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Bhatia K, Sandhu V, Wong MH, Iyer P, Bhatt S. Therapeutic biomarkers in acute myeloid leukemia: functional and genomic approaches. Front Oncol 2024; 14:1275251. [PMID: 38410111 PMCID: PMC10894932 DOI: 10.3389/fonc.2024.1275251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/17/2024] [Indexed: 02/28/2024] Open
Abstract
Acute myeloid leukemia (AML) is clinically and genetically a heterogeneous disease characterized by clonal expansion of abnormal hematopoietic progenitors. Genomic approaches to precision medicine have been implemented to direct targeted therapy for subgroups of AML patients, for instance, IDH inhibitors for IDH1/2 mutated patients, and FLT3 inhibitors with FLT3 mutated patients. While next generation sequencing for genetic mutations has improved treatment outcomes, only a fraction of AML patients benefit due to the low prevalence of actionable targets. In recent years, the adoption of newer functional technologies for quantitative phenotypic analysis and patient-derived avatar models has strengthened the potential for generalized functional precision medicine approach. However, functional approach requires robust standardization for multiple variables such as functional parameters, time of drug exposure and drug concentration for making in vitro predictions. In this review, we first summarize genomic and functional therapeutic biomarkers adopted for AML therapy, followed by challenges associated with these approaches, and finally, the future strategies to enhance the implementation of precision medicine.
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Affiliation(s)
- Karanpreet Bhatia
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
| | - Vedant Sandhu
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
| | - Mei Hsuan Wong
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
| | - Prasad Iyer
- Children's Blood and Cancer Centre, KK Women's and Children's Hospital, Singapore, Singapore
- Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore
| | - Shruti Bhatt
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
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2
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Tseng S, Lee ME, Lin PC. A Review of Childhood Acute Myeloid Leukemia: Diagnosis and Novel Treatment. Pharmaceuticals (Basel) 2023; 16:1614. [PMID: 38004478 PMCID: PMC10674205 DOI: 10.3390/ph16111614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/31/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
Acute myeloid leukemia (AML) is the second most common hematologic malignancy in children. The incidence of childhood AML is much lower than acute lymphoblastic leukemia (ALL), which makes childhood AML a rare disease in children. The role of genetic abnormalities in AML classification, management, and prognosis prediction is much more important than before. Disease classifications and risk group classifications, such as the WHO classification, the international consensus classification (ICC), and the European LeukemiaNet (ELN) classification, were revised in 2022. The application of the new information in childhood AML will be upcoming in the next few years. The frequency of each genetic abnormality in adult and childhood AML is different; therefore, in this review, we emphasize well-known genetic subtypes in childhood AML, including core-binding factor AML (CBF AML), KMT2Ar (KMT2A/11q23 rearrangement) AML, normal karyotype AML with somatic mutations, unbalanced cytogenetic abnormalities AML, NUP98 11p15/NUP09 rearrangement AML, and acute promyelocytic leukemia (APL). Current risk group classification, the management algorithm in childhood AML, and novel treatment modalities such as targeted therapy, immune therapy, and chimeric antigen receptor (CAR) T-cell therapy are reviewed. Finally, the indications of hematopoietic stem cell transplantation (HSCT) in AML are discussed.
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Affiliation(s)
- Serena Tseng
- School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan;
| | - Mu-En Lee
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Hsinchu 300, Taiwan;
| | - Pei-Chin Lin
- School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan;
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
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3
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Halpern AB, Rodríguez-Arbolí E, Othus M, Garcia KLA, Percival MEM, Cassaday RD, Oehler VG, Becker PS, Appelbaum JS, Abkowitz JL, Orozco JJ, Keel SB, Hendrie PC, Scott BL, Ghiuzeli MC, Estey EH, Walter RB. Phase 1/2 study of sorafenib added to cladribine, high-dose cytarabine, G-CSF, and mitoxantrone in untreated AML. Blood Adv 2023; 7:4950-4961. [PMID: 37339483 PMCID: PMC10463192 DOI: 10.1182/bloodadvances.2023010392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/22/2023] Open
Abstract
The multikinase inhibitor sorafenib improves event-free survival (EFS) when used with 7 + 3 in adults with newly-diagnosed acute myeloid leukemia (AML), irrespective of the FLT3-mutation status. Here, we evaluated adding sorafenib to cladribine, high-dose cytarabine, granulocyte colony-stimulating factor, and mitoxantrone (CLAG-M) in a phase 1/2 trial of 81 adults aged ≤60 years with newly diagnosed AML. Forty-six patients were treated in phase 1 with escalating doses of sorafenib and mitoxantrone. No maximum tolerated dose was reached, and a regimen including mitoxantrone 18 mg/m2 per day and sorafenib 400 mg twice daily was declared the recommended phase 2 dose (RP2D). Among 41 patients treated at RP2D, a measurable residual disease-negative complete remission (MRD- CR) rate of 83% was obtained. Four-week mortality was 2%. One-year overall survival (OS) and EFS were 80% and 76%, without differences in MRD- CR rates, OS, or EFS between patients with or without FLT3-mutated disease. Comparing outcomes using CLAG-M/sorafenib with those of a matched cohort of 76 patients treated with CLAG-M alone, multivariable-adjusted survival estimates were improved for 41 patients receiving CLAG-M/sorafenib at RP2D (OS: hazard ratio,0.24 [95% confidence interval, 0.07-0.82]; P = .023; EFS: hazard ratio, 0.16 [95% confidence interval, 0.05-0.53]; P = .003). Benefit was limited to patients with intermediate-risk disease (univariate analysis: P = .01 for OS; P = .02 for EFS). These data suggest that CLAG-M/sorafenib is safe and improves OS and EFS relative to CLAG-M alone, with benefits primarily in patients with intermediate-risk disease. The trial was registered at www.clinicaltrials.gov as #NCT02728050.
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Affiliation(s)
- Anna B. Halpern
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Eduardo Rodríguez-Arbolí
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
- Department of Hematology, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío, University of Seville, Seville, Spain
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA
| | | | - Mary-Elizabeth M. Percival
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Ryan D. Cassaday
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Vivian G. Oehler
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Pamela S. Becker
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Jacob S. Appelbaum
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
| | - Janis L. Abkowitz
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
| | - Johnnie J. Orozco
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA
| | - Siobán B. Keel
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
| | - Paul C. Hendrie
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
| | - Bart L. Scott
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA
| | - M. Cristina Ghiuzeli
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Elihu H. Estey
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Roland B. Walter
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
- Department of Laboratory Medicine & Pathology, University of Washington, Seattle, WA
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4
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Hruba L, Das V, Hajduch M, Dzubak P. Nucleoside-based anticancer drugs: Mechanism of action and drug resistance. Biochem Pharmacol 2023; 215:115741. [PMID: 37567317 DOI: 10.1016/j.bcp.2023.115741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/13/2023]
Abstract
Nucleoside-based drugs, recognized as purine or pyrimidine analogs, have been potent therapeutic agents since their introduction in 1950, deployed widely in the treatment of diverse diseases such as cancers, myelodysplastic syndromes, multiple sclerosis, and viral infections. These antimetabolites establish complex interactions with cellular molecular constituents, primarily via activation of phosphorylation cascades leading to consequential interactions with nucleic acids. However, the therapeutic efficacy of these agents is frequently compromised by the development of drug resistance, a continually emerging challenge in their clinical application. This comprehensive review explores the mechanisms of resistance to nucleoside-based drugs, encompassing a wide spectrum of phenomena from alterations in membrane transporters and activating kinases to changes in drug elimination strategies and DNA damage repair mechanisms. The critical analysis in this review underlines complex interactions of drug and cell and also guides towards novel therapeutic strategies to counteract resistance. The development of targeted therapies, novel nucleoside analogs, and synergistic drug combinations are promising approaches to restore tumor sensitivity and improve patient outcomes.
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Affiliation(s)
- Lenka Hruba
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacky University in Olomouc, Olomouc, Czech Republic
| | - Viswanath Das
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacky University in Olomouc, Olomouc, Czech Republic
| | - Marian Hajduch
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacky University in Olomouc, Olomouc, Czech Republic; Laboratory of Experimental Medicine, University Hospital, Olomouc 779 00, Czech Republic
| | - Petr Dzubak
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacky University in Olomouc, Olomouc, Czech Republic; Laboratory of Experimental Medicine, University Hospital, Olomouc 779 00, Czech Republic.
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5
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Perrone S, Ottone T, Zhdanovskaya N, Molica M. How acute myeloid leukemia (AML) escapes from FMS-related tyrosine kinase 3 (FLT3) inhibitors? Still an overrated complication? CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2023; 6:223-238. [PMID: 37457126 PMCID: PMC10344728 DOI: 10.20517/cdr.2022.130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 03/21/2023] [Accepted: 04/11/2023] [Indexed: 07/18/2023]
Abstract
FMS-related tyrosine kinase 3 (FLT3) mutations, present in about 25%-30% of acute myeloid leukemia (AML) patients, constitute one of the most frequently detected mutations in these patients. The binding of FLT3L to FLT3 activates the phosphatidylinositol 3-kinase (PI3K) and RAS pathways, producing increased cell proliferation and the inhibition of apoptosis. Two types of FLT3 mutations exist: FLT3-ITD and FLT3-TKD (point mutations in D835 and I836 or deletion of codon I836). A class of drugs, tyrosine-kinase inhibitors (TKI), targeting mutated FLT3, is already available with 1st and 2nd generation molecules, but only midostaurin and gilteritinib are currently approved. However, the emergence of resistance or the selection of clones not responding to FLT3 inhibitors has become an important clinical dilemma, as the duration of clinical responses is generally limited to a few months. This review analyzes the insights into mechanisms of resistance to TKI and poses a particular view on the clinical relevance of this phenomenon. Has resistance been overlooked? Indeed, FLT3 inhibitors have significantly contributed to reducing the negative impact of FLT3 mutations on the prognosis of AML patients who are no longer considered at high risk by the European LeukemiaNet (ELN) 2022. Finally, several ongoing efforts to overcome resistance to FLT3-inhibitors will be presented: new generation FLT3 inhibitors in monotherapy or combined with standard chemotherapy, hypomethylating drugs, or IDH1/2 inhibitors, Bcl2 inhibitors; novel anti-human FLT3 monoclonal antibodies (e.g., FLT3/CD3 bispecific antibodies); FLT3-CAR T-cells; CDK4/6 kinase inhibitor (e.g., palbociclib).
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Affiliation(s)
- Salvatore Perrone
- Hematology, Polo Universitario Pontino, S.M. Goretti Hospital, Latina 04100, Italy
| | - Tiziana Ottone
- Department of Biomedicine and Prevention, the University of Rome “Tor Vergata”, Rome 00100 Italy
- Neuro-Oncohematology, Santa Lucia Foundation, I.R.C.C.S., Rome 00100, Italy
| | - Nadezda Zhdanovskaya
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome 00161, Italy
| | - Matteo Molica
- Hematology Unit, S. Eugenio Hospital, ASL Roma 2, Rome 00144, Italy
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6
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Al-Kali A, Tibes R, Atherton P, Palmer J, Alkhateeb HB, Patnaik M, Begna K, Gangat N, Hashmi S, He R, Litzow M. A phase II study of combination daunorubicin, cytarabine (Ara-c), and nilotinib (TAsigna) (DATA) in patients newly diagnosed with acute myeloid leukemia with KIT expression. Am J Hematol 2023; 98:472-480. [PMID: 36625066 DOI: 10.1002/ajh.26831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 12/09/2022] [Accepted: 12/14/2022] [Indexed: 01/11/2023]
Abstract
Acute myeloid leukemia (AML) is a challenging cancer in terms of achieving and maintaining long-duration remissions. Many novel therapies have been added to the standard regimen (combining cytarabine and anthracycline "7 + 3") to achieve such goals. Nilotinib is an oral multikinase inhibitor that is active against KIT tyrosine kinase, an important stem cell target. In this trial, we combined nilotinib with 7 + 3 induction (daunorubicin 60 mg/m2), high-dose cytarabine consolidation, and subsequently, if the patient was a candidate, for 2 years' maintenance therapy in patients with AML and KIT (CD117) expression. Patients were allowed to proceed to allogeneic hematopoietic cell transplantation (HCT) if deemed necessary. Our primary goal was increased complete remission rate with this combination. Thirty-four patients (with a median age 58.5 years) were enrolled on a single-arm phase II bi-institutional study; 21 (62%) patients achieved remission. The complete remission rate was 78% in evaluable patients. Thirteen of 34 (38%) patients had allogeneic HCT, all thirteen of which are still alive (100%). Common (>20%) grade 3 non-hematological toxicities included febrile neutropenia, hypophosphatemia, elevated liver enzymes, and hypertension. Only one patient (3%) died in induction due to liver failure, which was thought secondary to daunorubicin. Our current study reveals good outcomes in patients who received HCT and may warrant a larger study to confirm our findings in that specific population.
