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Duong VH, Ruppert AS, Mims AS, Borate U, Stein EM, Baer MR, Stock W, Kovacsovics T, Blum W, Arellano ML, Schiller GJ, Olin RL, Foran JM, Litzow MR, Lin TL, Patel PA, Foster MC, Redner RL, Al-Mansour Z, Cogle CR, Swords RT, Collins RH, Vergilio JA, Heerema NA, Rosenberg L, Yocum AO, Marcus S, Chen T, Druggan F, Stefanos M, Gana TJ, Shoben AB, Druker BJ, Burd A, Byrd JC, Levine RL, Boyiadzis MM. Entospletinib with decitabine in acute myeloid leukemia with mutant TP53 or complex karyotype: A phase 2 substudy of the Beat AML Master Trial. Cancer 2023; 129:2308-2320. [PMID: 37078412 PMCID: PMC11225573 DOI: 10.1002/cncr.34780] [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: 10/21/2022] [Revised: 12/24/2022] [Accepted: 01/13/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Patients with acute myeloid leukemia (AML) who have tumor protein p53 (TP53) mutations or a complex karyotype have a poor prognosis, and hypomethylating agents are often used. The authors evaluated the efficacy of entospletinib, an oral inhibitor of spleen tyrosine kinase, combined with decitabine in this patient population. METHODS This was a multicenter, open-label, phase 2 substudy of the Beat AML Master Trial (ClinicalTrials.gov identifier NCT03013998) using a Simon two-stage design. Eligible patients aged 60 years or older who had newly diagnosed AML with mutations in TP53 with or without a complex karyotype (cohort A; n = 45) or had a complex karyotype without TP53 mutation (cohort B; n = 13) received entospletinib 400 mg twice daily with decitabine 20 mg/m2 on days 1-10 every 28 days for up to three induction cycles, followed by up to 11 consolidation cycles, in which decitabine was reduced to days 1-5. Entospletinib maintenance was given for up to 2 years. The primary end point was complete remission (CR) and CR with hematologic improvement by up to six cycles of therapy. RESULTS The composite CR rates for cohorts A and B were 13.3% (95% confidence interval, 5.1%-26.8%) and 30.8% (95% confidence interval, 9.1%-61.4%), respectively. The median duration of response was 7.6 and 8.2 months, respectively, and the median overall survival was 6.5 and 11.5 months, respectively. The study was stopped because the futility boundary was crossed in both cohorts. CONCLUSIONS The combination of entospletinib and decitabine demonstrated activity and was acceptably tolerated in this patient population; however, the CR rates were low, and overall survival was short. Novel treatment strategies for older patients with TP53 mutations and complex karyotype remain an urgent need.
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Affiliation(s)
- Vu H. Duong
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Amy S. Ruppert
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Alice S. Mims
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Uma Borate
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Eytan M. Stein
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Maria R. Baer
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Wendy Stock
- Section of Hematology/Oncology, University of Chicago, Chicago, Illinois, USA
| | - Tibor Kovacsovics
- Huntsman Cancer Institute, The University of Utah, Salt Lake City, Utah, USA
| | - William Blum
- Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | | | - Gary J. Schiller
- David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California, USA
| | - Rebecca L. Olin
- Helen Diller Family Comprehensive Cancer Center, University of California-San Francisco, San Francisco, California, USA
| | - James M. Foran
- Hematology and Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Mark R. Litzow
- Departments of Medical Oncology, Hematology, and Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tara L. Lin
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Prapti A. Patel
- University of Texas Southwestern Medical Center Medical School, Dallas, Texas, USA
| | - Matthew C. Foster
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Robert L. Redner
- Hillman Cancer Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Zeina Al-Mansour
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Ronan T. Swords
- Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Robert H. Collins
- University of Texas Southwestern Medical Center Medical School, Dallas, Texas, USA
| | | | - Nyla A. Heerema
- Department of Pathology, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | | | | | - Sonja Marcus
- The Leukemia & Lymphoma Society, Rye Brook, New York, USA
| | - Timothy Chen
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Franchesca Druggan
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Mona Stefanos
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | | | - Abigail B. Shoben
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Brian J. Druker
- Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Amy Burd
- The Leukemia & Lymphoma Society, Rye Brook, New York, USA
| | - John C. Byrd
- Internal Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Ross L. Levine
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michael M. Boyiadzis
- Hillman Cancer Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Marks JA, Wang X, Fenu EM, Bagg A, Lai C. TP53 in AML and MDS: The new (old) kid on the block. Blood Rev 2023; 60:101055. [PMID: 36841672 DOI: 10.1016/j.blre.2023.101055] [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: 12/25/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/16/2023]
Abstract
MDS and AML are clonal hematopoietic stem cell disorders of increasing incidence, having a variable prognosis based, among others, on co-occurring molecular abnormalities. TP53 mutations are frequently detected in these myeloid neoplasms and portend a poor prognosis with known therapeutic resistance. This article provides a timely review of the complexity of TP53 alterations, providing updates in diagnosis and prognosis based on new 2022 International Consensus Classification (ICC) and World Health Organization (WHO) guidelines. The article addresses optimal testing strategies and reviews current and arising therapeutic approaches. While the treatment landscape for this molecular subgroup is under active development, further exploration is needed to optimize the care of this group of patients with unmet needs.
