belgium; Oncology Department, University Hospital Antwerp, Edegem, Belgium (H.P.); and London Oncology Clinic, London, United Kingdom (P.G.H.)
| | - Bart Landuyt
- Plymouth Oncology Centre, Derriford Hospital, and Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom (M.S.H.); Department of Animal Physiology and Neurobiology (B.L.) and Laboratory for Experimental Oncology (E.A.D.B.), University of Leuven, Leuven, Belgium; Oncology Department, University Hospital Antwerp, Edegem, Belgium (H.P.); and London Oncology Clinic, London, United Kingdom (P.G.H.)
| | - Hans Prenen
- Plymouth Oncology Centre, Derriford Hospital, and Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom (M.S.H.); Department of Animal Physiology and Neurobiology (B.L.) and Laboratory for Experimental Oncology (E.A.D.B.), University of Leuven, Leuven, Belgium; Oncology Department, University Hospital Antwerp, Edegem, Belgium (H.P.); and London Oncology Clinic, London, United Kingdom (P.G.H.)
| | - Peter G Harper
- Plymouth Oncology Centre, Derriford Hospital, and Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom (M.S.H.); Department of Animal Physiology and Neurobiology (B.L.) and Laboratory for Experimental Oncology (E.A.D.B.), University of Leuven, Leuven, Belgium; Oncology Department, University Hospital Antwerp, Edegem, Belgium (H.P.); and London Oncology Clinic, London, United Kingdom (P.G.H.)
| | - Ernst A De Bruijn
- Plymouth Oncology Centre, Derriford Hospital, and Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom (M.S.H.); Department of Animal Physiology and Neurobiology (B.L.) and Laboratory for Experimental Oncology (E.A.D.B.), University of Leuven, Leuven, Belgium; Oncology Department, University Hospital Antwerp, Edegem, Belgium (H.P.); and London Oncology Clinic, London, United Kingdom (P.G.H.)
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Minot-This MS, Boudou-Rouquette P, Jouinot A, de Percin S, Balakirouchenane D, Khoudour N, Tlemsani C, Chauvin J, Thomas-Schoemann A, Goldwasser F, Blanchet B, Alexandre J. Relation between Plasma Trough Concentration of Pazopanib and Progression-Free Survival in Metastatic Soft Tissue Sarcoma Patients. Pharmaceutics 2022; 14:pharmaceutics14061224. [PMID: 35745797 PMCID: PMC9231369 DOI: 10.3390/pharmaceutics14061224] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/04/2022] [Accepted: 06/07/2022] [Indexed: 12/20/2022] Open
Abstract
Background: Pazopanib (PAZ) is an oral angiogenesis inhibitor approved to treat soft tissue sarcoma (STS) but associated with a large interpatient pharmacokinetic (PK) variability and narrow therapeutic index. We aimed to define the specific threshold of PAZ trough concentration (Cmin) associated with better progression-free survival (PFS) in STS patients. Methods: In this observational study, PAZ Cmin was monitored over the treatment course. For the primary endpoint, the 3-month PFS in STS was analyzed with logistic regression. Second, we performed exposure−overall survival (OS) (Cox model plus Kaplan−Meier analysis/log-rank test) and exposure−toxicity analyses. Results: Ninety-five STS patients were eligible for pharmacokinetic/pharmacodynamic (PK/PD) assessment. In the multivariable analysis, PAZ Cmin < 27 mg/L was independently associated with a risk of progression at 3 months (odds ratio (OR) 4.21, 95% confidence interval (CI) (1.47−12.12), p = 0.008). A higher average of PAZ Cmin over the first 3 months was associated with a higher risk of grade 3−4 toxicities according to the NCI-CTCAE version 5.0 (OR 1.07 per 1 mg/L increase, CI95 (1.02−1.13), p = 0.007). Conclusion: PAZ Cmin ≥ 27 mg/L was independently associated with improved 3-month PFS in STS patients. Pharmacokinetically-guided dosing could be helpful to optimize the clinical management of STS patients in daily clinical practice.
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Affiliation(s)
- Marie-Sophie Minot-This
- Institut du Cancer Paris CARPEM, AP-HP, APHP.Centre, Department of Medical Oncology, ARIANE, Cochin Hospital, 75014 Paris, France; (M.-S.M.-T.); (A.J.); (S.d.P.); (C.T.); (F.G.); (J.A.)
| | - Pascaline Boudou-Rouquette
- Institut du Cancer Paris CARPEM, AP-HP, APHP.Centre, Department of Medical Oncology, ARIANE, Cochin Hospital, 75014 Paris, France; (M.-S.M.-T.); (A.J.); (S.d.P.); (C.T.); (F.G.); (J.A.)
