Checkpoint inhibitors and acute myelogenous leukemia: promises and challenges

Acquired immune resistance is associated with interferon signature and modulation of KLF6/c-MYB transcription factors in myeloid leukemia

Resistance to immunity is associated with the selection of cancer cells with superior capacities to survive inflammatory reactions. Here, we tailored an ex vivo immune selection model for acute myeloid leukemia (AML) and isolated the residual subpopulations as "immune-experienced" AML (ieAML) cells. We confirmed that upon surviving the immune reactions, the malignant blasts frequently decelerated proliferation, displayed features of myeloid differentiation and activation, and lost immunogenicity. Transcriptomic analyses revealed a limited number of commonly altered pathways and differentially expressed genes in all ieAML cells derived from distinct parental cell lines. Molecular signatures predominantly associated with interferon and inflammatory cytokine signaling were enriched in the AML cells resisting the T-cell-mediated immune reactions. Moreover, the expression and nuclear localization of the transcription factors c-MYB and KLF6 were noted as the putative markers for immune resistance and identified in subpopulations of AML blasts in the patients' bone marrow aspirates. The immune modulatory capacities of ieAML cells lasted for a restricted period when the immune selection pressure was omitted. In conclusion, myeloid leukemia cells harbor subpopulations that can adapt to the harsh conditions established by immune reactions, and a previous "immune experience" is marked with IFN signature and may pave the way for susceptibility to immune intervention therapies.

Nanozymes: a new approach for leukemia therapy

Leukemia is a type of clonal disorder of hematopoietic stem and progenitor cells characterized by bone marrow failure, differentiation arrest, and lineage skewing. Despite leukemia being a complex disease and it being difficult to identify a single driving force, redox homeostasis, the balance between reactive oxygen species (ROS) producers and cellular antioxidant systems, is normally impaired during leukemogenesis. In this context, the modulation of ROS in leukemia cells can be harnessed for therapeutic purposes. Nanozymes are functional nanomaterials with enzyme-like characteristics, which address the intrinsic limitations of natural enzymes and exhibit great potential in synergistic antitumor therapy. Nanozymes possess catalytic activities (e.g., peroxidase-like activity, catalase-like activity, superoxide dismutase-like activity, and oxidase-like activity) to regulate ROS levels in vitro and in vivo, making them promising for leukemia therapy. On account of the rapid development of nanozymes recently, their application potentials in leukemia therapy are gradually being explored. To highlight the achievements of nanozymes in the leukemia field, this review summarizes the recent studies of nanozymes with anti-leukemia efficacy and the underlying mechanism. In addition, the challenges and prospects of nanozyme research in leukemia therapy are discussed.

Combination therapy of acute myeloid leukemia by dual PI3K/mTOR inhibitor BEZ235 and TLR-7/8 agonist R848 in murine model

BACKGROUND

Due to the high relapse rate and toxicity of the common therapies in patients with acute myeloid leukemia (AML), modifications in the treatment strategies are required. The present study was conducted to determine the effects of combinational therapy with a dual PI3K/mTOR inhibitor, BEZ235, and TLR7/8 agonist, R848, on murine AML model.

METHODS

BEZ235 and R848 were administered to AML leukemic mice in either a single or combination treatment. Frequency of T-CD4+, T-CD8+, MDSCs, NK, exhausted T cells and the degranulation levels was measured via flow cytometry. The cytotoxicity and proliferation levels were evaluated by MTT assay. Then, the expression of iNOS, arginase-1, PD-L1, Gal-9, PVR, IFN-γ, TNF-α, IL-4, IL-10, IL-12 and IL-17 was investigated by Real-Time PCR. Organomegaly, body weight and survival rate were also monitored.

RESULTS

Following combinational therapy with BEZ235 and R848, increasing in the frequency of anti-tumor immune cells including T-CD4+ cells and M1 macroghages, and decreasing in pro-tumor immune cells including MDSCs, exhausted T-CD4+ and T-CD8+ cells and also M2 macrophages were observed. The functional defects of immune cells in term of proliferation, cytotoxicity, degranulation, and cytokines expression were improved in leukemic mice after treatment with BEZ235 and R848. Finally, organomegaly, body weight and survival analysis showed significant improvements after treatment with BEZ235 and R848.