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Affiliation(s)
- Jennifer A Marks
- Department of Medicine, Division of Hematology and Oncology, Georgetown University, 3800 Reservoir Road NW, Washington, D.C. 20007, USA.
| | - Xin Wang
- Department of Medicine, Division of Hematology and Oncology, Georgetown University, 3800 Reservoir Road NW, Washington, D.C. 20007, USA; Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, 12 South Pavilion, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Elena M Fenu
- Department of Pathology and Laboratory Medicine, Division of Hematopathology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Adam Bagg
- Department of Pathology and Laboratory Medicine, Division of Hematopathology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Catherine Lai
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, 12 South Pavilion, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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4
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Zhu G, Cai J, Zhong H. TP53 signal pathway confers potential therapy target in acute myeloid leukemia. Eur J Haematol 2023; 110:480-489. [PMID: 36692074 DOI: 10.1111/ejh.13934] [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: 10/23/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 01/25/2023]
Abstract
TP53 mutation is a frequent tumor suppressor mutation and a critical prognostic indicator across studies in many malignant tumors including hematologic malignancies. However, the role of TP53 and its correlative pathway in acute myeloid leukemia (AML) is enigmatic, which may provide possible emerging strategies with the potential to improve outcomes in AML. Accordingly, we focus not only on the TP53 mutation but also on the underlying mechanisms of the mutated TP53 signal pathway. While it is now generally accepted that TP53 mutations are widely associated with a dismal prognosis, resistance to chemotherapy, and high incidence of relapse and refractory AML. Hereby, the current therapeutics targeting TP53 mutant AML are summarized in this review. This will address emerging TP53-based therapeutic approaches, facilizing the TP53-targeted treatment options.
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Affiliation(s)
- Gelan Zhu
- Department of Hematology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Jiayi Cai
- Department of Hematology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Hua Zhong
- Department of Hematology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
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Santini V, Lübbert M, Wierzbowska A, Ossenkoppele GJ. The Clinical Value of Decitabine Monotherapy in Patients with Acute Myeloid Leukemia. Adv Ther 2022; 39:1474-1488. [PMID: 34786648 PMCID: PMC8989816 DOI: 10.1007/s12325-021-01948-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/06/2021] [Indexed: 12/17/2022]
Abstract
Decitabine (5-aza-2′-deoxycytidine) is a hypomethylating agent used in the treatment of acute myeloid leukemia (AML). Decitabine inhibits DNA methyltransferases, causing DNA hypomethylation, and leading amongst others to re-expression of silenced tumor suppressor genes. Decitabine is indicated for the treatment of adult patients with newly diagnosed de novo or secondary AML who are not eligible for standard induction chemotherapy. The initial authorization in 2012 was based on the results of the open-label, randomized, multicenter phase 3 DACO-016 trial, and supported by data from the supportive phase 2 open-label DACO-017 trial. Compared with standard care, decitabine significantly improved overall survival, event-free survival, progression-free survival, and response rate. Decitabine was generally well tolerated, offering a valuable treatment option in patients with AML irrespective of age, especially for patients achieving a complete response. Several observational “real-life” studies confirmed these results. In contrast to standard chemotherapy, the presence of adverse-risk karyotypes or TP53 mutations does not negatively impact sensitivity to hypomethylating therapy albeit with lower durability. Data suggest a potential positive effect of decitabine in patients with monosomal karyotype-positive AML. For the time being, decitabine is an appropriate option as monotherapy for patients with AML who are unfit to receive more intensive combination therapies, but emerging data suggest that decitabine-based doublet or triplet combinations may be future treatment options for patients with AML.
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Affiliation(s)
- Valeria Santini
- Department of Experimental and Clinical Medicine, MDS Unit, AOUC- University of Florence, Florence, Italy.
| | - Michael Lübbert
- Department of Internal Medicine I, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg Medical Center, Freiburg, Germany
| | | | - Gert J Ossenkoppele
- Department of Haematology, Location VU University Medical Center, Amsterdam, The Netherlands
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6
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Fleischmann M, Schnetzke U, Hochhaus A, Scholl S. Management of Acute Myeloid Leukemia: Current Treatment Options and Future Perspectives. Cancers (Basel) 2021; 13:5722. [PMID: 34830877 PMCID: PMC8616498 DOI: 10.3390/cancers13225722] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/07/2021] [Accepted: 11/12/2021] [Indexed: 12/19/2022] Open
Abstract
Treatment of acute myeloid leukemia (AML) has improved in recent years and several new therapeutic options have been approved. Most of them include mutation-specific approaches (e.g., gilteritinib for AML patients with activating FLT3 mutations), or are restricted to such defined AML subgroups, such as AML-MRC (AML with myeloid-related changes) or therapy-related AML (CPX-351). With this review, we aim to present a comprehensive overview of current AML therapy according to the evolved spectrum of recently approved treatment strategies. We address several aspects of combined epigenetic therapy with the BCL-2 inhibitor venetoclax and provide insight into mechanisms of resistance towards venetoclax-based regimens, and how primary or secondary resistance might be circumvented. Furthermore, a detailed overview on the current status of AML immunotherapy, describing promising concepts, is provided. This review focuses on clinically important aspects of current and future concepts of AML treatment, but will also present the molecular background of distinct targeted therapies, to understand the development and challenges of clinical trials ongoing in AML patients.
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Affiliation(s)
| | | | | | - Sebastian Scholl
- Klinik für Innere Medizin II, Abteilung Hämatologie und Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07740 Jena, Germany; (M.F.); (U.S.); (A.H.)
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