- Correspondence:
| | - Anne Jouinot
- Institut du Cancer Paris CARPEM, AP-HP, APHP.Centre, Department of Medical Oncology, ARIANE, Cochin Hospital, 75014 Paris, France; (M.-S.M.-T.); (A.J.); (S.d.P.); (C.T.); (F.G.); (J.A.)
- INSERM U-1016, CNRS UMR-8104, University of Paris, Institut Cochin, 75014 Paris, France
| | - Sixtine de Percin
- Institut du Cancer Paris CARPEM, AP-HP, APHP.Centre, Department of Medical Oncology, ARIANE, Cochin Hospital, 75014 Paris, France; (M.-S.M.-T.); (A.J.); (S.d.P.); (C.T.); (F.G.); (J.A.)
| | - David Balakirouchenane
- Department of Pharmacokinetics and Pharmacochemistry, AP-HP, CARPEM, Cochin Hospital, 75014 Paris, France; (D.B.); (N.K.); (A.T.-S.); (B.B.)
- UMR8038 CNRS, U1268 INSERM, Faculty of Pharmacy, University of Paris, PRES Sorbonne Paris Cité, CARPEM, 75006 Paris, France
| | - Nihel Khoudour
- Department of Pharmacokinetics and Pharmacochemistry, AP-HP, CARPEM, Cochin Hospital, 75014 Paris, France; (D.B.); (N.K.); (A.T.-S.); (B.B.)
| | - Camille Tlemsani
- Institut du Cancer Paris CARPEM, AP-HP, APHP.Centre, Department of Medical Oncology, ARIANE, Cochin Hospital, 75014 Paris, France; (M.-S.M.-T.); (A.J.); (S.d.P.); (C.T.); (F.G.); (J.A.)
| | | | - Audrey Thomas-Schoemann
- Department of Pharmacokinetics and Pharmacochemistry, AP-HP, CARPEM, Cochin Hospital, 75014 Paris, France; (D.B.); (N.K.); (A.T.-S.); (B.B.)
- UMR8038 CNRS, U1268 INSERM, Faculty of Pharmacy, University of Paris, PRES Sorbonne Paris Cité, CARPEM, 75006 Paris, France
| | - François Goldwasser
- Institut du Cancer Paris CARPEM, AP-HP, APHP.Centre, Department of Medical Oncology, ARIANE, Cochin Hospital, 75014 Paris, France; (M.-S.M.-T.); (A.J.); (S.d.P.); (C.T.); (F.G.); (J.A.)
- Lixoft, 92160 Antony, France;
| | - Benoit Blanchet
- Department of Pharmacokinetics and Pharmacochemistry, AP-HP, CARPEM, Cochin Hospital, 75014 Paris, France; (D.B.); (N.K.); (A.T.-S.); (B.B.)
- UMR8038 CNRS, U1268 INSERM, Faculty of Pharmacy, University of Paris, PRES Sorbonne Paris Cité, CARPEM, 75006 Paris, France
| | - Jérôme Alexandre
- Institut du Cancer Paris CARPEM, AP-HP, APHP.Centre, Department of Medical Oncology, ARIANE, Cochin Hospital, 75014 Paris, France; (M.-S.M.-T.); (A.J.); (S.d.P.); (C.T.); (F.G.); (J.A.)