CONCLUSION

Taken together, we indicated that the combinational therapy with BEZ235 and R848 could be considered as a potential and powerful therapeutic option for AML patients. Further clinical studies are required to expand our current findings.

New Frontiers in Monoclonal Antibodies for the Targeted Therapy of Acute Myeloid Leukemia and Myelodysplastic Syndromes

Acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) represent an unmet clinical need whose prognosis is still dismal. Alterations of immune response play a prominent role in AML/MDS pathogenesis, revealing novel options for immunotherapy. Among immune system regulators, CD47, immune checkpoints, and toll-like receptor 2 (TLR2) are major targets. Magrolimab antagonizes CD47, which is overexpressed by AML and MDS cells, thus inducing macrophage phagocytosis with clinical activity in AML/MDS. Sabatolimab, an inhibitor of T-cell immunoglobulin and mucin domain-containing protein 3 (TIM3), which disrupts its binding to galectin-9, has shown promising results in AML/MDS, enhancing the effector functions of lymphocytes and triggering tumor cell death. Several other surface molecules, namely CD33, CD123, CD45, and CD70, can be targeted with monoclonal antibodies (mAbs) that exert different mechanisms of action and include naked and conjugated antibodies, bispecific T-cell engagers, trispecific killer engagers, and fusion proteins linked to toxins. These novel mAbs are currently under investigation for use as monotherapy or in combination with hypomethylating agents, BCL2 inhibitors, and chemotherapy in various clinical trials at different phases of development. Here, we review the main molecular targets and modes of action of novel mAb-based immunotherapies, which can represent the future of AML and higher risk MDS treatment.

High-Risk Acute Myeloid Leukemia: A Pediatric Prospective

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.

Hypomethylating Agent-Based Combination Therapies to Treat Post-Hematopoietic Stem Cell Transplant Relapse of Acute Myeloid Leukemia

Allogeneic stem cell transplantation still represents the best curative option for most patients with acute myeloid leukemia, but relapse is still dramatically high. Due to their immunologic activity and safety profile, hypomethylating agents (HMAs) represent an interesting backbone for combination therapies. This review reports mechanism of action, safety, and efficacy data on combination strategies based on HMAs in the setting of post-allogeneic stem cell transplant relapse. Several studies highlighted how HMAs and donor lymphocyte infusion (DLI) combination may be advantageous. The combination strategy of HMA with venetoclax, possibly in association with DLI, is showing excellent results in terms of response rate, including molecular responses. Lenalidomide, despite its well-known high rates of severe graft-versus-host disease in post-transplant settings, is showing an acceptable safety profile in association with HMAs with a competitive response rate. Regarding FLT3 internal tandem duplication (ITD) mutant AML, tyrosine kinase inhibitors and particularly sorafenib have promising results as monotherapy and in combination with HMAs. Conversely, combination strategies with gemtuzumab ozogamicin or immune checkpoint inhibitors did not show competitive response rates and seem to be currently less attractive strategies. Associations with histone deacetylase inhibitors and isocitrate dehydrogenase 1 and 2 (IDH1/2) inhibitors represent new possible strategies that need to be better investigated.

Preclinical Studies of PROTACs in Hematological Malignancies

Incorrectly expressed or mutated proteins associated with hematologic malignancies have been generally targeted by chemotherapy using small-molecule inhibitors or monoclonal antibodies. But the majority of these intracellular proteins are without active sites and antigens. PROTACs, proteolysis targeting chimeras, are bifunctional molecules designed to polyubiquitinate and degrade specific pathological proteins of interest (POIs) by hijacking the activity of E3-ubiquitin ligases for POI polyubiquitination and subsequent degradation by the proteasome. This strategy utilizes the ubiquitin-proteasome system for the degradation of specific proteins in the cell. In many cases, including hematologic malignancies, inducing protein degradation as a therapeutic strategy offers therapeutic benefits over classical enzyme inhibition connected with resistance to inhibitors. Limitations of small-molecule inhibitors are shown. PROTACs can polyubiquitinate and mark for degradation of "undruggable"proteins, e.g. transcription factor STAT3 and scaffold proteins. Today, this technology is used in preclinical studies in various hematologic malignancies, mainly for targeting drug-resistant bromodomain and extraterminal proteins and Bruton tyrosine kinase. Several mechanisms limiting selectivity and safety of PROTAC molecules function are also discussed.

