1
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Jen WY, Kantarjian H, Kadia TM, DiNardo CD, Issa GC, Short NJ, Yilmaz M, Borthakur G, Ravandi F, Daver NG. Combination therapy with novel agents for acute myeloid leukaemia: Insights into treatment of a heterogenous disease. Br J Haematol 2024; 205:30-47. [PMID: 38724457 DOI: 10.1111/bjh.19519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/27/2024] [Indexed: 07/13/2024]
Abstract
The treatment landscape of acute myeloid leukaemia (AML) is evolving rapidly. Venetoclax in combination with intensive chemotherapy or doublets or triplets with targeted or immune therapies is the focus of numerous ongoing trials. The development of mutation-targeted therapies has greatly enhanced the treatment armamentarium, with FLT3 inhibitors and isocitrate dehydrogenase inhibitors improving outcomes in frontline and relapsed/refractory (RR) AML, and menin inhibitors showing efficacy in RR NPM1mut and KMT2A-rearranged AML. With so many new drugs approved, the number of potential combinatorial approaches to leverage the maximal benefit of these agents has increased dramatically, while at the same time introducing clinical challenges, such as key preclinical and clinical data supporting the development of combinatorial therapy, how to optimally combine or sequence these novel agents, how to optimise dose and duration to maintain safety while enhancing efficacy, the optimal duration of therapy and the role of measurable residual disease in decision-making in both intensive and low-intensity therapy settings. In this review, we will outline the evidence leading to the approval of key agents in AML, their on-label current approvals and how they may be optimally combined in a safe and deliverable fashion to further improve outcomes in AML.
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Affiliation(s)
- Wei-Ying Jen
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ghayas C Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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2
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Shimony S, Garcia JS, Keating J, Chen EC, Luskin MR, Stahl M, Neuberg DS, DeAngelo DJ, Stone RM, Lindsley RC. Molecular ontogeny underlies the benefit of adding venetoclax to hypomethylating agents in newly diagnosed AML patients. Leukemia 2024; 38:1494-1500. [PMID: 38538860 PMCID: PMC11216982 DOI: 10.1038/s41375-024-02230-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/06/2024] [Accepted: 03/11/2024] [Indexed: 07/03/2024]
Abstract
The clinical impact of molecular ontogeny in acute myeloid leukemia (AML) was defined in patients treated with intensive chemotherapy. In a cohort of 314 newly diagnosed AML patients, we evaluated whether molecular ontogeny subgroups have differential benefit of venetoclax (VEN) added to hypomethylating agents (HMA). In secondary ontogeny (n = 115), median overall survival (OS)(14.1 vs. 6.9 months, P = 0.0054), composite complete remission (cCR 61% vs. 18%, P < 0.001) and allogeneic hematopoietic stem cell transplant (alloHCT) (24% vs. 6%, P = 0.02) rates were better in patients treated with HMA + VEN vs. HMA. In contrast, in TP53 AML(n = 111) median OS (5.7 vs. 6.1, P = 0.93), cCR (33% vs. 37%, P = 0.82) and alloHCT rates (15% vs. 8%, P = 0.38) did not differ between HMA + VEN vs. HMA. The benefit of VEN addition in the secondary group was preserved after adjustment for significant clinicopathologic variables (HR 0.59 [95% CI 0.38-0.94], P = 0.025). The OS benefit of HMA + VEN in secondary ontogeny was similar in those with vs. without splicing mutations (P = 0.92). Secondary ontogeny AML highlights a group of patients whose disease is selectively responsive to VEN added to HMA and that the addition of VEN has no clinical benefit in TP53-mutated AML.