- Centre de Recherche des Cordeliers, Université Paris-Sorbonne, INSERM, 75005 Paris, France
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5
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Weiss AR, Chen YL, Scharschmidt TJ, Chi YY, Tian J, Black JO, Davis JL, Fanburg-Smith JC, Zambrano E, Anderson J, Arens R, Binitie O, Choy E, Davis JW, Hayes-Jordan A, Kao SC, Kayton ML, Kessel S, Lim R, Meyer WH, Million L, Okuno SH, Ostrenga A, Parisi MT, Pryma DA, Randall RL, Rosen MA, Schlapkohl M, Shulkin BL, Smith EA, Sorger JI, Terezakis S, Hawkins DS, Spunt SL, Wang D. Pathological response in children and adults with large unresected intermediate-grade or high-grade soft tissue sarcoma receiving preoperative chemoradiotherapy with or without pazopanib (ARST1321): a multicentre, randomised, open-label, phase 2 trial. Lancet Oncol 2020; 21:1110-1122. [PMID: 32702309 DOI: 10.1016/s1470-2045(20)30325-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Outcomes for children and adults with advanced soft tissue sarcoma are poor with traditional therapy. We investigated whether the addition of pazopanib to preoperative chemoradiotherapy would improve pathological near complete response rate compared with chemoradiotherapy alone. METHODS In this joint Children's Oncology Group and NRG Oncology multicentre, randomised, open-label, phase 2 trial, we enrolled eligible adults (aged ≥18 years) and children (aged between 2 and <18 years) from 57 hospitals in the USA and Canada with unresected, newly diagnosed trunk or extremity chemotherapy-sensitive soft tissue sarcoma, which were larger than 5 cm in diameter and of intermediate or high grade. Eligible patients had Lansky (if aged ≤16 years) or Karnofsky (if aged >16 years) performance status score of at least 70. Patients received ifosfamide (2·5 g/m2 per dose intravenously on days 1-3 with mesna) and doxorubicin (37·5 mg/m2 per dose intravenously on days 1-2) with 45 Gy preoperative radiotherapy, followed by surgical resection at week 13. Patients were randomly assigned (1:1) using a web-based system, in an unmasked manner, to receive oral pazopanib (if patients <18 years 350 mg/m2 once daily; if patients ≥18 years 600 mg once daily) or not (control group), with pazopanib not given immediately before or after surgery at week 13. The study projected 100 randomly assigned patients were needed to show an improvement in the number of participants with a 90% or higher pathological response at week 13 from 40% to 60%. Analysis was done per protocol. This study has completed accrual and is registered with ClinicalTrials.gov, NCT02180867. FINDINGS Between July 7, 2014, and Oct 1, 2018, 81 eligible patients were enrolled and randomly assigned to the pazopanib group (n=42) or the control group (n=39). At the planned second interim analysis with 42 evaluable patients and a median follow-up of 0·8 years (IQR 0·3-1·6) in the pazopanib group and 1 year (0·3-1·6) in the control group, the number of patients with a 90% pathological response or higher was 14 (58%) of 24 patients in the pazopanib group and four (22%) of 18 patients in the control group, with a between-group difference in the number of 90% or higher pathological response of 36·1% (83·8% CI 16·5-55·8). On the basis of an interim analysis significance level of 0·081 (overall one-sided significance level of 0·20, power of 0·80, and O'Brien-Fleming-type cumulative error spending function), the 83·8% CI for response difference was between 16·5% and 55·8% and thus excluded 0. The improvement in pathological response rate with the addition of pazopanib crossed the predetermined boundary and enrolment was stopped. The most common grade 3-4 adverse events were leukopenia (16 [43%] of 37 patients), neutropenia (15 [41%]), and febrile neutropenia (15 [41%]) in the pazopanib group, and neutropenia (three [9%] of 35 patients) and febrile neutropenia (three [9%]) in the control group. 22 (59%) of 37 patients in the pazopanib group had a pazopanib-related serious adverse event. Paediatric and adult patients had a similar number of grade 3 and 4 toxicity. There were seven deaths (three in the pazopanib group and four in the control group), none of which were treatment related. INTERPRETATION In this presumed first prospective trial of soft tissue sarcoma spanning nearly the entire age spectrum, adding pazopanib to neoadjuvant chemoradiotherapy improved the rate of pathological near complete response, suggesting that this is a highly active and feasible combination in children and adults with advanced soft tissue sarcoma. The comparison of survival outcomes requires longer follow-up. FUNDING National Institutes of Health, St Baldrick's Foundation, Seattle Children's Foundation.