T-cell-based immunotherapy of acute myeloid leukemia: current concepts and future developments

Acute myeloid leukemia (AML) is a heterogeneous disease linked to a broad spectrum of molecular alterations, and as such, long-term disease control requires multiple therapeutic approaches. Driven largely by an improved understanding and targeting of these molecular aberrations, AML treatment has rapidly evolved over the last 3-5 years. The stellar successes of immunotherapies that harness the power of T cells to treat solid tumors and an improved understanding of the immune systems of patients with hematologic malignancies have led to major efforts to develop immunotherapies for the treatment of patients with AML. Several immunotherapies that harness T cells against AML are in various stages of preclinical and clinical development. These include bispecific and dual antigen receptor-targeting antibodies (targeted to CD33, CD123, CLL-1, and others), chimeric antigen receptor (CAR) T-cell therapies, and T-cell immune checkpoint inhibitors (including those targeting PD-1, PD-L1, CTLA-4, and newer targets such as TIM3 and STING). The current and future directions of these T-cell-based immunotherapies in the treatment landscape of AML are discussed in this review.

Risk factors associated with suicide among leukemia patients: A Surveillance, Epidemiology, and End Results analysis

Previous studies have found that the risk of suicide is higher in patients diagnosed with cancer than in the general population. We aimed to identify potential risk factors associated with suicide in leukemia patients by analyzing data obtained from the Surveillance, Epidemiology, and End Results (SEER) database. We screened the SEER database for leukemia patients added between 1975 and 2017, and calculated their suicide rate and standardized mortality rate (SMR) relative to the total United States population from 1981 to 2017 as a reference. Univariate and multivariate Cox regression analyses were used to determine the risk factors for suicide in leukemia patients. We collected 142,386 leukemia patients who had been added to the SEER database from 1975 to 2017, of whom 191 patients committed suicide over an observation period of 95,397 person‐years. The suicide rate of leukemia patients was 26.41 per 100,000 person‐years, and hence the SMR of the suicided leukemia patients was 2.16 (95% confidence interval [CI] = 1.85–2.47). The univariate and multivariate Cox regression analyses showed that a high risk of suicide was associated with male sex (vs. female: hazard ratio [HR] = 4.41, 95% CI = 2.93–6.63, p < 0.001), older age at diagnosis (60–69 years vs. ≤39 years: HR = 2.60, 95% CI = 1.60–4.23, p < 0.001; 70–79 years vs. ≤39 years: HR = 2.84, 95% CI = 1.72–4.68, p < 0.001; ≥80 years vs. ≤39 years: HR = 2.94, 95% CI = 1.65–5.21, p < 0.001), white race (vs. black: HR = 6.80, 95% CI = 1.69–27.40, p = 0.007), acute myeloid leukemia (vs. lymphocytic leukemia: HR = 1.59, 95% CI = 1.09–2.33, p = 0.016), unspecified and other specified leukemia (vs. lymphocytic leukemia: HR = 2.72, 95% CI = 1.55–4.75, p < 0.001), and living in a small city (vs. large city: HR = 2.10, 95% CI = 1.23–3.60, p = 0.007). Meanwhile, being a non‐Hispanic black (vs. Hispanic: HR = 0.06, 95% CI = 0.01–0.62, p = 0.019) was a protective factor for suicide. Male sex, older age at diagnosis, white race, and acute myeloid leukemia were risk factors for suicide in leukemia patients, while being a non‐Hispanic black was a protective factor. Medical workers should, therefore, provide targeted preventive measures to leukemia patients with a high risk of suicide.