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Affiliation(s)
- Aref Al-Kali
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Raoul Tibes
- AstraZeneca, Cambridge, UK.,Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Pamela Atherton
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeanne Palmer
- Division of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, Arizona, USA
| | | | - Mrinal Patnaik
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kebede Begna
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Naseema Gangat
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shahrukh Hashmi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rong He
- Division of hematopathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark Litzow
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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7
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Mohty R, El Hamed R, Brissot E, Bazarbachi A, Mohty M. New drugs before, during, and after hematopoietic stem cell transplantation for patients with acute myeloid leukemia. Haematologica 2023; 108:321-341. [PMID: 36722403 PMCID: PMC9890036 DOI: 10.3324/haematol.2022.280798] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 09/02/2022] [Indexed: 02/02/2023] Open
Abstract
The treatment of acute myeloid leukemia (AML) has evolved over the past few years with the advent of next-generation sequencing. Targeted therapies alone or in combination with low-dose or high-intensity chemotherapy have improved the outcome of patients with AML treated in the frontline and relapsed/refractory settings. Despite these advances, allogeneic stem cell transplantation (allo-HCT) remains essential as consolidation therapy following frontline treatment in intermediate-and adverse-risk and relapsed/refractory disease. However, many patients relapse, with limited treatment options, hence the need for post-transplant strategies to mitigate relapse risk. Maintenance therapy following allo-HCT was developed for this specific purpose and can exploit either a direct anti-leukemia effect and/or enhance the bona fide graft-versus-leukemia effect without increasing the risk of graft-versus-host disease. In this paper, we summarize novel therapies for AML before, during, and after allo-HCT and review ongoing studies.
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Affiliation(s)
- Razan Mohty
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL
| | - Rama El Hamed
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Eolia Brissot
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, Paris, France; INSERM, Saint-Antoine Research Center, Paris
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, Paris, France; INSERM, Saint-Antoine Research Center, Paris.
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8
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Garciaz S, Hospital MA. FMS-Like Tyrosine Kinase 3 Inhibitors in the Treatment of Acute Myeloid Leukemia: An Update on the Emerging Evidence and Safety Profile. Onco Targets Ther 2023; 16:31-45. [PMID: 36698434 PMCID: PMC9869913 DOI: 10.2147/ott.s236740] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 01/11/2023] [Indexed: 01/19/2023] Open
Abstract
FMS-like tyrosine kinase 3 (FLT3) is one of the most frequently mutated genes in acute myeloid leukemia (AML). Approximately 30% of the adult cases harbor an internal tandem duplication (FLT3-ITD) and 5-10% a tyrosine kinase domain (TKD) amino acid substitution (FLT3-TKD). The treatment paradigm of AML patients harboring FLT3 mutations (30%) has been modified by the discovery of tyrosine kinase inhibitors. First- and second-generation inhibitors classify FLT3 inhibitors according to FLT3 specificity: first-generation FLT3 inhibitors include sorafenib and midostaurin and second-generation inhibitors are represented by quizartinib, gilteritinib and crenolanib, among others. Activity of these inhibitors depends on their mechanism of receptor binding (active vs inactive conformation) and efficacy against the FLT3-ITD and -TKD mutations (type 1 inhibitors are active both on FLT3-ITD and TKD, whereas type 2 inhibitors are active only on FLT3-ITD). The FLT3 inhibitors sorafenib, midostaurin, quizartinib and gilteritinib have been tested in monotherapy in several settings including refractory or relapsed AML (R/R AML), post-transplant maintenance as well as in combination with intensive chemotherapy (ICT) or non-intensity regimens. The results of published randomized studies support the use of sorafenib in a post-transplant setting (SORMAIN trial), midostaurin in combination with ICT based (RATIFY trial) and gilteritinib for R/R AML (ADMIRAL trial). Gilteritinib in combination with hypomethylating agent as well as quizartinib are not supported by solid randomized trial results for their use in FLT3-mutated AML patients.
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Affiliation(s)
- Sylvain Garciaz
- Department of Hematology, Institut Paoli-Calmettes, Aix-Marseille Université, Centre National de la Recherche Scientifique, UMR7258, Centre de Recherche en Cancérologie de Marseille, INSERM U1068, Marseille, France,Correspondence: Sylvain Garciaz, Institut Paoli-Calmettes, Hematology Department, 232 Bd Sainte-Marguerite, Marseille, 13009, France, Tel + 33 4 91 22 37 54, Fax + 33 4 91 22 30 63, Email
| | - Marie-Anne Hospital
- Department of Hematology, Institut Paoli-Calmettes, Aix-Marseille Université, Centre National de la Recherche Scientifique, UMR7258, Centre de Recherche en Cancérologie de Marseille, INSERM U1068, Marseille, France
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9
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Ohoka N, Suzuki M, Uchida T, Tsuji G, Tsukumo Y, Yoshida M, Inoue T, Demizu Y, Ohki H, Naito M. Development of Gilteritinib-Based Chimeric Small Molecules that Potently Induce Degradation of FLT3-ITD Protein. ACS Med Chem Lett 2022; 13:1885-1891. [DOI: 10.1021/acsmedchemlett.2c00402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Nobumichi Ohoka
- Division of Molecular Target and Gene Therapy Products, National Institute of Health Sciences, Kawasaki, Kanagawa 210-9501, Japan
| | - Masanori Suzuki
- Modality Research Laboratories, Biologics Division, Daiichi Sankyo Co., Ltd., Tokyo 140-8710, Japan
| | - Takuya Uchida
- Medicinal Chemistry Research Laboratories, R&D Division, Daiichi Sankyo Co., Ltd., Tokyo 140-8710, Japan
| | - Genichiro Tsuji
- Division of Organic Chemistry, National Institute of Health Sciences, Kawasaki, Kanagawa 210-9501 Japan
| | - Yoshinori Tsukumo
- Division of Molecular Target and Gene Therapy Products, National Institute of Health Sciences, Kawasaki, Kanagawa 210-9501, Japan
| | - Masayuki Yoshida
- Modality Research Laboratories, Biologics Division, Daiichi Sankyo Co., Ltd., Tokyo 140-8710, Japan
| | - Takao Inoue
- Division of Molecular Target and Gene Therapy Products, National Institute of Health Sciences, Kawasaki, Kanagawa 210-9501, Japan
| | - Yosuke Demizu
- Division of Organic Chemistry, National Institute of Health Sciences, Kawasaki, Kanagawa 210-9501 Japan
| | - Hitoshi Ohki
- Modality Research Laboratories, Biologics Division, Daiichi Sankyo Co., Ltd., Tokyo 140-8710, Japan
| | - Mikihiko Naito
- Division of Molecular Target and Gene Therapy Products, National Institute of Health Sciences, Kawasaki, Kanagawa 210-9501, Japan
- Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo 113-0033, Japan
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10
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Visani G, Chiarucci M, Paolasini S, Loscocco F, Isidori A. Treatment options for acute myeloid leukemia patients aged <60 years. Front Oncol 2022; 12:897220. [PMID: 36276074 PMCID: PMC9581198 DOI: 10.3389/fonc.2022.897220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 08/31/2022] [Indexed: 11/17/2022] Open
Abstract
Treatment of acute myeloid leukemia (AML) has changed over the last few years, after the discovery of new drugs selectively targeting AML blasts. Although 3/7 remains the standard of care for most AML patients, several new targeted agents (such as FLT3 inhibitors, CPX-351, gemtuzumab ozogamicin, BCL-2 inhibitor, and oral azacitidine), either as single agents or combined with standard chemotherapy, are approaching clinical practice, starting a new era in AML management. Moreover, emerging evidence has demonstrated that high-risk AML patients might benefit from both allogeneic stem cell transplant and maintenance therapy, providing new opportunities, as well as new challenges, for treating clinicians. In this review, we summarize available data on first-line therapy in young AML patients focusing on targeted therapies, integrating established practice with new evidence, in the effort to outline the contours of a new therapeutic paradigm, that of a “total therapy”, which goes beyond obtaining complete remission.
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11
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The Role of Nutrition in Primary and Secondary Prevention of Cardiovascular Damage in Childhood Cancer Survivors. Nutrients 2022; 14:nu14163279. [PMID: 36014785 PMCID: PMC9415958 DOI: 10.3390/nu14163279] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/05/2022] [Accepted: 08/07/2022] [Indexed: 12/03/2022] Open
Abstract
Innovative therapeutic strategies in childhood cancer led to a significant reduction in cancer-related mortality. Cancer survivors are a growing fragile population, at risk of long-term side effects of cancer treatments, thus requiring customized clinical attention. Antineoplastic drugs have a wide toxicity profile that can limit their clinical usage and spoil patients’ life, even years after the end of treatment. The cardiovascular system is a well-known target of antineoplastic treatments, including anthracyclines, chest radiotherapy and new molecules, such as tyrosine kinase inhibitors. We investigated nutritional changes in children with cancer from the diagnosis to the end of treatment and dietary habits in cancer survivors. At diagnosis, children with cancer may present variable degrees of malnutrition, potentially affecting drug tolerability and prognosis. During cancer treatment, the usage of corticosteroids can lead to rapid weight gain, exposing children to overweight and obesity. Moreover, dietary habits and lifestyle often dramatically change in cancer survivors, who acquire sedentary behavior and weak adherence to dietary guidelines. Furthermore, we speculated on the role of nutrition in the primary prevention of cardiac damage, investigating the potential cardioprotective role of diet-derived compounds with antioxidative properties. Finally, we summarized practical advice to improve the dietary habits of cancer survivors and their families.
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Pollard JA, Alonzo TA, Gerbing R, Brown P, Fox E, Choi J, Fisher B, Hirsch B, Kahwash S, Getz K, Levine J, Brodersen LE, Loken MR, Raimondi S, Tarlock K, Wood A, Sung L, Kolb EA, Gamis A, Meshinchi S, Aplenc R. Sorafenib in Combination With Standard Chemotherapy for Children With High Allelic Ratio FLT3/ITD+ Acute Myeloid Leukemia: A Report From the Children's Oncology Group Protocol AAML1031. J Clin Oncol 2022; 40:2023-2035. [PMID: 35349331 PMCID: PMC9197362 DOI: 10.1200/jco.21.01612] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/05/2022] [Accepted: 02/03/2022] [Indexed: 01/17/2023] Open
Abstract
PURPOSE High allelic ratio (HAR) FLT3/ITD (AR > 0.4) mutations confer poor prognosis in pediatric acute myeloid leukemia (AML). COG AAML1031 studied the feasibility and efficacy of adding sorafenib, a multikinase tyrosine kinase inhibitor to standard chemotherapy and as single-agent maintenance therapy in this population. MATERIALS AND METHODS Patients were treated in three cohorts. The initial safety phase defined the maximum tolerated dose of sorafenib starting in induction 2. Cohorts 2 and 3 added sorafenib in induction and as single-agent maintenance. Clinical outcome analysis was limited to n = 72 patients in cohorts 2/3 and compared with n = 76 HAR FLT3/ITD+ AML patients who received identical chemotherapy without sorafenib. Sorafenib pharmacokinetics and plasma inhibitory activity were measured in a subset of patients. RESULTS The maximum tolerated dose of sorafenib was 200 mg/m2 once daily; dose-limiting toxicities included rash (n = 2; 1 grade 3 and 1 grade 2), grade 2 hand-foot syndrome, and grade 3 fever. Pharmacokinetics/plasma inhibitory activity data demonstrated that measured plasma concentrations were sufficient to inhibit phosphorylated FLT3. Although outcomes were superior with sorafenib in cohorts 2 and 3, patients treated with sorafenib also underwent hematopoietic stem-cell transplant more frequently than the comparator population. Multivariable analysis that accounted for both hematopoietic stem-cell transplant and favorable co-occurring mutations confirmed sorafenib's benefit. Specifically, risk of an event was approximately two-fold higher in HAR FLT3/ITD+ patients who did not receive sorafenib (event-free survival from study entry: hazard ratio [HR] 2.37, 95% CI, 1.45 to 3.88, P < .001, disease-free survival from complete remission: HR 2.28, 95% CI, 1.08 to 4.82, P = .032, relapse risk from complete remission: HR 3.03, 95% CI 1.31 to 7.04, P = .010). CONCLUSION Sorafenib can be safely added to conventional AML chemotherapy and may improve outcomes in pediatric HAR FLT3/ITD+ AML.