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Affiliation(s)
- Aaron R Weiss
- Department of Pediatrics, Maine Medical Center, Portland, ME, USA.
| | - Yen-Lin Chen
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas J Scharschmidt
- Department of Orthopaedics, James Cancer Hospital and Nationwide Children's Hospital, Columbus, OH, USA
| | - Yueh-Yun Chi
- Department of Pediatrics and Preventative Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jing Tian
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Jennifer O Black
- Department of Pathology, Children's Hospital Colorado, Aurora, CO, USA
| | - Jessica L Davis
- Department of Pathology, Oregon Health & Science University, Portland, OR, USA
| | | | - Eduardo Zambrano
- Department of Pathology, Rocky Mountain Hospital for Children, Presbyterian St Luke Medical Centre, Denver, CO, USA
| | - James Anderson
- Department of Biostatistics and Research Decision Sciences, Merck and Co, North Wales, PA, USA
| | - Robin Arens
- Department of Clinical Trials, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Odion Binitie
- Department of Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
| | - Edwin Choy
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Andrea Hayes-Jordan
- Department of Surgery, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Simon C Kao
- Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Mark L Kayton
- Department of Surgery, Palm Beach Children's Hospital, St Mary's Medical Center, Florida Atlantic University, West Palm Beach, FL, USA
| | - Sandy Kessel
- Imaging and Radiation Oncology Core Rhode Island, Lincoln, RI, USA
| | - Ruth Lim
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - William H Meyer
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Lynn Million
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Scott H Okuno
- Department of Oncology, Mayo Clinic, Rochester, MN, USA
| | - Andrew Ostrenga
- Department of Pharmacy, University of Mississippi Medical Center, Jackson, MS, USA
| | - Marguerite T Parisi
- Department of Radiology and Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA
| | - Daniel A Pryma
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - R Lor Randall
- Department of Orthopaedic Surgery, University of California Davis, Sacramento, CA, USA
| | - Mark A Rosen
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Mary Schlapkohl
- Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Barry L Shulkin
- Department of Diagnostic Imaging, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Ethan A Smith
- Department of Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Joel I Sorger
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Stephanie Terezakis
- Department of Radiation Oncology, University of Minnesota, Masonic Cancer Center, Minneapolis, MN, USA
| | - Douglas S Hawkins
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA
| | - Sheri L Spunt
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Dian Wang
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL, USA
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Abstract
BACKGROUND AND OBJECTIVE As pazopanib plasma trough concentrations are correlated with treatment outcome, we explored whether single nucleotide polymorphisms in the elimination pathway of pazopanib affect systemic pazopanib concentrations. METHODS The decreased function alleles CYP3A4 15389 C > T (*22), ABCB1 3435 C >T, ABCG2 421 C >A, and ABCG2 34G >A were analyzed within a recently developed population-pharmacokinetic model. RESULTS Incorporation of CYP3A4*22 in the model resulted in a 35% lower clearance for variant carriers (0.18 vs. 0.27 L/h; difference in objective function value: - 9.7; p < 0.005). Simulated median trough concentrations of cancer patients with CYP3A4*22 with 600 mg once daily or 800 mg once daily were 31 and 35 mg/L, respectively. The simulated trough concentrations for the population excluding the CYP3A4*22 carriers after 600 mg once daily or 800 mg once daily were 18 and 20 mg/L, respectively. CONCLUSION This analysis shows that CYP3A4*22 heterozygotes have a substantial lower pazopanib clearance and that dose adjustments based on CYP3A4*22 status could be considered.
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7
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Abstract
Pazopanib is an inhibitor of the vascular endothelial growth factor receptor, platelet-derived growth factor receptor, fibroblast growth factor receptor and stem cell receptor c-Kit, and has been approved for the treatment of renal cell carcinoma and soft tissue sarcoma. The pharmacokinetics of pazopanib are complex and are characterized by pH-dependent solubility, large interpatient variability and low, non-linear and time-dependent bioavailability. Exposure to pazopanib is increased by both food and coadministration of ketoconazole, but drastically reduced by proton pump inhibitors. Studies have demonstrated relationships between systemic exposure to pazopanib and toxicity, such as hypertension. Furthermore, a strong relationship between pazopanib trough level ≥20 mg/L and both tumor shrinkage and progression-free survival has been established. At the currently approved daily dose of 800 mg, approximately 20% of patients do not reach this threshold and may be at risk of suboptimal treatment. As a result of this, clinical trials have explored individualized pazopanib dosing, which demonstrate the safety and feasibility of individualized pazopanib dosing based on trough levels. In summary, we provide an overview of the complex pharmacokinetic and pharmacodynamic profiles of pazopanib and, based on the available data, we propose optimized dosing strategies.