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MESH Headings
- Humans
- Bridged Bicyclo Compounds, Heterocyclic/therapeutic use
- Bridged Bicyclo Compounds, Heterocyclic/administration & dosage
- Bridged Bicyclo Compounds, Heterocyclic/pharmacology
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Sulfonamides/therapeutic use
- Sulfonamides/administration & dosage
- Female
- Middle Aged
- Male
- Aged
- Adult
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- DNA Methylation
- Young Adult
- Aged, 80 and over
- Mutation
- Hematopoietic Stem Cell Transplantation
- Survival Rate
- Prognosis
- Tumor Suppressor Protein p53/genetics
- Adolescent
- Remission Induction
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Affiliation(s)
- Shai Shimony
- Division of Hematologic Neoplasia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Rabin Medical Center and Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Jacqueline S Garcia
- Division of Hematologic Neoplasia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Julia Keating
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Evan C Chen
- Division of Hematologic Neoplasia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Marlise R Luskin
- Division of Hematologic Neoplasia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Maximilian Stahl
- Division of Hematologic Neoplasia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Donna S Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Daniel J DeAngelo
- Division of Hematologic Neoplasia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Richard M Stone
- Division of Hematologic Neoplasia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - R Coleman Lindsley
- Division of Hematologic Neoplasia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
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3
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Kaur A, Rojek AE, Symes E, Nawas MT, Patel AA, Patel JL, Sojitra P, Aqil B, Sukhanova M, McNerney ME, Wu LP, Akmatbekov A, Segal J, Tjota MY, Gurbuxani S, Cheng JX, Yeon SY, Ravisankar HV, Fitzpatrick C, Lager A, Drazer MW, Saygin C, Wanjari P, Katsonis P, Lichtarge O, Churpek JE, Ghosh SB, Patel AB, Menon MP, Arber DA, Wang P, Venkataraman G. Real world predictors of response and 24-month survival in high-grade TP53-mutated myeloid neoplasms. Blood Cancer J 2024; 14:99. [PMID: 38890297 PMCID: PMC11189545 DOI: 10.1038/s41408-024-01077-9] [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: 04/08/2024] [Revised: 05/28/2024] [Accepted: 05/30/2024] [Indexed: 06/20/2024] Open
Abstract
Current therapies for high-grade TP53-mutated myeloid neoplasms (≥10% blasts) do not offer a meaningful survival benefit except allogeneic stem cell transplantation in the minority who achieve a complete response to first line therapy (CR1). To identify reliable pre-therapy predictors of complete response to first-line therapy (CR1) and outcomes, we assembled a cohort of 242 individuals with TP53-mutated myeloid neoplasms and ≥10% blasts with well-annotated clinical, molecular and pathology data. Key outcomes examined were CR1 & 24-month survival (OS24). In this elderly cohort (median age 68.2 years) with 74.0% receiving frontline non-intensive regimens (hypomethylating agents +/- venetoclax), the overall cohort CR1 rate was 25.6% (50/195). We additionally identified several pre-therapy factors predictive of inferior CR1 including male gender (P = 0.026), ≥2 autosomal monosomies (P < 0.001), -17/17p (P = 0.011), multi-hit TP53 allelic state (P < 0.001) and CUX1 co-alterations (P = 0.010). In univariable analysis of the entire cohort, inferior OS24 was predicated by ≥2 monosomies (P = 0.004), TP53 VAF > 25% (P = 0.002), TP53 splice junction mutations (P = 0.007) and antecedent treated myeloid neoplasm (P = 0.001). In addition, mutations/deletions in CUX1, U2AF1, EZH2, TET2, CBL, or KRAS ('EPI6' signature) predicted inferior OS24 (HR = 2.0 [1.5-2.8]; P < 0.0001). In a subgroup analysis of HMA +/-Ven treated individuals (N = 144), TP53 VAF and monosomies did not impact OS24. A risk score for HMA +/-Ven treated individuals incorporating three pre-therapy predictors including TP53 splice junction mutations, EPI6 and antecedent treated myeloid neoplasm stratified 3 prognostic distinct groups: intermediate, intermediate-poor, and poor with significantly different median (12.8, 6.0, 4.3 months) and 24-month (20.9%, 5.7%, 0.5%) survival (P < 0.0001). For the first time, in a seemingly monolithic high-risk cohort, our data identifies several baseline factors that predict response and 24-month survival.