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Affiliation(s)
- Jessica A. Pollard
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Todd A. Alonzo
- University of Southern California Keck School of Medicine, Los Angeles, CA
| | | | - Patrick Brown
- Johns Hopkins Kimmel Comprehensive Cancer Center, Baltimore, MD
| | | | - John Choi
- University of Alabama, Birmingham AL
| | - Brian Fisher
- Children's Hospital of Philadelphia, Philadelphia, PA
| | | | | | - Kelly Getz
- University of Pennsylvania, Department of Epidemiology, Biostatistics and Informatics, Philadelphia, PA
| | | | | | | | | | - Katherine Tarlock
- Fred Hutchinson Cancer Research Center, Seattle, WA
- Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Andrew Wood
- University of Auckland, Auckland, New Zealand
| | | | | | - Alan Gamis
- Children's Mercy Hospital and Clinics, Kansas City, MO
| | - Soheil Meshinchi
- Fred Hutchinson Cancer Research Center, Seattle, WA
- Seattle Children's Hospital, University of Washington, Seattle, WA
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13
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High-Risk Acute Myeloid Leukemia: A Pediatric Prospective. Biomedicines 2022; 10:biomedicines10061405. [PMID: 35740427 PMCID: PMC9220202 DOI: 10.3390/biomedicines10061405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/19/2022] [Accepted: 05/31/2022] [Indexed: 11/16/2022] Open
Abstract
Pediatric acute myeloid leukemia is a clonal disorder characterized by malignant transformation of the hematopoietic stem cell. The incidence and the outcome remain inferior when compared to pediatric ALL, although prognosis has improved in the last decades, with 80% overall survival rate reported in some studies. The standard therapeutic approach is a combined cytarabine and anthracycline-based regimen followed by consolidation with allogeneic stem cell transplantation (allo-SCT) for high-risk AML and allo-SCT for non-high-risk patients only in second complete remission after relapse. In the last decade, several drugs have been used in clinical trials to improve outcomes in pediatric AML treatment.
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14
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Andreozzi F, Massaro F, Wittnebel S, Spilleboudt C, Lewalle P, Salaroli A. New Perspectives in Treating Acute Myeloid Leukemia: Driving towards a Patient-Tailored Strategy. Int J Mol Sci 2022; 23:3887. [PMID: 35409248 PMCID: PMC8999556 DOI: 10.3390/ijms23073887] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/27/2022] [Accepted: 03/28/2022] [Indexed: 12/16/2022] Open
Abstract
For decades, intensive chemotherapy (IC) has been considered the best therapeutic option for treating acute myeloid leukemia (AML), with no curative option available for patients who are not eligible for IC or who have had failed IC. Over the last few years, several new drugs have enriched the therapeutic arsenal of AML treatment for both fit and unfit patients, raising new opportunities but also new challenges. These include the already approved venetoclax, the IDH1/2 inhibitors enasidenib and ivosidenib, gemtuzumab ozogamicin, the liposomal daunorubicin/cytarabine formulation CPX-351, and oral azacitidine. Venetoclax, an anti BCL2-inhibitor, in combination with hypomethylating agents (HMAs), has markedly improved the management of unfit and elderly patients from the perspective of improved quality of life and better survival. Venetoclax is currently under investigation in combination with other old and new drugs in early phase trials. Recently developed drugs with different mechanisms of action and new technologies that have already been investigated in other settings (BiTE and CAR-T cells) are currently being explored in AML, and ongoing trials should determine promising agents, more synergic combinations, and better treatment strategies. Access to new drugs and inclusion in clinical trials should be strongly encouraged to provide scientific evidence and to define the future standard of treatment in AML.
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Affiliation(s)
- Fabio Andreozzi
- Hematology Department, Institut Jules Bordet, Université Libre de Bruxelles, 1000 Bruxelles, Belgium; (F.M.); (S.W.); (C.S.); (P.L.); (A.S.)
| | - Fulvio Massaro
- Hematology Department, Institut Jules Bordet, Université Libre de Bruxelles, 1000 Bruxelles, Belgium; (F.M.); (S.W.); (C.S.); (P.L.); (A.S.)
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Sebastian Wittnebel
- Hematology Department, Institut Jules Bordet, Université Libre de Bruxelles, 1000 Bruxelles, Belgium; (F.M.); (S.W.); (C.S.); (P.L.); (A.S.)
| | - Chloé Spilleboudt
- Hematology Department, Institut Jules Bordet, Université Libre de Bruxelles, 1000 Bruxelles, Belgium; (F.M.); (S.W.); (C.S.); (P.L.); (A.S.)
| | - Philippe Lewalle
- Hematology Department, Institut Jules Bordet, Université Libre de Bruxelles, 1000 Bruxelles, Belgium; (F.M.); (S.W.); (C.S.); (P.L.); (A.S.)
| | - Adriano Salaroli
- Hematology Department, Institut Jules Bordet, Université Libre de Bruxelles, 1000 Bruxelles, Belgium; (F.M.); (S.W.); (C.S.); (P.L.); (A.S.)
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15
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Reville PK, Sasaki K, Kantarjian HM, Daver NG, Yilmaz M, Dinardo CD, Short NJ, Borthakur G, Pemmaraju N, Mehta RS, Pierce S, Konoplev SN, Khoury JD, Garcia-Manero G, Konopleva MY, Jabbour E, Ravandi F, Kadia TM. Improved outcomes among newly diagnosed patients with FMS-like tyrosine kinase 3 internal tandem duplication mutated acute myeloid leukemia treated with contemporary therapy: Revisiting the European LeukemiaNet adverse risk classification. Am J Hematol 2022; 97:329-337. [PMID: 34981570 PMCID: PMC8884919 DOI: 10.1002/ajh.26451] [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: 11/29/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 12/17/2022]
Abstract
Mutations in fms-like tyrosine kinase 3 (FLT3) gene are common genomic alterations in acute myeloid leukemia (AML). FLT3 internal tandem duplication mutations (FLT3-ITD) have consistently been shown to be adversely prognostic, particularly those with high allelic ratio (AR). Current AML treatment strategies, including high dose cytarabine, purine analogs, FLT3 inhibitors (FLT3i), and with or without allogeneic stem cell transplant (SCT) have been shown to improve the outcomes in patients with FLT3 mutations. We analyzed a consecutive cohort of newly diagnosed patients with AML treated at a large academic medical center from January 2012 to January 2020. A total of 1576 patients with a new diagnosis of AML were reviewed. Among these, 1438 (91%) had molecular testing for FLT3 mutations and 21% (304/1438) had an FLT3 mutation, including 17% with an FLT3-ITD mutation. We show that FLT3-ITD high AR with NPM1 wild-type have significantly improved survival compared with other European LeukemiaNet (ELN) adverse risk disease. In multivariable cox proportional hazards model of patients receiving intensive or low-intensity induction regimens, FLT3 mutations did not have prognostic significance. The use of allogeneic SCT in CR1 for patients with FLT3 mutations appears to improve survival, particularly in those with ELN adverse risk disease. Overall, this data highlights the changing prognostic impact of FLT3 mutations in a contemporary era with appropriate use of induction therapy combined with targeted agents and allogenic SCT.
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Affiliation(s)
- Patrick K. Reville
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Hagop M. Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Naval G. Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Courtney D. Dinardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Nicholas J. Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Rohtesh S Mehta
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Sherry Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Sergej N. Konoplev
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Joseph D. Khoury
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Marina Y. Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Tapan M. Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030
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16
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Zhao JC, Agarwal S, Ahmad H, Amin K, Bewersdorf JP, Zeidan AM. A review of FLT3 inhibitors in acute myeloid leukemia. Blood Rev 2022; 52:100905. [PMID: 34774343 PMCID: PMC9846716 DOI: 10.1016/j.blre.2021.100905] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 01/26/2023]
Abstract
FLT3 mutations are the most common genetic aberrations found in acute myeloid leukemia (AML) and associated with poor prognosis. Since the discovery of FLT3 mutations and their prognostic implications, multiple FLT3-targeted molecules have been evaluated. Midostaurin is approved in the U.S. and Europe for newly diagnosed FLT3 mutated AML in combination with standard induction and consolidation chemotherapy based on data from the RATIFY study. Gilteritinib is approved for relapsed or refractory FLT3 mutated AML as monotherapy based on the ADMIRAL study. Although significant progress has been made in the treatment of AML with FLT3-targeting, many challenges remain. Several drug resistance mechanisms have been identified, including clonal selection, stromal protection, FLT3-associated mutations, and off-target mutations. The benefit of FLT3 inhibitor maintenance therapy, either post-chemotherapy or post-transplant, remains controversial, although several studies are ongoing.
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Affiliation(s)
- Jennifer C Zhao
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Sonal Agarwal
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Hiba Ahmad
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Kejal Amin
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Jan Philipp Bewersdorf
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA.
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17
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Huang A, Zeng P, Li Y, Lu W, Lai Y. LY294002 Is a Promising Inhibitor to Overcome Sorafenib Resistance in FLT3-ITD Mutant AML Cells by Interfering With PI3K/Akt Signaling Pathway. Front Oncol 2021; 11:782065. [PMID: 34820336 PMCID: PMC8606661 DOI: 10.3389/fonc.2021.782065] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 10/13/2021] [Indexed: 11/13/2022] Open
Abstract
Internal tandem duplications (ITD) mutation within FMS-like tyrosine kinase 3 (FLT3), the most frequent mutation happens in almost 20% acute myeloid leukemia (AML) patients, always predicts a poor prognosis. As a small molecule tyrosine kinase inhibitor, sorafenib is clinically used for the treatment of advanced renal cell carcinoma (RCC), hepatocellular carcinoma (HCC), and differentiated thyroid cancer (DTC), with its preclinical and clinical activity demonstrated in the treatment of Fms-like tyrosine kinase 3-internal tandem duplication (FLT3-ITD) mutant AML. Even though it shows a rosy future in the AML treatment, the short response duration remains a vital problem that leads to treatment failure. Rapid onset of drug resistance is still a thorny problem that we cannot overlook. Although the mechanisms of drug resistance have been studied extensively in the past years, there is still no consensus on the exact reason for resistance and without effective therapeutic regimens established clinically. My previous work reported that sorafenib-resistant FLT3-ITD mutant AML cells displayed mitochondria dysfunction, which rendered cells depending on glycolysis for energy supply. In my present one, we further illustrated that losing the target protein FLT3 and the continuously activated PI3K/Akt signaling pathway may be the reason for drug resistance, with sustained activation of PI3K/AKT signaling responsible for the highly glycolytic activity and adenosine triphosphate (ATP) generation. PI3K inhibitor, LY294002, can block PI3K/AKT signaling, further inhibit glycolysis to disturb ATP production, and finally induce cell apoptosis. This finding would pave the way to remedy the FLT3-ITD mutant AML patients who failed with FLT3 targeted therapy.