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Abstract
OPINION STATEMENT Synovial sarcoma (SS) is a rare, yet highly malignant, type of soft tissue sarcoma (STS), for which survival has not improved significantly during the past years. In this review, we focus on systemic treatment in adults. Compared to other STS, SS are relatively chemosensitive. Ifosfamide and ifosfamide combinations are active in different lines of treatment. In high-risk extremity and chest wall STS, neoadjuvant doxorubicin and ifosfamide has shown as much activity as high-dose ifosfamide. There are indications that combination chemotherapy with doxorubicin and ifosfamide in this setting improves outcome. In the first-line metastatic setting, combination treatment with doxorubicin and ifosfamide is a preferred option in fit patients, while in other patients, sequential doxorubicin and ifosfamide can be considered. In second and later lines, pazopanib and trabectedin have shown activity. Many new approaches to treat metastatic SS are currently under investigation, both preclinical as well as clinical, including other receptor tyrosine kinase inhibitors, epigenetic modulators, compounds interfering with DNA damage response (DDR), and immunotherapy.
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Affiliation(s)
- Ingrid M E Desar
- Department of Medical Oncology, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | | | - Winette T A van der Graaf
- Department of Medical Oncology, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands.
- The Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, London, UK.
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9
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Development of a Pharmacokinetic Model to Describe the Complex Pharmacokinetics of Pazopanib in Cancer Patients. Clin Pharmacokinet 2017; 56:293-303. [PMID: 27534647 DOI: 10.1007/s40262-016-0443-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVE Pazopanib is a multi-targeted anticancer tyrosine kinase inhibitor. This study was conducted to develop a population pharmacokinetic (popPK) model describing the complex pharmacokinetics of pazopanib in cancer patients. METHODS Pharmacokinetic data were available from 96 patients from three clinical studies. A multi-compartment model including (i) a complex absorption profile, (ii) the potential non-linear dose-concentration relationship and (iii) the potential long-term decrease in exposure was developed. RESULTS A two-compartment model best described pazopanib pharmacokinetics. The absorption phase was modelled by two first-order processes: 36 % (relative standard error [RSE] 34 %) of the administered dose was absorbed with a relatively fast rate (0.4 h-1 [RSE 31 %]); after a lag time of 1.0 h (RSE 6 %), the remaining dose was absorbed at a slower rate (0.1 h-1 [RSE 28 %]). The relative bioavailability (rF) at a dose of 200 mg was fixed to 1. With an increasing dose, the rF was strongly reduced, which was modelled with an E max (maximum effect) model (E max was fixed to 1, the dose at half of maximum effect was estimated as 480 mg [RSE 23 %]). Interestingly, the plasma exposure to pazopanib also decreased over time, modelled on rF with a maximum magnitude of 50 % (RSE 27 %) and a first-order decay constant of 0.15 day-1 (RSE 43 %). The inter-patient and intra-patient variability on rF were estimated as 36 % (RSE 16 %) and 75 % (RSE 22 %), respectively. CONCLUSION A popPK model for pazopanib was developed that illustrated the complex absorption process, the non-linear dose-concentration relationship, the high inter-patient and intra-patient variability, and the first-order decay of pazopanib concentration over time. The developed popPK model can be used in clinical practice to screen covariates and guide therapeutic drug monitoring.
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Ferrero S, Leone Roberti Maggiore U, Aiello N, Barra F, Ditto A, Bogani G, Raspagliesi F, Lorusso D. Pharmacokinetic drug evaluation of pazopanib for the treatment of uterine leiomyosarcomas. Expert Opin Drug Metab Toxicol 2017; 13:881-889. [PMID: 28678537 DOI: 10.1080/17425255.2017.1351943] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Uterine leiomyosarcomas (ULMS) represent 1.3% of all uterine malignant tumors. Surgery is the curative treatment for patients with early stage disease. In case of advanced, persistent or recurrent tumor, chemotherapy represents the standard of care, but these patients have a poor prognosis. As the results with available therapies are far from being satisfactory, research is focusing on identification of new compounds. In 2012 the Food and Drug Administration (FDA) licensed pazopanib for the treatment of advanced soft-tissue sarcomas failing previous chemotherapy. Areas covered: The aim of this article is to review the literature on the pharmacokinetics, pharmacodynamics, clinical efficacy and safety of the tyrosine kinase inhibitor (TKI), pazopanib in the treatment of ULMS. Expert opinion: The discovery of some relevant signalling pathways in LMS cells led to the development of new targeted drugs with promising results in the management of these tumors. Pazopanib is a multi-target second-generation TKI with activity against growth factors involved in angiogenesis. It has shown promising results both in terms of efficacy and safety, as shown in the EORTC 62043 Study and the PALETTE trial. Further studies are awaited to evaluate its efficacy in uterine leiomyosarcomas.