A Screening of Antineoplastic Drugs for Acute Myeloid Leukemia Reveals Contrasting Immunogenic Effects of Etoposide and Fludarabine

BACKGROUND

Recent evidence demonstrated that the treatment of acute myeloid leukemia (AML) cells with daunorubicin (DNR) but not cytarabine (Ara-C) results in immunogenic cell death (ICD). In the clinical setting, chemotherapy including anthracyclines and Ara-C remains a gold standard for AML treatment. In the last decade, etoposide (Eto) and fludarabine (Flu) have been added to the standard treatment for AML to potentiate its therapeutic effect and have been tested in many trials. Very little data are available about the ability of these drugs to induce ICD.

METHODS

AML cells were treated with all four drugs. Calreticulin and heat shock protein 70/90 translocation, non-histone chromatin-binding protein high mobility group box 1 and adenosine triphosphate release were evaluated. The treated cells were pulsed into dendritic cells (DCs) and used for in vitro immunological tests.

RESULTS

Flu and Ara-C had no capacity to induce ICD-related events. Interestingly, Eto was comparable to DNR in inducing all ICD events, resulting in DC maturation. Moreover, Flu was significantly more potent in inducing suppressive T regulatory cells compared to other drugs.

CONCLUSIONS

Our results indicate a novel and until now poorly investigated feature of antineoplastic drugs commonly used for AML treatment, based on their different immunogenic potential.

Targeting FTO Suppresses Cancer Stem Cell Maintenance and Immune Evasion

Fat mass and obesity-associated protein (FTO), an RNA N⁶-methyladenosine (m⁶A) demethylase, plays oncogenic roles in various cancers, presenting an opportunity for the development of effective targeted therapeutics. Here, we report two potent small-molecule FTO inhibitors that exhibit strong anti-tumor effects in multiple types of cancers. We show that genetic depletion and pharmacological inhibition of FTO dramatically attenuate leukemia stem/initiating cell self-renewal and reprogram immune response by suppressing expression of immune checkpoint genes, especially LILRB4. FTO inhibition sensitizes leukemia cells to T cell cytotoxicity and overcomes hypomethylating agent-induced immune evasion. Our study demonstrates that FTO plays critical roles in cancer stem cell self-renewal and immune evasion and highlights the broad potential of targeting FTO for cancer therapy.

Increased PD-1+Tim-3+ exhausted T cells in bone marrow may influence the clinical outcome of patients with AML

Background

Altered expression of T cell immune inhibitory receptors may result in immunosuppression and associate with the poor prognosis of leukemia patients in which the leukemic bone marrow (BM) microenvironment may contribute to such immunosuppression. We found higher numbers of programmed death-1 (PD-1) + exhausted T cells in peripheral blood (PB) from acute myeloid leukemia (AML) patients. To investigate the leukemic BM influence on immunosuppression, we further compared the distributions of PD-1 and T cell immunoglobulin mucin-3 (Tim-3) and the exhausted T cell phenotype in PB and BM from AML patients and characterized their relationship with clinical outcome.

Methods

PB and BM samples from 15 patients with newly diagnosed AML were collected and analyzed for the expression of PD-1, Tim-3, CD244, and CD57 on CD3+, CD4+, and CD8+ T cells by multicolor flow cytometry.

Results

The proportions of PD-1 + CD3+ and PD-1 + CD8+ T cells were significantly higher in BM compared with PB. Similarly, higher PD-1 + CD244 + CD3+ and PD-1 + CD244 + CD8+ T cells were found in BM, and an increased tendency for PD-1 + CD244 + CD4+ T cells was also detected in this group. In contrast, increased Tim-3 + CD4+/Tim-3 + CD244 + CD4+ T cells were predominant in BM compared with PB, but there was no statistically significant difference in Tim-3 + CD8+ T cells. Moreover, PD-1 and Tim-3 double-positive CD3+/CD4+/CD8+ T cells were significantly increased in the BM group. In addition, a higher proportion of PD-1 + Tim-3 + CD3+ T cells in the BM and PD-1 + Tim-3 + CD4+ T cells in PB was detected in non-complete remission (NCR) compared with complete remission (CR) patients after first-cycle chemotherapy.