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Affiliation(s)
- Amandeep Kaur
- Department of Pathology, Sections of Hematopathology and Genomic Pathology, University of Chicago Medicine, Chicago, IL, USA
| | - Alexandra E Rojek
- Hematology/Oncology Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Emily Symes
- Department of Pathology, Sections of Hematopathology and Genomic Pathology, University of Chicago Medicine, Chicago, IL, USA
| | - Mariam T Nawas
- Hematology/Oncology Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Anand A Patel
- Hematology/Oncology Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Jay L Patel
- Departments of Pathology and Hematology/Oncology, University of Utah/ARUP, Salt Lake City, UT, USA
| | - Payal Sojitra
- Department of Pathology, Rutgers Robert Wood Johnson Medical School New Brunswick NJ, New Brunswick, NJ, USA
| | - Barina Aqil
- Department of Pathology, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Madina Sukhanova
- Department of Pathology, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Megan E McNerney
- Department of Pathology, Sections of Hematopathology and Genomic Pathology, University of Chicago Medicine, Chicago, IL, USA
| | - Leo P Wu
- Department of Pathology, Sections of Hematopathology and Genomic Pathology, University of Chicago Medicine, Chicago, IL, USA
| | - Aibek Akmatbekov
- Department of Pathology, Sections of Hematopathology and Genomic Pathology, University of Chicago Medicine, Chicago, IL, USA
| | - Jeremy Segal
- Department of Pathology, Sections of Hematopathology and Genomic Pathology, University of Chicago Medicine, Chicago, IL, USA
| | - Melissa Y Tjota
- Department of Pathology, Sections of Hematopathology and Genomic Pathology, University of Chicago Medicine, Chicago, IL, USA
| | - Sandeep Gurbuxani
- Department of Pathology, Sections of Hematopathology and Genomic Pathology, University of Chicago Medicine, Chicago, IL, USA
| | - Jason X Cheng
- Department of Pathology, Sections of Hematopathology and Genomic Pathology, University of Chicago Medicine, Chicago, IL, USA
| | - Su-Yeon Yeon
- Department of Pathology, University of Illinois, Chicago, IL, USA
| | - Harini V Ravisankar
- Department of Pathology, Sections of Hematopathology and Genomic Pathology, University of Chicago Medicine, Chicago, IL, USA
| | - Carrie Fitzpatrick
- Department of Pathology, Sections of Hematopathology and Genomic Pathology, University of Chicago Medicine, Chicago, IL, USA
| | - Angela Lager
- Hematology/Oncology Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Michael W Drazer
- Hematology/Oncology Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Caner Saygin
- Hematology/Oncology Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Pankhuri Wanjari
- Department of Pathology, Sections of Hematopathology and Genomic Pathology, University of Chicago Medicine, Chicago, IL, USA
| | | | - Olivier Lichtarge
- Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Jane E Churpek
- Division of Hematology, Department of Medicine, University of Wisconsin, Madison, WI, USA
| | - Sharmila B Ghosh
- Department of Pathology, Henry Ford Health Systems, Detroit, MI, USA
| | - Ami B Patel
- Departments of Pathology and Hematology/Oncology, University of Utah/ARUP, Salt Lake City, UT, USA
| | - Madhu P Menon
- Departments of Pathology and Hematology/Oncology, University of Utah/ARUP, Salt Lake City, UT, USA
| | - Daniel A Arber
- Department of Pathology, Sections of Hematopathology and Genomic Pathology, University of Chicago Medicine, Chicago, IL, USA
| | - Peng Wang
- Department of Pathology, Sections of Hematopathology and Genomic Pathology, University of Chicago Medicine, Chicago, IL, USA
| | - Girish Venkataraman
- Department of Pathology, Sections of Hematopathology and Genomic Pathology, University of Chicago Medicine, Chicago, IL, USA.