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Affiliation(s)
- Amin Huang
- Department of Medical Oncology of the East Division, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Peiting Zeng
- State Key Laboratory of Oncology in Southern China, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Yinguang Li
- Department of Obstetrics and Gynecology of the East Division, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Wenhua Lu
- State Key Laboratory of Oncology in Southern China, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Yaoming Lai
- Department of Rehabilitation, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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18
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New Drugs Bringing New Challenges to AML: A Brief Review. J Pers Med 2021; 11:jpm11101003. [PMID: 34683144 PMCID: PMC8537004 DOI: 10.3390/jpm11101003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/01/2021] [Accepted: 10/01/2021] [Indexed: 02/04/2023] Open
Abstract
The better understanding of the genomic landscape in acute myeloid leukaemia (AML) has progressively paved the way for precision medicine in AML. There is a growing number of drugs with novel mechanisms of action and unique side-effect profiles. This review examines the impact of evolving novel therapies on survival in AML and the challenges that ensue.
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19
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Novatcheva ED, Anouty Y, Saunders I, Mangan JK, Goodman AM. FMS-Like Tyrosine Kinase 3 Inhibitors for the Treatment of Acute Myeloid Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 22:e161-e184. [PMID: 34649791 DOI: 10.1016/j.clml.2021.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 09/07/2021] [Indexed: 12/18/2022]
Abstract
Acute myeloid leukemia (AML) is the most common acute leukemia of adults, with a five-year survival that remains poor (approximately 25%). Knowledge and understanding of AML genomics have expanded tremendously over the past decade and are now included in AML prognostication and treatment decisions. FMS-like tyrosine kinase 3 (FLT3) is a Class III receptor tyrosine kinase (RTK) expressed primarily in the cell membranes of early hematopoietic progenitor cells, found in 28% of all patients with AML. FLT3 is the second most frequent mutation in adult AML following Nuclear-cytoplasmic shuttling phosphoprotein (NPM1), which is found in 50% of cases.1 FLT3 inhibitors are promising new molecular therapeutics increasingly becoming standard of care for both newly diagnosed and relapsed/refractory FLT3 positive AML. This review will focus on the clinical trials/evidence, similarities, differences, clinical toxicities, and drug interactions relevant to treating clinicians as pertains to 5 FLT3-inhibitors: midostaurin, sorafenib, gilteritinib, crenolanib, and quizartinib.
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Affiliation(s)
| | - Yasmine Anouty
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA
| | - Ila Saunders
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA; UC San Diego Skaggs School of Pharmacy & Pharmaceutical Sciences, La Jolla, CA
| | - James K Mangan
- Department of Medicine, Division of Blood and Marrow Transplantation, University of California San Diego, La Jolla, CA
| | - Aaron M Goodman
- Department of Medicine, Division of Blood and Marrow Transplantation, University of California San Diego, La Jolla, CA.
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20
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Hogan FL, Williams V, Knapper S. FLT3 Inhibition in Acute Myeloid Leukaemia - Current Knowledge and Future Prospects. Curr Cancer Drug Targets 2021; 20:513-531. [PMID: 32418523 DOI: 10.2174/1570163817666200518075820] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 03/12/2020] [Accepted: 03/29/2020] [Indexed: 12/20/2022]
Abstract
Activating mutations of FMS-like tyrosine kinase 3 (FLT3) are present in 30% of acute myeloid leukaemia (AML) patients at diagnosis and confer an adverse clinical prognosis. Mutated FLT3 has emerged as a viable therapeutic target and a number of FLT3-directed tyrosine kinase inhibitors have progressed through clinical development over the last 10-15 years. The last two years have seen United States Food and Drug Administration (US FDA) approvals of the multi-kinase inhibitor midostaurin for newly-diagnosed FLT3-mutated patients, when used in combination with intensive chemotherapy, and of the more FLT3-selective agent gilteritinib, used as monotherapy, for patients with relapsed or treatment-refractory FLT3-mutated AML. The 'second generation' agents, quizartinib and crenolanib, are also at advanced stages of clinical development. Significant challenges remain in negotiating a variety of potential acquired drug resistance mechanisms and in optimizing sequencing of FLT3 inhibitory drugs with existing and novel treatment approaches in different clinical settings, including frontline therapy, relapsed/refractory disease, and maintenance treatment. In this review, the biology of FLT3, the clinical challenge posed by FLT3-mutated AML, the developmental history of the key FLT3-inhibitory compounds, mechanisms of disease resistance, and the future outlook for this group of agents, including current and planned clinical trials, is discussed.
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Affiliation(s)
- Francesca L Hogan
- Department of Haematology, University Hospital of Wales, Cardiff, United Kingdom
| | - Victoria Williams
- Department of Haematology, University Hospital of Wales, Cardiff, United Kingdom
| | - Steven Knapper
- School of Medicine, Cardiff University, Cardiff, United Kingdom
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21
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Burchert A. Maintenance therapy for FLT3-ITD-mutated acute myeloid leukemia. Haematologica 2021; 106:664-670. [PMID: 33472354 PMCID: PMC7927878 DOI: 10.3324/haematol.2019.240747] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Indexed: 12/15/2022] Open
Abstract
FLT3-ITD is a constitutively activated variant of the FLT3 tyrosine kinase receptor. Its expression in acute myeloid leukemia (AML) is associated with a poor prognosis. Due to this, the development of tyrosine kinase inhibitors (TKI) blocking FLT3-ITD became a rational therapeutic concept. This review describes key milestones in the clinical development of different FLT3-specific TKI with a particular focus on FLT3-TKI maintenance therapy in remission after allogeneic hematopoietic stem cell transplantation (HCT). Recent evidence from randomized trials using sorafenib in FLT3-ITD mutated AML provided a proof of concept that targeted post-HCT maintenance therapy could become a new treatment paradigm in AML.
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Affiliation(s)
- Andreas Burchert
- Department of Internal Medicine, Hematology, Oncology and Immunology, Philipps University Marburg and University Hospital Giessen and Marburg, Campus Marburg, Marburg.
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22
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Conneely SE, Stevens AM. Acute Myeloid Leukemia in Children: Emerging Paradigms in Genetics and New Approaches to Therapy. Curr Oncol Rep 2021; 23:16. [PMID: 33439382 PMCID: PMC7806552 DOI: 10.1007/s11912-020-01009-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Acute myeloid leukemia (AML) in children remains a challenging disease to cure with suboptimal outcomes particularly when compared to the more common lymphoid leukemias. Recent advances in the genetic characterization of AML have enhanced understanding of individualized patient risk, which has also led to the development of new therapeutic strategies. Here, we review key cytogenetic and molecular features of pediatric AML and how new therapies are being used to improve outcomes. RECENT FINDINGS Recent studies have revealed an increasing number of mutations, including WT1, CBFA2T3-GLIS2, and KAT6A fusions, DEK-NUP214 and NUP98 fusions, and specific KMT2A rearrangements, which are associated with poor outcomes. However, outcomes are starting to improve with the addition of therapies such as gemtuzumab ozogamicin and FLT3 inhibitors, initially developed in adult AML. The combination of advanced risk stratification and ongoing improvements and innovations in treatment strategy will undoubtedly lead to better outcomes for children with AML.
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Affiliation(s)
- Shannon E Conneely
- Department of Pediatric Hematology/Oncology, Baylor College of Medicine/Texas Children's Hospital, 6701 Fannin, Suite 1510, Houston, TX, 77030, USA.
| | - Alexandra M Stevens
- Department of Pediatric Hematology/Oncology, Baylor College of Medicine/Texas Children's Hospital, 6701 Fannin, Suite 1510, Houston, TX, 77030, USA
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23
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Tyrosine kinase inhibitors for acute myeloid leukemia: A step toward disease control? Blood Rev 2020; 44:100675. [DOI: 10.1016/j.blre.2020.100675] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/17/2020] [Accepted: 02/11/2020] [Indexed: 12/24/2022]
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24
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Abstract
OPINION STATEMENT There is increasing awareness that AML is a widely heterogeneous disease, not only based on clinical characteristics and demographics of the patients we treat but also based on the genomics of the disease. Wider accessibility to next-generation DNA sequencing in AML has identified recurrent genetic abnormalities that drive disease biology, define overall prognosis, and predict for response to newly developed target-specific therapies. This knowledge has allowed the field to move away from a "one-size-fits-all" approach in newly diagnosed AML, to a more thoughtful, individualized approachy based on these factors. The first steps in realizing this new approach involve developing systems to efficiently obtain and analyze patient- and disease-related factors prior to starting therapy and having available clinical trials to address each subtype.
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25
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Ketterl TG, Latham GJ. Perioperative Cardiothoracic and Vascular Risk in Childhood Cancer and its Survivors. J Cardiothorac Vasc Anesth 2020; 35:162-175. [PMID: 32360009 DOI: 10.1053/j.jvca.2020.02.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 02/11/2020] [Accepted: 02/28/2020] [Indexed: 11/11/2022]
Abstract
CHILDREN with cancer and survivors of childhood cancer have an increased risk of cardiovascular disease, and this risk in the perioperative period must be understood. During diagnosis and treatment of pediatric cancer, multiple acute cardiovascular morbidities are possible, including anterior mediastinal mass, tamponade, hypertension, cardiomyopathy,and heart failure. Childhood cancer survivors reaching late childhood and adulthood experience substantially increased rates of cardiomyopathy, heart failure, valvular disease, pericardiac disease, ischemia, and arrhythmias. Despite considerable advances in the understanding and therapeutic options of pediatric malignancies, cardiac disease remains the most common treatment-related, noncancer cause of death in childhood cancer survivors. Increasingly, molecularly targeted agents, including small molecule inhibitors, are being incorporated into pediatric oncology. The acute and chronic risks associated with these newer therapeutic options in children are not yet well-described, which poses challenges for clinicians caring for these patients. In the present review, the unique risks factors, prevention strategies, and treatment of cardiovascular toxicities of the child with cancer and the childhood cancer survivor are examined, with an emphasis on the perioperative period.
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Affiliation(s)
- Tyler G Ketterl
- Department of Pediatric Hematology and Oncology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Gregory J Latham
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA.
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Antar AI, Otrock ZK, Jabbour E, Mohty M, Bazarbachi A. FLT3 inhibitors in acute myeloid leukemia: ten frequently asked questions. Leukemia 2020; 34:682-696. [PMID: 31919472 DOI: 10.1038/s41375-019-0694-3] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/22/2019] [Accepted: 12/06/2019] [Indexed: 12/18/2022]
Abstract
The FMS-like tyrosine kinase 3 (FLT3) gene is mutated in approximately one third of patients with acute myeloid leukemia (AML), either by internal tandem duplications (FLT3-ITD), or by a point mutation mainly involving the tyrosine kinase domain (FLT3-TKD). Patients with FLT3-ITD have a high risk of relapse and low cure rates. Several FLT3 tyrosine kinase inhibitors have been developed in the last few years with variable kinase inhibitory properties, pharmacokinetics, and toxicity profiles. FLT3 inhibitors are divided into first generation multi-kinase inhibitors (such as sorafenib, lestaurtinib, midostaurin) and next generation inhibitors (such as quizartinib, crenolanib, gilteritinib) based on their potency and specificity of FLT3 inhibition. These diverse FLT3 inhibitors have been evaluated in myriad clinical trials as monotherapy or in combination with conventional chemotherapy or hypomethylating agents and in various settings, including front-line, relapsed or refractory disease, and maintenance therapy after consolidation chemotherapy or allogeneic stem cell transplantation. In this practical question-and-answer-based review, the main issues faced by the leukemia specialists on the use of FLT3 inhibitors in AML are addressed.