Conclusions

Upregulation of PD-1 and Tim-3 and the exhausted phenotype of CD4+ and CD8+ T cells in the BM of AML patients may contribute to mediating the leukemic immunosuppressive microenvironment, and increased PD-1 + Tim-3+ CD8+ T cells may be related to T cell dysfunction in AML, which may influence clinical outcome.

Specific T-cell immune responses against colony-forming cells including leukemic progenitor cells of AML patients were increased by immune checkpoint inhibition

The efficacy of immunotherapies in cancer treatment becomes more and more apparent not only in different solid tumors but also in hematological malignancies. However, in acute myeloid leukemia (AML), mechanisms to increase the efficacy of immunotherapeutic approaches have to be further elucidated. Targeting leukemic progenitor and stem cells (LPC/LSC) by specific CTL, for instance, in an adjuvant setting or in minimal residual disease, might be an option to prevent relapse of AML or to treat MRD. Therefore, we investigated the influence of immune checkpoint inhibitors on LAA-specific immune responses by CTL against leukemic myeloid blasts and colony-forming cells including leukemic progenitor cells (CFC/LPC). In functional immunoassays like CFU/CFI (colony-forming units/immunoassays) and ELISpot analysis, we detected specific LAA-directed immune responses against CFC/LPC that are postulated to be the source population of relapse of the disease. The addition of nivolumab (anti-PD-1) significantly increases LAA-directed immune responses against CFC/LPC, no effect is seen when ipilimumab (anti-CTLA-4) is added. The combination of ipilimumab and nivolumab does not improve the effect compared to nivolumab alone. The anti-PD1-directed immune response correlates to PD-L1 expression on progenitor cells. Our data suggest that immunotherapeutic approaches have the potential to target malignant CFC/LPC and anti-PD-1 antibodies could be an immunotherapeutic approach in AML. Moreover, combination with LAA-directed vaccination strategies might also open interesting application possibilities.

Opportunities for immunotherapy in childhood acute myeloid leukemia

Clinical outcomes for children with acute myeloid leukemia (AML) have improved minimally during the past 4 decades despite maximally intensive chemotherapy, hematopoietic stem cell transplantation, and optimized supportive care. Chemoresistance and relapse remain major sources of childhood cancer-associated mortality and highlight the need for alternative treatment approaches. The remarkable recent success of humoral and cellular immunotherapies in children and adults with relapsed/refractory B-acute lymphoblastic leukemia has inspired hope for similar accomplishments in patients with AML. However, unique challenges exist, including the biologic and immunophenotypic heterogeneity of childhood AML and the significant potential for on-target/off-tumor immunotherapeutic toxicity due to target antigen expression on nonmalignant cells. This article reviews the current landscape of antibody-based and cellular immunotherapies under current clinical evaluation with an emphasis on active or soon-to-open phase 1 trials for children with relapsed/refractory AML.

Opportunities for immunotherapy in childhood acute myeloid leukemia

Clinical outcomes for children with acute myeloid leukemia (AML) have improved minimally during the past 4 decades despite maximally intensive chemotherapy, hematopoietic stem cell transplantation, and optimized supportive care. Chemoresistance and relapse remain major sources of childhood cancer-associated mortality and highlight the need for alternative treatment approaches. The remarkable recent success of humoral and cellular immunotherapies in children and adults with relapsed/refractory B-acute lymphoblastic leukemia has inspired hope for similar accomplishments in patients with AML. However, unique challenges exist, including the biologic and immunophenotypic heterogeneity of childhood AML and the significant potential for on-target/off-tumor immunotherapeutic toxicity due to target antigen expression on nonmalignant cells. This article reviews the current landscape of antibody-based and cellular immunotherapies under current clinical evaluation with an emphasis on active or soon-to-open phase 1 trials for children with relapsed/refractory AML.