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4
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Pereira MP, Herrity E, Kim DDH. TP53-mutated acute myeloid leukemia and myelodysplastic syndrome: biology, treatment challenges, and upcoming approaches. Ann Hematol 2024; 103:1049-1067. [PMID: 37770618 DOI: 10.1007/s00277-023-05462-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/17/2023] [Indexed: 09/30/2023]
Abstract
Improved understanding of TP53 biology and the clinicopathological features of TP53-mutated myeloid neoplasms has led to the recognition of TP53-mutated acute myeloid leukemia/myelodysplastic syndrome (TP53m AML/MDS) as a unique entity, characterized by dismal outcomes following conventional therapies. Several clinical trials have investigated combinations of emerging therapies for these patients with the poorest molecular prognosis among myeloid neoplasms. Although some emerging therapies have shown improvement in overall response rates, this has not translated into better overall survival, hence the notion that p53 remains an elusive target. New therapeutic strategies, including novel targeted therapies, immune checkpoint inhibitors, and monoclonal antibodies, represent a shift away from cytotoxic and hypomethylating-based therapies, towards approaches combining non-immune and novel immune therapeutic strategies. The triple combination of azacitidine and venetoclax with either magrolimab or eprenetapopt have demonstrated safety in early trials, with phase III trials currently underway, and promising interim clinical results. This review compiles background on TP53 biology, available and emerging therapies along with their mechanisms of action for the TP53m disease entity, current treatment challenges, and recently published data and status of ongoing clinical trials for TP53m AML/MDS.
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Affiliation(s)
- Mariana Pinto Pereira
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, M5G2M9, Toronto, ON, Canada
| | - Elizabeth Herrity
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, M5G2M9, Toronto, ON, Canada
| | - Dennis D H Kim
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, M5G2M9, Toronto, ON, Canada.
- Leukemia Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada.
- Department of Hematology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
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5
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Bataller A, Bazinet A, DiNardo CD, Maiti A, Borthakur G, Daver NG, Short NJ, Jabbour EJ, Issa GC, Pemmaraju N, Yilmaz M, Montalban-Bravo G, Takahashi K, Loghavi S, Garcia-Manero G, Ravandi F, Kantarjian HM, Kadia TM. Prognostic risk signature in patients with acute myeloid leukemia treated with hypomethylating agents and venetoclax. Blood Adv 2024; 8:927-935. [PMID: 38113472 PMCID: PMC10877112 DOI: 10.1182/bloodadvances.2023011757] [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: 09/22/2023] [Revised: 10/30/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
ABSTRACT Hypomethylating agents (HMAs) and venetoclax (Ven) represent the standard of care for patients with acute myeloid leukemia (AML) who are ineligible for intensive chemotherapy. However, the European LeukemiaNet (ELN) risk classifications have been validated for patients treated with intensive therapy. In this study, we validate a recently proposed new molecular prognostic risk signature (mPRS) for patients with AML treated with HMAs and Ven. This classification allocated patients to favorable, intermediate (N/KRAS or FLT3-internal tandem duplication mutations), and lower (TP53 mutations) benefit groups. We retrospectively analyzed 159 patients treated with HMA and Ven. The mPRS classification allocated 74 (47%), 31 (19%), and 54 (34%) patients to the higher, intermediate, and lower-benefit groups, respectively. The overall response rate was 71% (86%, 54%, and 59% in the higher, intermediate, and lower-benefit groups, respectively). The median overall survival (OS) and event-free survival (EFS) times were 30 and 19 months, respectively, in the higher-benefit group; 12 and 8 months in the intermediate-benefit group; and 5 and 4 months in the lower-benefit group (P < .001). The C-index for OS and EFS was higher when stratifying patients according to mPRS classification than with the ELN 2022 classification. The 2-year cumulative incidence of relapse was 35%, 70%, and 60% in the higher, intermediate, and lower-benefit groups, respectively (P = .005). The mPRS classification accurately segregated groups of patients with AML treated with HMA plus Ven. In these patients, N/KRAS and TP53 mutations appear to negatively affect outcomes; therefore, new treatment approaches are warranted.