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Affiliation(s)
- Simone Ferrero
- a Academic Unit of Obstetrics and Gynaecology , IRCCS AOU San Martino - IST , Genova , Italy.,b Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI) , University of Genoa , Genoa , Italy
| | | | - Nicoletta Aiello
- a Academic Unit of Obstetrics and Gynaecology , IRCCS AOU San Martino - IST , Genova , Italy.,b Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI) , University of Genoa , Genoa , Italy
| | - Fabio Barra
- a Academic Unit of Obstetrics and Gynaecology , IRCCS AOU San Martino - IST , Genova , Italy.,b Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI) , University of Genoa , Genoa , Italy
| | - Antonino Ditto
- c Gynecologic Oncology Unit , IRCCS National Cancer Institute , Milan , Italy
| | - Giorgio Bogani
- c Gynecologic Oncology Unit , IRCCS National Cancer Institute , Milan , Italy
| | | | - Domenica Lorusso
- c Gynecologic Oncology Unit , IRCCS National Cancer Institute , Milan , Italy
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Boudou-Rouquette P, Tlemsani C, Blanchet B, Huillard O, Jouinot A, Arrondeau J, Thomas-Schoemann A, Vidal M, Alexandre J, Goldwasser F. Clinical pharmacology, drug-drug interactions and safety of pazopanib: a review. Expert Opin Drug Metab Toxicol 2016; 12:1433-1444. [PMID: 27556889 DOI: 10.1080/17425255.2016.1225038] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION In the past decade, treatment options for metastatic renal cell carcinoma and soft-tissue sarcoma have expanded. Pazopanib was discovered during the screening of compounds that suppressed vascular endothelial growth factor receptor-2 (VEGFR-2). As other tyrosine kinase inhibitors (TKI), pazopanib is not totally specific for one target since it also inhibits stem-cell factor receptor (cKIT), platelet-derived growth factor receptors (PDGFRα, β), VEGFR-1 and -3. Areas covered: Clinical pharmacology, drug-drug interactions and safety data published on pazopanib, between January 2006 and April 2016, are reviewed. Expert opinion: This new therapy has been shown to improve progression-free survival compared with previous approaches, in renal cell cancer and soft-tissue sarcoma. However, some specific sub-populations, such as elderly patients, patients with brain metastases or with Eastern Cooperative Oncology Group Performance Status (ECOG PS) 2 or comorbidities, are poorly represented in pivotal pazopanib phase III studies. Pazopanib meets criteria defining therapies as candidates for therapeutic drug monitoring: large intra- and inter-patient pharmacokinetic variability, potential pharmacokinetic drug-drug interactions, pharmacokinetic/pharmacodynamic relationship and narrow therapeutic index. Knowledge of predictors that can be used to guide dosing regimens in the target population and in special populations needs to be improved.
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Affiliation(s)
- Pascaline Boudou-Rouquette
- a Department of Medical Oncology, CERIA , Paris Descartes University, AP-HP, Cochin Hospital , Paris , France
| | - Camille Tlemsani
- a Department of Medical Oncology, CERIA , Paris Descartes University, AP-HP, Cochin Hospital , Paris , France
| | - Benoit Blanchet
- a Department of Medical Oncology, CERIA , Paris Descartes University, AP-HP, Cochin Hospital , Paris , France
| | - Olivier Huillard
- a Department of Medical Oncology, CERIA , Paris Descartes University, AP-HP, Cochin Hospital , Paris , France
| | - Anne Jouinot
- a Department of Medical Oncology, CERIA , Paris Descartes University, AP-HP, Cochin Hospital , Paris , France
| | - Jennifer Arrondeau
- a Department of Medical Oncology, CERIA , Paris Descartes University, AP-HP, Cochin Hospital , Paris , France
| | - Audrey Thomas-Schoemann