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Affiliation(s)
- Ahmad I Antar
- Department of Hematology and Oncology, Hammoud Hospital University Medical Center, Saida, Lebanon
| | - Zaher K Otrock
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mohamad Mohty
- Service d'hématologie clinique et thérapie cellulaire, Hôpital Saint-Antoine, INSERM UMRs 938 and université Sorbonne, Paris, France
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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Yalniz F, Abou Dalle I, Kantarjian H, Borthakur G, Kadia T, Patel K, Loghavi S, Garcia‐Manero G, Sasaki K, Daver N, DiNardo C, Pemmaraju N, Short NJ, Yilmaz M, Bose P, Naqvi K, Pierce S, Nogueras González GM, Konopleva M, Andreeff M, Cortes J, Ravandi F. Prognostic significance of baseline FLT3-ITD mutant allele level in acute myeloid leukemia treated with intensive chemotherapy with/without sorafenib. Am J Hematol 2019; 94:984-991. [PMID: 31237017 DOI: 10.1002/ajh.25553] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/01/2019] [Accepted: 06/06/2019] [Indexed: 11/11/2022]
Abstract
Internal tandem duplication (ITD) of the fms-related tyrosine kinase-3 gene (FLT3) confer a poor prognosis in adult AML. Studies have reported that a higher mutant allelic burden is associated with a worse prognosis. Adult patients with FLT3-ITD mutated AML treated at our institution were identified. Patients were assigned into 2 groups; patients who received idarubicin and cytarabine (IA, group one) containing induction, and who received sorafenib in addition to IA containing regimens at induction (group two). The optimal FLT3-ITD mutant allele cut-off was defined as the cut-off to divide the whole cohort with the highest statistical significance. A total of 183 patients including 104 (57%) in group one and 79 (43%) in group two were identified. The complete remission (CR)/CR with incomplete hematologic recovery (CRi) for group one and group two were 85% and 99%, respectively (P = .004). The median relapse free survival (RFS) for group one and two were 12 and 45 months, respectively (P = .02). The median overall survival (mOS) was 17 months in group one, and has not been reached in group two (P = .008). The optimal FLT3-ITD mutant allele cut-off for OS was 6.9% in group one, there was no optimal cut-off in group two. On multivariate analysis, poor performance status (PS) (P = .003), sorafenib (P = .01), and presenting white blood cells (WBC) (P < .001) were independent predictors of OS. Higher FLT3-ITD allele burden is associated with a worse outcome in patients treated with IA-based chemotherapy. Addition of sorafenib to chemotherapy not only nullifies the negative prognostic impact of higher allele burden, but also improves outcome of FLT3-ITD mutated AML patients regardless of the allele burden.
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Affiliation(s)
- Fevzi Yalniz
- Department of LeukemiaThe University of Texas MD Anderson Cancer Center Houston Texas
| | - Iman Abou Dalle
- Department of LeukemiaThe University of Texas MD Anderson Cancer Center Houston Texas
| | - Hagop Kantarjian
- Department of LeukemiaThe University of Texas MD Anderson Cancer Center Houston Texas
| | - Gautam Borthakur
- Department of LeukemiaThe University of Texas MD Anderson Cancer Center Houston Texas
| | - Tapan Kadia
- Department of LeukemiaThe University of Texas MD Anderson Cancer Center Houston Texas
| | - Keyur Patel
- Department of PathologyThe University of Texas MD Anderson Cancer Center Houston Texas
| | - Sanam Loghavi
- Department of PathologyThe University of Texas MD Anderson Cancer Center Houston Texas
| | | | - Koji Sasaki
- Department of LeukemiaThe University of Texas MD Anderson Cancer Center Houston Texas
| | - Naval Daver
- Department of LeukemiaThe University of Texas MD Anderson Cancer Center Houston Texas
| | - Courtney DiNardo
- Department of LeukemiaThe University of Texas MD Anderson Cancer Center Houston Texas
| | - Naveen Pemmaraju
- Department of LeukemiaThe University of Texas MD Anderson Cancer Center Houston Texas
| | - Nicholas J. Short
- Department of LeukemiaThe University of Texas MD Anderson Cancer Center Houston Texas
| | - Musa Yilmaz
- Department of LeukemiaThe University of Texas MD Anderson Cancer Center Houston Texas
| | - Prithviraj Bose
- Department of LeukemiaThe University of Texas MD Anderson Cancer Center Houston Texas
| | - Kiran Naqvi
- Department of LeukemiaThe University of Texas MD Anderson Cancer Center Houston Texas
| | - Sherry Pierce
- Department of LeukemiaThe University of Texas MD Anderson Cancer Center Houston Texas
| | | | - Marina Konopleva
- Department of LeukemiaThe University of Texas MD Anderson Cancer Center Houston Texas
| | - Michael Andreeff
- Department of LeukemiaThe University of Texas MD Anderson Cancer Center Houston Texas
| | - Jorge Cortes
- Department of LeukemiaThe University of Texas MD Anderson Cancer Center Houston Texas
| | - Farhad Ravandi
- Department of LeukemiaThe University of Texas MD Anderson Cancer Center Houston Texas
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28
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Jia JS, Zhu HH, Gong LZ, Zhao T, Wang J, Jiang Q, Huang XJ, Jiang H. [Analysis of induction efficacy and prognostic factors in FLT3-ITD positive acute myeloid leukemia in the real world]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 40:398-403. [PMID: 31207705 PMCID: PMC7342235 DOI: 10.3760/cma.j.issn.0253-2727.2019.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To investigate the efficacy and prognostic factors of induction therapy in FLT3-ITD(+) acute myeloid leukemia (AML) in the real world data. Methods: From January 2013 to December 2016, 114 de novo patients with FLT3-ITD(+)AML were enrolled in this study. Out of 114 cases, 75 were male, and 39 were female. The median age was 42 years old (ranged from 14 to 72 years old) . The chemotherapy regimens were used for induction therapy and all cases were followed up. The treatment response was evaluated by MICM and the comparison of the ratio were analyzed by chi-square test and the survival was estimated by Kaplan-Meier analysis and Cox proportional hazards model was used to identify independent prognostic factors. Results: There were 52 FLT3-ITD(+)AML patients with favorable prognosis genes (46 cases with NPM1, 5 cases with RUNX1-RUNX1T1, 1 case with CEBPA double mutation) and 62 patients with other types of FLT3-ITD(+)AML at diagnosis. All patients completed at least one cycle of induction therapy and the clinical curative effect was evaluated, complete remission (CR) rate was 50.0% (57/114) in one cycle and total CR rate was 72.5% (74/104) in two cycles. The CR rate of the FLT3-ITD(+) AML patients with favorable prognosis genes was 67.3% (35/52) in one cycle and 83.3% (40/48) in two cycles; for the other types FLT3-ITD(+)AML patients, the CR rate was 35.5% (22/62) in one cycle and 64.8% (35/54) in two cycles. There was a significant difference in CR rate between the FLT3-ITD(+)AML patients with and without favorable prognosis genes (P<0.05) . This indicates that the FLT3-ITD(+)AML patients with favorable prognosis gene had relatively good therapeutic effect. Among other types of FLT3-ITD(+)AML patients who did not achieve remission from one cycle of chemotherapy, 9 patients were given sorafenib plus chemotherapy and 6 cases (66.7%) achieved CR; 23 patients were given conventional chemotherapy and 7 cases (30.4%) achieved CR. There was a significant difference between sorafenib plus chemotherapy and conventional chemotherapy groups (χ(2)=4.47, P<0.05) and this indicates that sorafenib plus chemotherapy can significantly improve the CR rate of FLT3-ITD(+)AML patients. Comparing overall survival (OS) and disease free survival (DFS) , there was no significant difference between sorafenib plus chemotherapy and conventional chemotherapy groups (P values were 0.641 and 0.517, respectively) . Conclusion: The overall prognosis of FLT3-ITD(+)AML patients is poor, and the stratification therapeutic efficacy of FLT3-ITD(+)AML without favorable prognosis gene can be improved by sorafenib combined with chemotherapy.
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Affiliation(s)
- J S Jia
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
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29
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Chow EJ, Leger KJ, Bhatt NS, Mulrooney DA, Ross CJ, Aggarwal S, Bansal N, Ehrhardt MJ, Armenian SH, Scott JM, Hong B. Paediatric cardio-oncology: epidemiology, screening, prevention, and treatment. Cardiovasc Res 2019; 115:922-934. [PMID: 30768157 PMCID: PMC6452306 DOI: 10.1093/cvr/cvz031] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 01/18/2019] [Accepted: 02/13/2019] [Indexed: 12/11/2022] Open
Abstract
With 5-year survival of children with cancer exceeding 80% in developed countries, premature cardiovascular disease is now a major cause of early morbidity and mortality. In addition to the acute and chronic cardiotoxic effects of anthracyclines, related chemotherapeutics, and radiation, a growing number of new molecular targeted agents may also have detrimental effects on the cardiovascular system. Survivors of childhood cancer also may have earlier development of conventional cardiovascular risk factors such as hypertension, dyslipidaemia, and diabetes, which further increase their risk of serious cardiovascular disease. This review will examine the epidemiology of acute and chronic cardiotoxicity relevant to paediatric cancer patients, including genetic risk factors. We will also provide an overview of current screening recommendations, including the evidence regarding both imaging (e.g. echocardiography and magnetic resonance imaging) and blood-based biomarkers. Various primary and secondary prevention strategies will also be discussed, primarily in relation to anthracycline-related cardiomyopathy. Finally, we review the available evidence related to the management of systolic and diastolic dysfunction in paediatric cancer patients and childhood cancer survivors.
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Affiliation(s)
- Eric J Chow
- Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N., PO Box 19024, Mailstop M4-C308, Seattle, WA 98109, USA
| | - Kasey J Leger
- Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | - Neel S Bhatt
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Daniel A Mulrooney
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Colin J Ross
- Faculty of Pharmaceutical Sciences, University of British Columbia, BC Children’s Hospital, Vancouver, BC, Canada
| | - Sanjeev Aggarwal
- Division of Pediatric Cardiology, Children’s Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Neha Bansal
- Division of Pediatric Cardiology, Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthew J Ehrhardt
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Saro H Armenian
- Department of Population Sciences, City of Hope Medical Center, Duarte, CA, USA
| | - Jessica M Scott
- Exercise Oncology Research Laboratory, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Borah Hong
- Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
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30
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Ten-year outcome of patients with acute myeloid leukemia not treated with allogeneic transplantation in first complete remission. Blood Adv 2019; 2:1645-1650. [PMID: 29991495 DOI: 10.1182/bloodadvances.2017015222] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 06/05/2018] [Indexed: 12/31/2022] Open
Abstract
The probability that adult patients with de novo acute myeloid leukemia (AML) receiving intensive chemotherapy in the absence of allogeneic hematopoietic stem cell transplantation (Allo-HCT) in first complete remission (CR1) will be disease-free at 10 years after diagnosis, a long-term surrogate of cure, is unknown. To address this question, we examined 2551 AML patients (1607 aged <60 years, and 944 aged ≥60 years) enrolled in Cancer and Leukemia Group B treatment protocols and the cytogenetics companion protocol 8461 between 1983 and 2004. At 10 years, 267 (16.6%) of patients aged <60 years and 23 (2.4%) of those aged ≥60 years were alive and disease-free. This disease-free AML group consisted predominantly of patients with core-binding factor AML with t(8;21)(q22;q22) or inv(16)(p13q22)/t(16;16)(p13;q22) and those with a normal karyotype. Occurrences of AML beyond 10 years were infrequent and associated with cytogenetic findings different from those at diagnosis. These data provide evidence that the frequency of long-term cure of AML is low among younger and especially older patients in the absence of Allo-HCT in CR1. In older patients not appropriate for Allo-HCT, these data provide further justification for early use of alternative treatments outside of intensive chemotherapy.