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Affiliation(s)
- Alex Bataller
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alexandre Bazinet
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Courtney D. DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Abhishek Maiti
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naval G. Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nicholas J. Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elias J. Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ghayas C. Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Koichi Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hagop M. Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tapan M. Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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6
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Badar T, Nanaa A, Atallah E, Shallis RM, Guilherme SDCC, Goldberg AD, Saliba AN, Patel A, Bewersdorf JP, DuVall AS, Bradshaw D, Abaza Y, Murthy GSG, Palmisiano N, Zeidan AM, Kota V, Litzow MR. Comparing venetoclax in combination with hypomethylating agents to hypomethylating agent-based therapies for treatment naive TP53-mutated acute myeloid leukemia: results from the Consortium on Myeloid Malignancies and Neoplastic Diseases (COMMAND). Blood Cancer J 2024; 14:32. [PMID: 38378617 PMCID: PMC10879201 DOI: 10.1038/s41408-024-01000-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 02/22/2024] Open
Affiliation(s)
- Talha Badar
- Division of Hematology-Oncology, Mayo Clinic, Jacksonville, FL, USA.
| | - Ahmad Nanaa
- Division of Hematology-Oncology, Mayo Clinic, Jacksonville, FL, USA
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Ehab Atallah
- Division of Hematology and Medical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rory M Shallis
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Aaron D Goldberg
- Division of Hematologic Malignancies, Department of Medicine Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Anand Patel
- Section of Hematology and Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Jan P Bewersdorf
- Division of Hematologic Malignancies, Department of Medicine Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Adam S DuVall
- Division of Hematology and Oncology, Georgia Cancer Center, Augusta, GA, USA
| | - Danielle Bradshaw
- Division of Hematology and Oncology, Georgia Cancer Center, Augusta, GA, USA
| | - Yasmin Abaza
- Robert H. Lurie Comprehensive Cancer Center, Northwestern Hospital, Chicago, IL, USA
| | | | - Neil Palmisiano
- Division of Hematology and Oncology, Jefferson University Hospital, Philadelphia, PA, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Vamsi Kota
- Division of Hematology and Oncology, Georgia Cancer Center, Augusta, GA, USA
| | - Mark R Litzow
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
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7
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Stafylidis C, Vlachopoulou D, Kontandreopoulou CN, Diamantopoulos PΤ. Unmet Horizons: Assessing the Challenges in the Treatment of TP53-Mutated Acute Myeloid Leukemia. J Clin Med 2024; 13:1082. [PMID: 38398394 PMCID: PMC10889132 DOI: 10.3390/jcm13041082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
Acute myeloid leukemia (AML) remains a challenging hematologic malignancy. The presence of TP53 mutations in AML poses a therapeutic challenge, considering that standard treatments face significant setbacks in achieving meaningful responses. There is a pressing need for the development of innovative treatment modalities to overcome resistance to conventional treatments attributable to the unique biology of TP53-mutated (TP53mut) AML. This review underscores the role of TP53 mutations in AML, examines the current landscape of treatment options, and highlights novel therapeutic approaches, including targeted therapies, combination regimens, and emerging immunotherapies, as well as agents being explored in preclinical studies according to their potential to address the unique hurdles posed by TP53mut AML.
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Affiliation(s)
| | | | | | - Panagiotis Τ. Diamantopoulos
- Hematology Unit, First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (C.S.); (D.V.); (C.-N.K.)