- a Department of Medical Oncology, CERIA , Paris Descartes University, AP-HP, Cochin Hospital , Paris , France.,b UMR8638 CNRS, UFR de Pharmacie , Université Paris Descartes, PRES Sorbonne Paris Cité , Paris , France
| | - Michel Vidal
- a Department of Medical Oncology, CERIA , Paris Descartes University, AP-HP, Cochin Hospital , Paris , France.,b UMR8638 CNRS, UFR de Pharmacie , Université Paris Descartes, PRES Sorbonne Paris Cité , Paris , France
| | - Jérôme Alexandre
- a Department of Medical Oncology, CERIA , Paris Descartes University, AP-HP, Cochin Hospital , Paris , France
| | - François Goldwasser
- a Department of Medical Oncology, CERIA , Paris Descartes University, AP-HP, Cochin Hospital , Paris , France
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A Phase I, Dose-Escalation Trial of Pazopanib in Combination with Cisplatin in Patients with Advanced Solid Tumors: A UNICANCER Study. Oncol Ther 2016; 4:211-223. [PMID: 28261651 PMCID: PMC5315079 DOI: 10.1007/s40487-016-0027-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Indexed: 02/02/2023] Open
Abstract
Introduction To determine the feasibility, maximum-tolerated dose (MTD), and dose-limiting toxicities (DLT) of pazopanib in combination with cisplatin. Methods Patients with advanced malignancies were included in a 3 + 3 dose-escalation phase I study. Pazopanib administration started 8 days before the first infusion of cisplatin; some patients were treated according to a reverse sequence (cisplatin first). Five dose levels (DLs) were planned. MTD was based on DLT observed during cycles 1 and 2. Results Thirty-five patients were enrolled. The MTD was reached at the first DL, (pazopanib 400 mg daily + cisplatin 75 mg/m2 every 21 days). Main DLTs were pulmonary embolism, neutropenia, thrombocytopenia, and elevation of liver enzymes. Overall, most common adverse events were anemia (83%), fatigue (80%), thrombocytopenia (80%), neutropenia (73%), hypertension (59%), neurotoxicity (56%), and anorexia (53%). Sixteen patients (46%) discontinued the study due to toxicity. One patient (sarcoma) had a complete response, and three patients (one with breast cancer and two with ovarian cancers) had a partial response. Pharmacokinetic (PK) analyses showed interactions with aprepitant, resulting in increased exposure to pazopanib, which might explain partly the poor tolerance of the combination. Conclusion Cisplatin and pazopanib could not be administered at their single agent full doses, partly due to a PK interaction between pazopanib and aprepitant. Funding This work was funded by GlaxoSmithKline and by the charity Ligue Nationale de Lutte Contre le Cancer. Trial registered ClinicalTrials.gov identifier, NCT01165385.
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Vo KT, Matthay KK, DuBois SG. Targeted antiangiogenic agents in combination with cytotoxic chemotherapy in preclinical and clinical studies in sarcoma. Clin Sarcoma Res 2016; 6:9. [PMID: 27274393 PMCID: PMC4896001 DOI: 10.1186/s13569-016-0049-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 05/11/2016] [Indexed: 02/07/2023] Open
Abstract
Sarcomas are a heterogeneous group of mesenchymal malignancies. In recent years, studies have demonstrated that inhibition of angiogenic pathways or disruption of established vasculature can attenuate the growth of sarcomas. However, when used as monotherapy in the clinical setting, these targeted antiangiogenic agents have only provided modest survival benefits in some sarcoma subtypes, and have not been efficacious in others. Preclinical and early clinical data suggest that the addition of conventional chemotherapy to antiangiogenic agents may lead to more effective therapies for patients with these tumors. In the current review, the authors summarize the available evidence and possible mechanisms supporting this approach.