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31
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Gokhale P, Chauhan APS, Arora A, Khandekar N, Nayarisseri A, Singh SK. FLT3 inhibitor design using molecular docking based virtual screening for acute myeloid leukemia. Bioinformation 2019; 15:104-115. [PMID: 31435156 PMCID: PMC6677903 DOI: 10.6026/97320630015104] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 02/10/2019] [Accepted: 02/19/2019] [Indexed: 02/08/2023] Open
Abstract
Acute Myeloid Leukaemia (AML) is a blood cancer, which affects the red blood cells in the bone marrow. Of the possible proteins that are affected in AML, fms-like tyrosine kinase 3 (FLT3) has long been recognized as a potential therapeutic target as it affects the other signaling pathways and leads to a cascade of events. First-generation inhibitors sorafenib and midostaurin, as well as secondgeneration agents such as quizartinib and crenolanib are known. It is of interest to identify new compounds against FLT3 with improved activity using molecular docking and virtual screening. Molecular docking of existing inhibitors selected a top scoring bestestablished candidate Quizartinib having PubChem CID: 24889392. Similarity searching resulted in compound XGIQBUNWFCCMASUHFFFAOYSA-NPubChemCID: 44598530 which shows higher affinity scores. A comparative study of both the compounds using a drug-drug comparison, ADMET studies, boiled egg plot and pharmacophore parameters and properties confirmed the result and predicted the ligand to be an efficient inhibitor of FLT3.
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Affiliation(s)
- Padmini Gokhale
- In silico Research Laboratory,Eminent Biosciences,Mahalakshmi Nagar,Indore-452010,Madhya Pradesh,India
| | | | - Anushka Arora
- In silico Research Laboratory,Eminent Biosciences,Mahalakshmi Nagar,Indore-452010,Madhya Pradesh,India
| | - Natasha Khandekar
- In silico Research Laboratory,Eminent Biosciences,Mahalakshmi Nagar,Indore-452010,Madhya Pradesh,India
| | - Anuraj Nayarisseri
- In silico Research Laboratory,Eminent Biosciences,Mahalakshmi Nagar,Indore-452010,Madhya Pradesh,India
- Bioinformatics Research Laboratory,LeGene Biosciences Pvt Ltd.,Mahalakshmi Nagar,Indore-452010,Madhya Pradesh,India
- Computer Aided Drug Designing and Molecular Modeling Lab,Department of Bioinformatics,Alagappa University,Karaikudi-630 003,Tamil Nadu,India
| | - Sanjeev Kumar Singh
- Computer Aided Drug Designing and Molecular Modeling Lab,Department of Bioinformatics,Alagappa University,Karaikudi-630 003,Tamil Nadu,India
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32
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Short NJ, Kantarjian H, Ravandi F, Daver N. Emerging treatment paradigms with FLT3 inhibitors in acute myeloid leukemia. Ther Adv Hematol 2019; 10:2040620719827310. [PMID: 30800259 PMCID: PMC6378516 DOI: 10.1177/2040620719827310] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 01/07/2019] [Indexed: 11/17/2022] Open
Abstract
Mutations in the fms-like tyrosine kinase 3 (FLT3) gene are detected in approximately one-third of patients with newly diagnosed acute myeloid leukemia (AML). These consist of the more common FLT3-internal tandem duplication (ITD) in approximately 20-25% of AML cases, and point mutations in the tyrosine kinase domain (TKD) in approximately 5-10%. FLT3 mutations, especially FLT3-ITD, are associated with proliferative disease, increased risk of relapse, and inferior overall survival when treated with conventional regimens. However, the recent development of well tolerated and active FLT3 inhibitors has significantly improved the outcomes of this aggressive subtype of AML. The multikinase inhibitor midostaurin was approved by the United States Food and Drug Administration (US FDA) in April 2017 for the frontline treatment of patients with FLT3-mutated (either ITD or TKD) AML in combination with induction chemotherapy, representing the first new drug approval in AML in nearly two decades. In November 2018, the US FDA also approved the second-generation FLT3 inhibitor gilteritinib as a single agent for patients with relapsed or refractory FLT3-mutated AML. Promising phase I and II efficacy data for quizartinib is likely to lead to a third regulatory approval in relapsed/refractory AML in the near future. However, despite the significant progress made in managing FLT3-mutated AML, many questions remain regarding the best approach to integrate these inhibitors into combination regimens, and also the optimal sequencing of different FLT3 inhibitors in various clinical settings. This review comprehensively examines the FLT3 inhibitors currently in clinical development, with an emphasis on their spectra of activity against different FLT3 mutations and other kinases, clinical safety and efficacy data, and their current and future roles in the management of AML. The mechanisms of resistance to FLT3 inhibitors and potential combination strategies to overcome such resistance pathways are also discussed.
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Affiliation(s)
- Nicholas J. Short
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop Kantarjian
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naval Daver
- Department of Leukemia, Unit 428, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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33
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Daver N, Schlenk RF, Russell NH, Levis MJ. Targeting FLT3 mutations in AML: review of current knowledge and evidence. Leukemia 2019; 33:299-312. [PMID: 30651634 PMCID: PMC6365380 DOI: 10.1038/s41375-018-0357-9] [Citation(s) in RCA: 581] [Impact Index Per Article: 116.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/18/2018] [Accepted: 10/24/2018] [Indexed: 02/07/2023]
Abstract
Genomic investigations of acute myeloid leukemia (AML) have demonstrated that several genes are recurrently mutated, leading to new genomic classifications, predictive biomarkers, and new therapeutic targets. Mutations of the FMS-like tyrosine kinase 3 (FLT3) gene occur in approximately 30% of all AML cases, with the internal tandem duplication (ITD) representing the most common type of FLT3 mutation (FLT3-ITD; approximately 25% of all AML cases). FLT3-ITD is a common driver mutation that presents with a high leukemic burden and confers a poor prognosis in patients with AML. The prognostic value of a FLT3 mutation in the tyrosine kinase domain (FLT3-TKD), which has a lower incidence in AML (approximately 7-10% of all cases), is uncertain. Accumulating evidence demonstrates that FLT3 mutational status evolves throughout the disease continuum. This so-called clonal evolution, together with the identification of FLT3-ITD as a negative prognostic marker, serves to highlight the importance of FLT3-ITD testing at diagnosis and again at relapse. Earlier identification of FLT3 mutations will help provide a better understanding of the patient's disease and enable targeted treatment that may help patients achieve longer and more durable remissions. First-generation FLT3 inhibitors developed for clinical use are broad-spectrum, multikinase inhibitors; however, next-generation FLT3 inhibitors are more specific, more potent, and have fewer toxicities associated with off-target effects. Primary and secondary acquired resistance to FLT3 inhibitors remains a challenge and provides a rationale for combining FLT3 inhibitors with other therapies, both conventional and investigational. This review focuses on the pathological and prognostic role of FLT3 mutations in AML, clinical classification of the disease, recent progress with next-generation FLT3 inhibitors, and mechanisms of resistance to FLT3 inhibitors.
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Affiliation(s)
- Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard F Schlenk
- National Center of Tumor Diseases, German Cancer Research Center, Heidelberg, Germany
| | - Nigel H Russell
- Centre for Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Mark J Levis
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA.
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34
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Kakiuchi S, Yakushijin K, Sakai R, Kawaguchi K, Higashime A, Kurata K, Ichikawa H, Nagao S, Rikitake J, Kiyota N, Matsuoka H, Minami H. Discontinuation of sorafenib can lead to the emergence of FLT3-ITD-positive acute myeloid leukemia. J Oncol Pharm Pract 2018; 25:2010-2015. [PMID: 30514174 DOI: 10.1177/1078155218816768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 69-year-old woman who had been diagnosed with unresectable papillary thyroid cancer was referred to our hospital. We initially treated her with sorafenib, but she subsequently developed erythema multiforme, which was suspected to be a drug rush due to sorafenib; therefore, sorafenib was discontinued. At the time of discontinuation, immature blast cells were detected in her peripheral blood. Approximately two weeks later, her skin rash improved substantially, but the proportion of blasts in the peripheral blood increased. We performed a bone marrow examination, and she was diagnosed with FLT3-ITD-positive acute myeloid leukemia. FLT3-ITD expression is found in 20-25% of AML and is a known independent poor prognostic factor. To overcome the poor prognosis associated with FLT3-ITD, molecular drugs targeting FLT3-ITD are attracting much attention. Sorafenib, a multi-kinase inhibitor, also has an effect on FLT3-ITD. Although primary disease flares after tyrosine kinase inhibitor discontinuation have been reported, this is the first report to describe discontinuation of sorafenib treatment as a potential trigger of FLT3-ITD-positive acute myeloid leukemia in papillary thyroid cancer.
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Affiliation(s)
- Seiji Kakiuchi
- Division of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan.,Department of Hematology, Yodogawa Christian Hospital, Osaka, Osaka, Japan
| | - Kimikazu Yakushijin
- Division of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Rina Sakai
- Division of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Koji Kawaguchi
- Division of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Ako Higashime
- Division of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Keiji Kurata
- Division of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Hiroya Ichikawa
- Division of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Shigeki Nagao
- Division of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan.,Division of Hematology, Department of Internal Medicine, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Junpei Rikitake
- Division of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan.,Department of Hematology, Yodogawa Christian Hospital, Osaka, Osaka, Japan
| | - Naomi Kiyota
- Division of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Hiroshi Matsuoka
- Division of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Hironobu Minami
- Division of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan
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35
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Staudt D, Murray HC, McLachlan T, Alvaro F, Enjeti AK, Verrills NM, Dun MD. Targeting Oncogenic Signaling in Mutant FLT3 Acute Myeloid Leukemia: The Path to Least Resistance. Int J Mol Sci 2018; 19:ijms19103198. [PMID: 30332834 PMCID: PMC6214138 DOI: 10.3390/ijms19103198] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 10/10/2018] [Accepted: 10/11/2018] [Indexed: 02/07/2023] Open
Abstract
The identification of recurrent driver mutations in genes encoding tyrosine kinases has resulted in the development of molecularly-targeted treatment strategies designed to improve outcomes for patients diagnosed with acute myeloid leukemia (AML). The receptor tyrosine kinase FLT3 is the most commonly mutated gene in AML, with internal tandem duplications within the juxtamembrane domain (FLT3-ITD) or missense mutations in the tyrosine kinase domain (FLT3-TKD) present in 30–35% of AML patients at diagnosis. An established driver mutation and marker of poor prognosis, the FLT3 tyrosine kinase has emerged as an attractive therapeutic target, and thus, encouraged the development of FLT3 tyrosine kinase inhibitors (TKIs). However, the therapeutic benefit of FLT3 inhibition, particularly as a monotherapy, frequently results in the development of treatment resistance and disease relapse. Commonly, FLT3 inhibitor resistance occurs by the emergence of secondary lesions in the FLT3 gene, particularly in the second tyrosine kinase domain (TKD) at residue Asp835 (D835) to form a ‘dual mutation’ (ITD-D835). Individual FLT3-ITD and FLT3-TKD mutations influence independent signaling cascades; however, little is known about which divergent signaling pathways are controlled by each of the FLT3 specific mutations, particularly in the context of patients harboring dual ITD-D835 mutations. This review provides a comprehensive analysis of the known discrete and cooperative signaling pathways deregulated by each of the FLT3 specific mutations, as well as the therapeutic approaches that hold the most promise of more durable and personalized therapeutic approaches to improve treatments of FLT3 mutant AML.
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Affiliation(s)
- Dilana Staudt
- School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia.
- Priority Research Centre for Cancer Research, Innovation & Translation, Faculty of Health & Medicine, Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia.
| | - Heather C Murray
- School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia.
- Priority Research Centre for Cancer Research, Innovation & Translation, Faculty of Health & Medicine, Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia.
| | - Tabitha McLachlan
- School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia.
- Priority Research Centre for Cancer Research, Innovation & Translation, Faculty of Health & Medicine, Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia.
| | - Frank Alvaro
- Priority Research Centre for Cancer Research, Innovation & Translation, Faculty of Health & Medicine, Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia.
- John Hunter Children's Hospital, Faculty of Health and Medicine, University of Newcastle, New Lambton Heights, NSW 2305, Australia.
| | - Anoop K Enjeti
- Priority Research Centre for Cancer Research, Innovation & Translation, Faculty of Health & Medicine, Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia.
- Calvary Mater Hospital, Hematology Department, Waratah, NSW 2298, Australia.
- NSW Health Pathology North, John Hunter Hospital, New Lambton Heights, NSW 2305, Australia.
| | - Nicole M Verrills
- School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia.