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8
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Nawas MT, Kosuri S. Utility or futility? A contemporary approach to allogeneic hematopoietic cell transplantation for TP53-mutated MDS/AML. Blood Adv 2024; 8:553-561. [PMID: 38096805 PMCID: PMC10835231 DOI: 10.1182/bloodadvances.2023010417] [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: 09/26/2023] [Accepted: 12/07/2023] [Indexed: 01/25/2024] Open
Abstract
ABSTRACT TP 53-mutated myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) are among the most lethal malignancies, characterized by dismal outcomes with currently available therapies. Allogeneic hematopoietic cell transplantation (allo-HCT) is widely thought to be the only treatment option to offer durable disease control. However, outcomes with allo-HCT in this context are quite poor, calling into question the utility of transplantation. In this review, we summarize the latest data on allo-HCT outcomes in this subgroup, evaluating the limitations of available evidence; we review the molecular heterogeneity of this disease, delineating outcomes based on distinct biological features to aid in patient selection; and we critically examine whether allo-HCT should be routinely applied in this disease on the basis of currently available data. We propose that the exceptionally poor outcomes of patients with TP53-mutated MDS/AML with biallelic loss and/or adverse-risk cytogenetics should motivate randomized-controlled trials of HCT vs non-HCT to determine whether transplantation can prolong survival and/or positively impact other clinically relevant outcomes such as patient-reported outcomes or healthcare resource utilization in this disease subset. Without dedicated prospective randomized trials, selecting who may actually derive benefit from allo-HCT for TP53-mutated MDS/AML can be described as ambiguous guesswork and must be carefully contemplated.
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Affiliation(s)
- Mariam T. Nawas
- Hematopoietic Cellular Therapy Program, Department of Medicine, The University of Chicago Medicine, Chicago, IL
| | - Satyajit Kosuri
- Hematopoietic Cellular Therapy Program, Department of Medicine, The University of Chicago Medicine, Chicago, IL
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9
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Hernández-Sánchez A, Bullinger L. Recent advances in precision medicine for acute myeloid leukemia. Curr Opin Oncol 2023; 35:581-588. [PMID: 37621173 DOI: 10.1097/cco.0000000000000965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
PURPOSE OF REVIEW Acute myeloid leukemia (AML) is a heterogeneous disease, in which treatment response and patient survival are highly conditioned by the leukemia biology. The aim of this review is to summarize recent advances in AML classification, risk stratification models, measurable residual disease (MRD) and the increasing number of treatment options that are paving the way towards precision medicine in AML. RECENT FINDINGS AML classification and risk stratification were recently updated by incorporating novel molecular markers that are important for diagnosis and outcome prediction. In addition, the impact of co-mutational patterns is under investigation and novel approaches using machine learning algorithms are starting to be used for individualized risk estimation. Molecular markers are also becoming useful in predicting response to non-intensive treatments. MRD informs of treatment response with high sensitivity, allowing dynamic patient risk assessment and early intervention. Finally, important advances were made in AML therapy, with an increasing number of targeted therapies becoming available and many novel treatment approaches being under development with promising early results. SUMMARY A better understanding of AML biology is leading to improved risk stratification and important advances in treatments, which are allowing the development of precision medicine in AML at an unprecedented pace.
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Affiliation(s)
- Alberto Hernández-Sánchez
- University Hospital of Salamanca
- Institute of Biomedical Research of Salamanca (IBSAL) , Salamanca, Spain
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10
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Patel SA, Cerny J, Gerber WK, Ramanathan M, Ediriwickrema A, Tanenbaum B, Hutchinson L, Meng X, Flahive J, Barton B, Gillis‐Smith AJ, Suzuki S, Khedr S, Selove W, Higgins AW, Miron PM, Simin K, Woda B, Gerber JM. Prognostic heterogeneity and clonal dynamics within distinct subgroups of myelodysplastic syndrome and acute myeloid leukemia with TP53 disruptions. EJHAEM 2023; 4:1059-1070. [PMID: 38024632 PMCID: PMC10660125 DOI: 10.1002/jha2.791] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/01/2023] [Accepted: 09/04/2023] [Indexed: 12/01/2023]
Abstract
TP53 aberrations constitute the highest risk subset of myelodysplastic neoplasms (MDS) and acute myeloid leukemia (AML). The International Consensus Classification questions the blast threshold between MDS and AML. In this study, we assess the distinction between MDS and AML for 76 patients with TP53 aberrations. We observed no significant differences between MDS and AML regarding TP53 genomics. Median overall survival (OS) was 223 days for the entire group, but prognostic discrimination within subgroups showed the most inferior OS (46 days) for AML with multihit allelic state plus TP53 variant allele frequency (VAF) > 50%. In multivariate analysis, unadjusted Cox models revealed the following variables as independent risk factors for mortality: AML (vs. MDS) (hazard ratio [HR]: 2.50, confidence interval [CI]: 1.4-4.4, p = 0.001), complex karyotype (HR: 3.00, CI: 1.4-6.1, p = 0.003), multihit status (HR: 2.30, CI 1.3-4.2, p = 0.005), and absence of hematopoietic cell transplant (HCT) (HR: 3.90, CI: 1.8-8.9, p = 0.0009). Clonal dynamic modeling showed a significant reduction in TP53 VAF with front-line hypomethylating agents. These findings clarify the impact of specific covariates on outcomes of TP53-aberrant myeloid neoplasms, irrespective of the diagnosis of MDS versus AML, and may influence HCT decisions.