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Affiliation(s)
- Kieuhoa T. Vo
- />Department of Pediatrics, UCSF School of Medicine, San Francisco School of Medicine, UCSF Benioff Children’s Hospital, University of California, 550 16th Street, 4th Floor, Box 0434, San Francisco, CA 94158 USA
| | - Katherine K. Matthay
- />Department of Pediatrics, UCSF School of Medicine, San Francisco School of Medicine, UCSF Benioff Children’s Hospital, University of California, 550 16th Street, 4th Floor, Box 0434, San Francisco, CA 94158 USA
| | - Steven G. DuBois
- />Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, 450 Brookline Avenue, Dana 3, Boston, MA 02215 USA
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Stagg BC, Uehara H, Lambert N, Rai R, Gupta I, Radmall B, Bates T, Ambati BK. Morpholino-Mediated Isoform Modulation of Vascular Endothelial Growth Factor Receptor-2 (VEGFR2) Reduces Colon Cancer Xenograft Growth. Cancers (Basel) 2014; 6:2330-42. [PMID: 25534570 PMCID: PMC4276969 DOI: 10.3390/cancers6042330] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 10/12/2014] [Accepted: 11/18/2014] [Indexed: 12/22/2022] Open
Abstract
Angiogenesis plays a key role in tumor growth. Vascular endothelial growth factor (VEGF) is a pro-angiogenic that is involved in tumor angiogenesis. When VEGF binds to membrane-bound vascular endothelial growth factor receptor 2 (mVEGFR2), it promotes angiogenesis. Through alternative polyadenylation, VEGFR2 is also expressed in a soluble form (sVEGFR2). sVEGFR2 sequesters VEGF and is therefore anti-angiogenic. The aim of this study was to show that treatment with a previously developed and reported antisense morpholino oligomer that shifts expression from mVEGFR2 to sVEGFR2 would lead to reduced tumor vascularization and growth in a murine colon cancer xenograft model. Xenografts were generated by implanting human HCT-116 colon cancer cells into the flanks of NMRI nu/nu mice. Treatment with the therapeutic morpholino reduced both tumor growth and tumor vascularization. Because the HCT-116 cells used for the experiments did not express VEGFR2 and because the treatment morpholino targeted mouse rather than human VEGFR2, it is likely that treatment morpholino was acting on the mouse endothelial cells rather than directly on the tumor cells.
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Affiliation(s)
- Brian C Stagg
- John A Moran Eye Center, University of Utah, Salt Lake City, UT, 65 Mario Capecchi Drive, Salt Lake City, UT 84132, USA.
| | - Hironori Uehara
- John A Moran Eye Center, University of Utah, Salt Lake City, UT, 65 Mario Capecchi Drive, Salt Lake City, UT 84132, USA.
| | - Nathan Lambert
- John A Moran Eye Center, University of Utah, Salt Lake City, UT, 65 Mario Capecchi Drive, Salt Lake City, UT 84132, USA.
| | - Ruju Rai
- John A Moran Eye Center, University of Utah, Salt Lake City, UT, 65 Mario Capecchi Drive, Salt Lake City, UT 84132, USA.
| | - Isha Gupta
- John A Moran Eye Center, University of Utah, Salt Lake City, UT, 65 Mario Capecchi Drive, Salt Lake City, UT 84132, USA.
| | - Bryce Radmall
- John A Moran Eye Center, University of Utah, Salt Lake City, UT, 65 Mario Capecchi Drive, Salt Lake City, UT 84132, USA.
| | - Taylor Bates
- John A Moran Eye Center, University of Utah, Salt Lake City, UT, 65 Mario Capecchi Drive, Salt Lake City, UT 84132, USA.
| | - Balamurali K Ambati
- John A Moran Eye Center, University of Utah, Salt Lake City, UT, 65 Mario Capecchi Drive, Salt Lake City, UT 84132, USA.
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(Lymph)angiogenic influences on hematopoietic cells in acute myeloid leukemia. Exp Mol Med 2014; 46:e122. [PMID: 25412683 PMCID: PMC4262793 DOI: 10.1038/emm.2014.72] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 08/26/2014] [Accepted: 09/21/2014] [Indexed: 02/07/2023] Open
Abstract
The purpose of this review is to provide an overview of the effect of (lymph)angiogenic cytokines on hematopoietic cells involved in acute myeloid leukemia (AML). Like angiogenesis, lymphangiogenesis occurs in pathophysiological conditions but not in healthy adults. AML is closely associated with the vasculature system, and the interplay between lymphangiogenic cytokines maintains leukemic blast survival in the bone marrow (BM). Once AML is induced, proangiogenic cytokines function as angiogenic or lymphangiogenic factors and affect hematopoietic cells, including BM-derived immune cells. Simultaneously, the representative cytokines, VEGFs and their receptors are expressed on AML blasts in vascular and osteoblast niches in both the BM and the peripheral circulation. After exposure to (lymph)angiogenic cytokines in leukemogenesis and infiltration, immune cell phenotypes and functions are affected. These dynamic behaviors in the BM reflect the clinical features of AML. In this review, we note the importance of lymphangiogenic factors and their receptors in hematopoietic cells in AML. Understanding the functional characterization of (lymph)angiogenic factors in the BM niche in AML will also be helpful in interrupting the engraftment of leukemic stem cells and for enhancing immune cell function by modulating the tumor microenvironment.
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