- Priority Research Centre for Cancer Research, Innovation & Translation, Faculty of Health & Medicine, Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia.
| | - Matthew D Dun
- School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia.
- Priority Research Centre for Cancer Research, Innovation & Translation, Faculty of Health & Medicine, Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia.
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Abstract
Acute myeloid leukemia (AML) is a highly heterogeneous disease. Mutation with internal tandem duplication of fms-like tyrosine kinase-3 (FLT3-ITD) is one of the two most common driver mutations and the presence of FLT3-ITD delivers poor prognosis. A number of ongoing clinical efforts are focused on FLT3 inhibitor use to improve the outcomes of this otherwise difficult leukemia. Midostaurin has been shown to improve outcomes in FLT3-mutated AML in the frontline setting. Several FLT3 inhibitors, especially second-generation agents, have shown clinically meaningful activity in relapsed or refractory AML and in patients not amenable to intensive therapy. In this article, we briefly review the biology of FLT3 in the physiological state and its role in leukemogenesis. We present a detailed review of current clinical evidence of FLT3 inhibitors and their use in the induction, treatment of relapsed or refractory disease, and maintenance setting.
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Affiliation(s)
- Grerk Sutamtewagul
- Division of Hematology, Oncology and Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA,
| | - Carlos E Vigil
- Division of Hematology, Oncology and Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA,
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37
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McMahon CM, Perl AE. Management of primary refractory acute myeloid leukemia in the era of targeted therapies. Leuk Lymphoma 2018; 60:583-597. [PMID: 30234399 DOI: 10.1080/10428194.2018.1504937] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Primary refractory acute myeloid leukemia (AML), or primary induction failure, represents a continued challenge in clinical management. This review presents an overview of primary refractory disease and a discussion of risk factors for induction failure, including current evidence regarding the impact of karyotype and molecular mutation status on responsiveness to chemotherapy. We review the evidence for various treatment options for refractory AML including salvage chemotherapy regimens, allogeneic hematopoietic stem cell transplantation, targeted agents, and non-intensive therapies such as hypomethylating agents. A therapeutic approach to this patient population is presented, and several new and emerging therapies are reviewed.
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Affiliation(s)
- Christine M McMahon
- a Department of Medicine, Division of Hematology and Oncology , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , PA , USA
| | - Alexander E Perl
- a Department of Medicine, Division of Hematology and Oncology , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , PA , USA
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38
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Ohanian M, Garcia-Manero G, Levis M, Jabbour E, Daver N, Borthakur G, Kadia T, Pierce S, Burger J, Richie MA, Patel K, Andreeff M, Estrov Z, Cortes J, Kantarjian H, Ravandi F. Sorafenib Combined with 5-azacytidine in Older Patients with Untreated FLT3-ITD Mutated Acute Myeloid Leukemia. Am J Hematol 2018; 93:1136-1141. [PMID: 30028037 DOI: 10.1002/ajh.25198] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 06/07/2017] [Accepted: 06/11/2017] [Indexed: 02/03/2023]
Abstract
Based on our previous study of the combination of sorafenib with 5-azacytidine (AZA) in relapsed/refractory patients with FLT3 mutated acute myeloid leukemia (AML), we hypothesized that the combination would be efficacious and well tolerated in untreated patients with FLT3 mutated AML who are unsuitable for standard chemotherapy due to advanced age or lack of fitness. Newly diagnosed patients with untreated FLT3 mutated AML who underwent frontline therapy on 2 separate protocols of AZA plus sorafenib were analyzed. The clinical trials were registered at clinicaltrials.gov (NCT02196857 and NCT01254890). Overall, 27 patients with untreated FLT3 mutated AML (median age of 74 years, range, 61-86) were enrolled. The overall response rate was 78% (7 [26%] CR, 12 [44%] CRi/CRp, and 2 [7%] PR). Patients received a median of 3 treatment cycles (1-35). The median duration of CR/CRp/CRi is 14.5 months (1.1-28.7 months). Three (11%) responding patients (1 CR, 2 CRi) proceeded to allogeneic stem cell transplant. The median follow-up for surviving patients was 4.1 months (3.0-17.3 months). The median overall survival for the entire group was 8.3 months, and 9.2 months in the 19 responders. The regimen was well tolerated in elderly patients with untreated FLT3 mutated AML with no early deaths.
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Affiliation(s)
- Maro Ohanian
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Mark Levis
- Division of Hematological Malignancies, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Elias Jabbour
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naval Daver
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gautam Borthakur
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tapan Kadia
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sherry Pierce
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jan Burger
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mary Ann Richie
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Keyur Patel
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael Andreeff
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zeev Estrov
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jorge Cortes
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hagop Kantarjian
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Farhad Ravandi
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas
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39
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Yang M, Zhao J, Liu T, Yang X, Wei H, Xu W, Xiao J. Use of FLT3 inhibitors in acute myeloid leukemia remission induction or salvage therapy: systematic review and meta-analysis. Cancer Manag Res 2018; 10:2635-2652. [PMID: 30147364 PMCID: PMC6097505 DOI: 10.2147/cmar.s166387] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background Previous studies showed that FLT3 inhibitors played an important role in acute myeloid leukemia (AML) therapy. However, discrepancies remain regarding the association between FLT3 inhibitors use and prognosis of AML patients in clinical trials. Aim The aim of this study was to evaluate the effect of FLT3 inhibitors on the treatment of AML in a systematic review and meta-analysis. Materials and methods PubMed, Embase, and Cochrane Library databases were searched for studies published before August 2017 that used FLT3 inhibitors in AML. Fixed- and random-effect models were used, and between-study heterogeneity was assessed. Results A total of 26 studies fitting our inclusion and exclusion criteria were included. The FLT3 status of patients and main treatment outcomes including overall survival (OS), event-free survival (EFS), relapse-free survival (RFS), complete remission (CR), and overall response rate (ORR) after therapy were extracted. Five studies comparing addition of FLT3 inhibitors and placebo or blank control to chemotherapy were analyzed in Part I, showing improved OS (hazard ratio [HR]=0.86, 95% confidence interval [CI]=0.75–0.99, P=0.03) in the FLT3 inhibitor group but without a significant improvement on EFS (HR=0.86, 95% CI=0.62–1.21, P=0.39) and ORR (odds ratio [OR]=1.10, 95% CI=0.89–1.35, P=0.38). Twenty-one studies evaluating the benefit of using FLT3 inhibitors in different FLT3-type AML patients were analyzed in Part II, showing that FLT3–internal tandem duplication (ITD)-positive patients were more sensitive to FLT3 inhibitor treatment and achieved better CR (OR=1.89, 95% CI=1.06–3.37, P=0.03) and ORR (OR=3.07, 95% CI=2.13–4.43, P<0.001). Conclusion Our study showed that combined use of FLT3 inhibitors improved OS and that the FLT3 status of AML patients could affect their sensitivity to FLT3 inhibitors in terms of CR and ORR.
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Affiliation(s)
- Minglei Yang
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China, ;
| | - Jian Zhao
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China, ;
| | - Tielong Liu
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China, ;
| | - Xinghai Yang
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China, ;
| | - Haifeng Wei
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China, ;
| | - Wei Xu
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China, ;
| | - Jianru Xiao
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China, ;
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40
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Liu T, Ivaturi V, Sabato P, Gobburu JVS, Greer JM, Wright JJ, Smith BD, Pratz KW, Rudek MA. Sorafenib Dose Recommendation in Acute Myeloid Leukemia Based on Exposure-FLT3 Relationship. Clin Transl Sci 2018; 11:435-443. [PMID: 29702736 PMCID: PMC6039208 DOI: 10.1111/cts.12555] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/14/2018] [Indexed: 01/12/2023] Open
Abstract
Sorafenib administered at the approved dose continuously is not tolerated long-term in patients with acute myeloid leukemia (AML). The purpose of this study was to optimize the dosing regimen by characterizing the sorafenib exposure-response relationship in patients with AML. A one-compartment model with a transit absorption compartment and enterohepatic recirculation described the exposure. The relationship between sorafenib exposure and target modulation of kinase targets (FMS-like tyrosine kinase 3 (FLT3)-ITD and extracellular signal-regulated kinase (ERK)) were described by an inhibitory maximum effect (Emax ) model. Sorafenib could inhibit FLT3-ITD activity by 100% with an IC50 of 69.3 ng/mL and ERK activity by 84% with an IC50 of 85.7 ng/mL (both adjusted for metabolite potency). Different dosing regimens utilizing 200 or 400 mg at varying frequencies were simulated based on the exposure-response relationship. Simulations demonstrate that a 200 mg twice daily (b.i.d.) dosing regimen showed similar FLT3-ITD and ERK inhibitory activity compared with 400 mg b.i.d. and is recommended in further clinical trials in patients with AML.
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Affiliation(s)
- Tao Liu
- Center for Translational MedicineUniversity of Maryland BaltimoreMarylandUSA
| | - Vijay Ivaturi
- Center for Translational MedicineUniversity of Maryland BaltimoreMarylandUSA
| | - Philip Sabato
- Center for Translational MedicineUniversity of Maryland BaltimoreMarylandUSA
| | | | - Jacqueline M. Greer
- The Sidney Kimmel Comprehensive Cancer Center at Johns HopkinsBaltimoreMarylandUSA
| | - John J. Wright
- Investigational Drug Branch, Cancer Therapy Evaluation Program, Division of Cancer Treatment and DiagnosisNational Cancer InstituteBethesdaMarylandUSA
| | - B. Douglas Smith
- The Sidney Kimmel Comprehensive Cancer Center at Johns HopkinsBaltimoreMarylandUSA
- Department of OncologyJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Keith W. Pratz
- The Sidney Kimmel Comprehensive Cancer Center at Johns HopkinsBaltimoreMarylandUSA
- Department of OncologyJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Michelle A. Rudek
- The Sidney Kimmel Comprehensive Cancer Center at Johns HopkinsBaltimoreMarylandUSA
- Department of OncologyJohns Hopkins UniversityBaltimoreMarylandUSA
- Department of Medicine, Division of Clinical PharmacologyJohns Hopkins UniversityBaltimoreMarylandUSA
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41
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Role of drug transporters in the sensitivity of acute myeloid leukemia to sorafenib. Oncotarget 2018; 9:28474-28485. [PMID: 29983874 PMCID: PMC6033373 DOI: 10.18632/oncotarget.25494] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 04/24/2018] [Indexed: 12/11/2022] Open
Abstract
Background Chemoresistance often limits the success of the pharmacological treatment in acute myeloid leukemia (AML) patients. Although positive results have been obtained with tyrosine kinase inhibitors (TKIs), such as sorafenib, especially in patients with Fms-like tyrosine kinase 3 (FLT3)-positive AML, the success of chemotherapy is very heterogeneous. Here we have investigated in vitro whether the transportome (set of expressed plasma membrane transporters) is involved in the differential response of AML to sorafenib. Methods The sensitivity to sorafenib-induced cell death (MTT test and anexin V/7-AAD method) was evaluated in five different cell lines: MOLM-13, OCI-AML2, HL-60, HEL and K-562. The transportome was characterized by measuring mRNA using RT-qPCR. Drug uptake/efflux was determined by flow cytometry using specific substrates and inhibitors. Results The cytostatic response to sorafenib was: MOLM-13>>OCI-AML2>HL-60>HEL≈K-562. Regarding efflux pumps, MDR1 was highly expressed in HEL>K-562≈MOLM-13, but not in OCI-AML2 and HL-60. BCRP and MPR3 expression was low in all cell lines, whereas MRP4 and MRP5 expression was from moderate to high. Flow cytometry studies demonstrated that MRP4, but not MRP5, was functional. The expression of the organic cation transporter 1 (OCT1), involved in sorafenib uptake, was MOLM-13>OCI-AML2≈HL-60 and non detectable in HEL and K-562. Transfection of HEL cells with OCT1 increased the sensitivity of these cells to sorafenib, whereas inactive genetic variants failed to induce this change. Conclusion Together with changes in the expression/function of receptors targeted by TKIs, the expression of plasma membrane transporters involved in sorafenib uptake/efflux may affect the response of leukemia cells to this drug.