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Affiliation(s)
- Shyam A. Patel
- Division of Hematology and Oncology, Department of MedicineUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Jan Cerny
- Division of Hematology and Oncology, Department of MedicineUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - William K. Gerber
- Division of Hematology and Oncology, Department of MedicineUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Muthalagu Ramanathan
- Division of Hematology and Oncology, Department of MedicineUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Asiri Ediriwickrema
- Institute for Stem Cell Biology & Regenerative Medicine; Division of Hematology, Department of MedicineStanford UniversityStanfordCaliforniaUnited States
| | - Benjamin Tanenbaum
- Division of Hematology and Oncology, Department of MedicineUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Lloyd Hutchinson
- Department of PathologyUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Xiuling Meng
- Department of PathologyUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Julie Flahive
- Department of Population & Quantitative Health SciencesUMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Bruce Barton
- Department of Population & Quantitative Health SciencesUMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Andrew J. Gillis‐Smith
- Division of Hematology and Oncology, Department of MedicineUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Sakiko Suzuki
- Division of Hematology and Oncology, Department of MedicineUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Salwa Khedr
- Department of PathologyUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - William Selove
- Department of PathologyUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Anne W. Higgins
- Department of PathologyUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Patricia M. Miron
- Department of PathologyUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Karl Simin
- Dept. of MolecularCell & Cancer BiologyUMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Bruce Woda
- Department of PathologyUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Jonathan M. Gerber
- Division of Hematology and Oncology, Department of MedicineUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
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Shin DY. TP53 Mutation in Acute Myeloid Leukemia: An Old Foe Revisited. Cancers (Basel) 2023; 15:4816. [PMID: 37835510 PMCID: PMC10571655 DOI: 10.3390/cancers15194816] [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: 08/02/2023] [Revised: 09/20/2023] [Accepted: 09/29/2023] [Indexed: 10/15/2023] Open
Abstract
INTRODUCTION TP53 is the most commonly mutated gene in human cancers and was the first tumor suppressor gene to be discovered in the history of medical science. Mutations in the TP53 gene occur at various genetic locations and exhibit significant heterogeneity among patients. Mutations occurring primarily within the DNA-binding domain of TP53 result in the loss of the p53 protein's DNA-binding capability. However, a complex phenotypic landscape often combines gain-of-function, dominant negative, or altered specificity features. This complexity poses a significant challenge in developing an effective treatment strategy, which eradicates TP53-mutated cancer clones. This review summarizes the current understanding of TP53 mutations in AML and their implications. TP53 mutation in AML: In patients with acute myeloid leukemia (AML), six hotspot mutations (R175H, G245S, R248Q/W, R249S, R273H/S, and R282W) within the DNA-binding domain are common. TP53 mutations are frequently associated with a complex karyotype and subgroups of therapy-related or secondary AML. The presence of TP53 mutation is considered as a poor prognostic factor. TP53-mutated AML is even classified as a distinct subgroup of AML by itself, as TP53-mutated AML exhibits a significantly distinct landscape in terms of co-mutation and gene expression profiles compared with wildtype (WT)-TP53 AML. CLINICAL IMPLICATIONS To better predict the prognosis in cancer patients with different TP53 mutations, several predictive scoring systems have been proposed based on screening experiments, to assess the aggressiveness of TP53-mutated cancer cells. Among those scoring systems, a relative fitness score (RFS) could be applied to AML patients with TP53 mutations in terms of overall survival (OS) and event-free survival (EFS). The current standard treatment, which includes cytotoxic chemotherapy and allogeneic hematopoietic stem cell transplantation, is largely ineffective for patients with TP53-mutated AML. Consequently, most patients with TP53-mutated AML succumb to leukemia within several months, despite active anticancer treatment. Decitabine, a hypomethylating agent, is known to be relatively effective in patients with AML. Numerous trials are ongoing to investigate the effects of novel drugs combined with hypomethylating agents, TP53-targeting agents or immunologic agents. CONCLUSIONS Developing an effective treatment strategy for TP53-mutated AML through innovative and multidisciplinary research is an urgent task. Directly targeting mutated TP53 holds promise as an approach to combating TP53-mutated AML, and recent developments in immunologic agents for AML offer hope in this field.
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Affiliation(s)
- Dong-Yeop Shin
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea; ; Tel.: +82-2-2072-7209; Fax: +82-2-762-9662
- Center for Medical Innovation, Biomedical Research Institute, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
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12
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Chen EC, Garcia JS. Immunotherapy for Acute Myeloid Leukemia: Current Trends, Challenges, and Strategies. Acta Haematol 2023; 147:198-218. [PMID: 37673048 DOI: 10.1159/000533990] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 09/03/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND In the past decade, there have been significant breakthroughs in immunotherapies for B-cell lymphoid malignancies and multiple myeloma, but progress has been much less for acute myeloid leukemia (AML). Nevertheless, challenge begets innovation and several therapeutic strategies are under investigation. SUMMARY In this review, we review the state of the art in AML immunotherapy including CD33- and CD123-targeted agents, immune checkpoint inhibition, and adoptive cell therapy strategies. We also share conceptual frameworks for approaching the growing catalog of investigational AML immunotherapies and propose future directions for the field. KEY MESSAGES Immunotherapies for AML face significant challenges but novel strategies are in development.
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Affiliation(s)
- Evan C Chen
- Department of Medical Oncology, Division of Leukemia, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jacqueline S Garcia
- Department of Medical Oncology, Division of Leukemia, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Testa U, Castelli G, Pelosi E. TP53-Mutated Myelodysplasia and Acute Myeloid Leukemia. Mediterr J Hematol Infect Dis 2023; 15:e2023038. [PMID: 37435040 PMCID: PMC10332352 DOI: 10.4084/mjhid.2023.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/01/2023] [Indexed: 07/13/2023] Open
Abstract
TP53-mutated myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) form a distinct and heterogeneous group of myeloid malignancies associated with poor outcomes. Studies carried out in the last years have in part elucidated the complex role played by TP53 mutations in the pathogenesis of these myeloid disorders and in the mechanisms of drug resistance. A consistent number of studies has shown that some molecular parameters, such as the presence of a single or multiple TP53 mutations, the presence of concomitant TP53 deletions, the association with co-occurring mutations, the clonal size of TP53 mutations, the involvement of a single (monoallelic) or of both TP53 alleles (biallelic) and the cytogenetic architecture of concomitant chromosome abnormalities are major determinants of outcomes of patients. The limited response of these patients to standard treatments, including induction chemotherapy, hypomethylating agents and venetoclax-based therapies and the discovery of an immune dysregulation have induced a shift to new emerging therapies, some of which being associated with promising efficacy. The main aim of these novel immune and nonimmune strategies consists in improving survival and in increasing the number of TP53-mutated MDS/AML patients in remission amenable to allogeneic stem cell transplantation.
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Affiliation(s)
- Ugo Testa
- Department of Oncology, Istituto Superiore di Sanità, Rome Italy
| | - Germana Castelli
- Department of Oncology, Istituto Superiore di Sanità, Rome Italy
| | - Elvira Pelosi
- Department of Oncology, Istituto Superiore di Sanità, Rome Italy
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