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42
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Wang L, Min Z, Wang X, Hu M, Song D, Ren Z, Cheng Y, Wang Y. Arsenic trioxide and sorafenib combination therapy for human hepatocellular carcinoma functions via up-regulation of TNF-related apoptosis-inducing ligand. Oncol Lett 2018; 16:3341-3350. [PMID: 30127933 DOI: 10.3892/ol.2018.8981] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 04/27/2018] [Indexed: 12/18/2022] Open
Abstract
The survival benefits of sorafenib treatment for patients with hepatocellular carcinoma (HCC) are limited due to drug resistance and side effects. Therefore, combinations of sorafenib with other low toxicity drugs, including arsenic trioxide (As2O3) require investigation. The present study aimed to evaluate the potency of apoptosis-induction by As2O3/sorafenib treatment in HCC cell lines, Huh7, 97H and freshly-isolated HCC cells, and also to elucidate the underlying mechanism. A total of 10 patients with HCC were enrolled in the present study. Freshly-isolated HCC cells were purified from HCC tissues collected at surgery. HCC-cell apoptosis was measured by flow cytometry using proprium iodide/Annexin-V staining. The impacts of As2O3 and/or sorafenib on Huh7, 97H and fresh-isolated HCC-cell proliferation were evaluated by Cell Counting Kit-8 assay. The expression of TNF-related apoptosis-inducing ligand (TRAIL) was determined by reverse transcription-quantitative polymerase chain reaction and western blotting. The downregulation of TRAIL protein expression was achieved using small interfering RNA. The combination of As2O3 and sorafenib had anti-proliferative and pro-apoptotic effects in the liver cancer cell line, Huh7, via increased expression of TRAIL, but not in 97H cells. TRAIL-knockdown increased the drug-resistance of Huh7 cells. Freshly-isolated HCC cells were more sensitive to the As2O3 and sorafenib combination than the single drug treatments. Overall, the combination of As2O3 and sorafenib demonstrated potent anti-tumor activity in Huh7 and freshly-isolated HCC cells via a TRAIL-dependent pathway. This may be a potential therapeutic approach for advanced HCC treatment.
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Affiliation(s)
- Lingyan Wang
- Institute of Clinical Science, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China.,Biomedical Research Center, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China.,Shanghai Institute of Clinical Bioinformatics, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Zhihui Min
- Institute of Clinical Science, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China.,Biomedical Research Center, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China.,Shanghai Institute of Clinical Bioinformatics, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Xiangdong Wang
- Institute of Clinical Science, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China.,Biomedical Research Center, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China.,Shanghai Institute of Clinical Bioinformatics, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Mushuang Hu
- Institute of Clinical Science, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Dongli Song
- Institute of Clinical Science, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China.,Biomedical Research Center, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China.,Shanghai Institute of Clinical Bioinformatics, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Zhenggang Ren
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Yunfeng Cheng
- Institute of Clinical Science, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China.,Biomedical Research Center, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China.,Shanghai Institute of Clinical Bioinformatics, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China.,Department of Hematology, Zhongshan Hospital Qingpu Branch, Shanghai 201700, P.R. China
| | - Yanhong Wang
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
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43
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Yang X, Wang J. Precision therapy for acute myeloid leukemia. J Hematol Oncol 2018; 11:3. [PMID: 29301553 PMCID: PMC5755341 DOI: 10.1186/s13045-017-0543-7] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 12/19/2017] [Indexed: 01/21/2023] Open
Abstract
Acute myeloid leukemia (AML) is a molecularly and clinically heterogeneous disease. Despite advances in understanding the pathogenesis of AML, the standard therapy remained nearly unchanged over the past three decades. With the poor survival for older patients and high relapse rate, multiple studies are ongoing to address this important issue. Novel therapies for AML, including the refinements of conventional cytotoxic chemotherapies and genetic and epigenetic targeted drugs, as well as immunotherapies, have been developed in recent years. Here, we present a mechanism-based review of some promising new drugs with clinical efficacy, focus on targeted drugs that are most potential to pave the road to success, and put forward the major challenges in promoting the precision therapy for AML.
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Affiliation(s)
- Xue Yang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Jianxiang Wang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China.
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44
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Kim M, Williams S. Midostaurin in Combination With Standard Chemotherapy for Treatment of Newly Diagnosed FMS-Like Tyrosine Kinase 3 (FLT3) Mutation–Positive Acute Myeloid Leukemia. Ann Pharmacother 2017; 52:364-369. [DOI: 10.1177/1060028017747900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Miryoung Kim
- The Arthur G James Cancer Hospital at The Ohio State University, Columbus, OH, USA
| | - Sherry Williams
- The Arthur G James Cancer Hospital at The Ohio State University, Columbus, OH, USA
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45
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DiNardo CD, Stone RM, Medeiros BC. Novel Therapeutics in Acute Myeloid Leukemia. Am Soc Clin Oncol Educ Book 2017; 37:495-503. [PMID: 28561688 DOI: 10.1200/edbk_175401] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
In this review, we focus on three key areas in acute myeloid leukemia (AML) developmental therapeutics: FLT3 inhibitors, IDH inhibitors, and drugs that may be particularly beneficial in secondary AML.
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Affiliation(s)
- Courtney D DiNardo
- From the Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Richard M Stone
- From the Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Bruno C Medeiros
- From the Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Medicine, Stanford University School of Medicine, Stanford, CA
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46
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Short NJ, Ravandi F. Acute Myeloid Leukemia: Past, Present, and Prospects for the Future. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 16 Suppl:S25-9. [PMID: 27521321 DOI: 10.1016/j.clml.2016.02.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 02/09/2016] [Indexed: 10/21/2022]
Abstract
Dose intensification of chemotherapy and the combination of a third cytotoxic agent with standard cytarabine and anthracycline-based induction chemotherapy have led to improved outcomes in select groups of patients with acute myeloid leukemia (AML). However, despite some progress in this area, it appears that we might be reaching the limit of cytotoxic chemotherapy for the treatment of AML, especially in older patients and in those with poor-risk features whose disease tends to be relatively chemoresistant. Recent advances in the molecular classification of AML have identified pathogenic pathways that can be exploited with targeted agents and rational drug combinations. Novel nontransplant immunotherapies also show promise in the treatment of AML, especially when a targetable molecular aberration cannot be identified. Sensitive methods for detecting minimal residual disease in AML have not only improved prognostication of these patients but also provide the framework for risk-adapted strategies in this heterogeneous disease.
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Affiliation(s)
- Nicholas J Short
- Division of Cancer Medicine, University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Farhad Ravandi
- Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston, TX.
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47
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Lam SSY, He ABL, Leung AYH. Treatment of acute myeloid leukemia in the next decade – Towards real-time functional testing and personalized medicine. Blood Rev 2017; 31:418-425. [DOI: 10.1016/j.blre.2017.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 07/23/2017] [Accepted: 08/03/2017] [Indexed: 12/20/2022]
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48
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Her Z, Yong KSM, Paramasivam K, Tan WWS, Chan XY, Tan SY, Liu M, Fan Y, Linn YC, Hui KM, Surana U, Chen Q. An improved pre-clinical patient-derived liquid xenograft mouse model for acute myeloid leukemia. J Hematol Oncol 2017; 10:162. [PMID: 28985760 PMCID: PMC5639594 DOI: 10.1186/s13045-017-0532-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 09/29/2017] [Indexed: 11/10/2022] Open
Abstract
Background Xenotransplantation of patient-derived AML (acute myeloid leukemia) cells in NOD-scid Il2rγnull (NSG) mice is the method of choice for evaluating this human hematologic malignancy. However, existing models constructed using intravenous injection in adult or newborn NSG mice have inferior engraftment efficiency, poor peripheral blood engraftment, or are difficult to construct. Methods Here, we describe an improved AML xenograft model where primary human AML cells were injected into NSG newborn pups intrahepatically. Results Introduction of primary cells from AML patients resulted in high levels of engraftment in peripheral blood, spleen, and bone marrow (BM) of recipient mice. The phenotype of engrafted AML cells remained unaltered during serial transplantation. The mice developed features that are consistent with human AML including spleen enlargement and infiltration of AML cells into multiple organs. Importantly, we demonstrated that although leukemic stem cell activity is enriched and mediated by CD34+CD117+ subpopulation, CD34+CD117− subpopulation can acquire CD34+CD117+ phenotype through de-differentiation. Lastly, we evaluated the therapeutic potential of Sorafenib and Regorafenib in this AML model and found that periphery and spleen AML cells are sensitive to these treatments, whereas BM provides a protective environment to AML. Conclusions Collectively, our improved model is robust, easy-to-construct, and reliable for pre-clinical AML studies. Electronic supplementary material The online version of this article (10.1186/s13045-017-0532-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zhisheng Her
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Proteos, 61 Biopolis Drive, Singapore, 138673, Singapore
| | - Kylie Su Mei Yong
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Proteos, 61 Biopolis Drive, Singapore, 138673, Singapore
| | - Kathirvel Paramasivam
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Proteos, 61 Biopolis Drive, Singapore, 138673, Singapore
| | - Wilson Wei Sheng Tan
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Proteos, 61 Biopolis Drive, Singapore, 138673, Singapore
| | - Xue Ying Chan
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Proteos, 61 Biopolis Drive, Singapore, 138673, Singapore
| | - Sue Yee Tan
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Proteos, 61 Biopolis Drive, Singapore, 138673, Singapore
| | - Min Liu
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Proteos, 61 Biopolis Drive, Singapore, 138673, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yong Fan
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Yeh Ching Linn
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Kam Man Hui
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Proteos, 61 Biopolis Drive, Singapore, 138673, Singapore.,Division of Cellular and Molecular Research, National Cancer Centre, Singapore, Singapore
| | - Uttam Surana
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Proteos, 61 Biopolis Drive, Singapore, 138673, Singapore. .,Department of Pharmacology, National University of Singapore, Singapore, Singapore. .,Bioprocessing Technology Institute, Agency for Science, Technology and Research, Singapore, Singapore.
| | - Qingfeng Chen
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Proteos, 61 Biopolis Drive, Singapore, 138673, Singapore. .,Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China. .,Division of Cellular and Molecular Research, National Cancer Centre, Singapore, Singapore. .,Department of Microbiology and Immunology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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Abstract
OPINION STATEMENT Approximately 40-45% of younger and 10-20% of older adults with acute myeloid leukemia (AML) will be cured with current standard chemotherapy. The outlook is particularly gloomy for patients with relapsed and/or refractory disease (cure rates no higher than 10%). Allogeneic hematopoietic stem cell transplantation (HSCT), the only realistic hope of cure for these patients, is an option for only a minority. In recent years, much has been learned about the genomic and epigenomic landscapes of AML, and the clonal architecture of both de novo and secondary AML has begun to be unraveled. These advances have paved the way for rational drug development as new "drugable" targets have emerged. Although no new drug has been approved for AML in over four decades, with the exception of gemtuzumab ozogamycin, which was subsequently withdrawn, there is progress on the horizon with the possible regulatory approval soon of agents such as CPX-351 and midostaurin, the Food and Drug Administration "breakthrough" designation granted to venetoclax, and promising agents such as the IDH inhibitors AG-221 and AG-120, the smoothened inhibitor glasdegib and the histone deacetylase inhibitor pracinostat. In our practice, we treat most patients with relapsed/refractory AML on clinical trials, taking into consideration their prior treatment history and response to the same. We utilize targeted sequencing of genes frequently mutated in AML to identify "actionable" mutations, e.g., in FLT3 or IDH1/2, and incorporate small-molecule inhibitors of these oncogenic kinases into our therapeutic regimens whenever possible. In the absence of actionable mutations, we rationally combine conventional agents with other novel therapies such as monoclonal antibodies and other targeted drugs. For fit patients up to the age of 65, we often use high-dose cytarabine-containing backbone regimens. For older or unfit patients, we prefer hypomethylating agent-based therapy. Finally, all patients with relapsed/refractory AML are evaluated for allogeneic HSCT.
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