Lower T cell inhibitory receptor level in mononuclear cells from cord blood compared with peripheral blood

T cell inhibitory receptors play important role in maintaining T cell homeostasis. The feature of such negative costimulator signal transduction pathway in cord blood (CB) T cells remains unclear. In this study, the expression levels of T cell inhibitory receptors including programmed death-1 (PD-1), cytotoxic T lymphocyte antigen-4 (CTLA-4), T cell immunoglobulin mucin-3 (Tim-3), lymphocyte activation gene-3 (LAG-3) and B and T lymphocyte attenuator (BTLA) were characterized in CB and compared with peripheral blood (PB). Significant lower expression of PD-1, CTLA-4, LAG-3 and BTLA was found in CB, while similar expression level of Tim-3 was showed between CB and PB. Together, different expression pattern of such T cell inhibitory receptor in CB is worthy to further discuss their role on immune response when CB is used in cord blood stem cell transplantation as well as allogeneic chimeric antigen receptor T-cell producing.

Chemotherapy-Induced Tumor Cell Death at the Crossroads Between Immunogenicity and Immunotolerance: Focus on Acute Myeloid Leukemia

In solid tumors and hematological malignancies, including acute myeloid leukemia, some chemotherapeutic agents, such as anthracyclines, have proven to activate an immune response via dendritic cell-based cross-priming of anti-tumor T lymphocytes. This process, known as immunogenic cell death, is characterized by a variety of tumor cell modifications, i.e., cell surface translocation of calreticulin, extracellular release of adenosine triphosphate and pro-inflammatory factors, such as high mobility group box 1 proteins. However, in addition to with immunogenic cell death, chemotherapy is known to induce inflammatory modifications within the tumor microenvironment, which may also elicit immunosuppressive pathways. In particular, DCs may be driven to acquire tolerogenic features, such as the overexpression of indoleamine 2,3-dioxygensase 1, which may ultimately hamper anti-tumor T-cells via the induction of T regulatory cells. The aim of this review is to summarize the current knowledge about the mechanisms and effects by which chemotherapy results in both activation and suppression of anti-tumor immune response. Indeed, a better understanding of the whole process underlying chemotherapy-induced alterations of the immunological tumor microenvironment has important clinical implications to fully exploit the immunogenic potential of anti-leukemia agents and tune their application.

Myeloid maturation potentiates STAT3-mediated atypical IFN-γ signaling and upregulation of PD-1 ligands in AML and MDS

Interferon (IFN)-γ is the major mediator of anti-tumor immune responses; nevertheless, cancer cells use intrigue strategies to alter IFN-γ signaling and avoid elimination. Understanding the immune regulatory mechanisms employed by acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) cells upon exposure to IFN-γ is critical for development of immunotherapy and checkpoint blockade therapy approaches. This study aims to explore the influence of myeloid maturation on IFN-γ-induced PD-L1 and PD-L2 expression and on pro-leukemogenic transcription factor STAT3 signaling in AML and MDS. Stimulation of myeloid blasts’ maturation by all-trans retinoic acid (ATRA) or 1α,25-dihydroxyvitamin D3 (vitamin D) increased the CD11b⁺ fraction that expressed PD-1 ligands in response to IFN-γ. Intriguingly, STAT3 pathway was potently induced by IFN-γ and strengthened upon prolonged exposure. Nonetheless, STAT3-mediated atypical IFN-γ signaling appeared as a negligible factor for PD-L1 and PD-L2 expression. These negative influences of IFN-γ could be alleviated by a small-molecule inhibitor of STAT3, stattic, which also inhibited the upregulation of PD-L1. In conclusion, induction of myeloid maturation enhances the responsiveness of AML and MDS cells to IFN-γ. However, these malignant myeloid cells can exploit both STAT3 pathway and PD-1 ligands to survive IFN-γ-mediated immunity and maintain secondary immune resistance.

Acute Myeloid Leukemia: Is That All There Is?

Acute myeloid leukemia (AML) is characterized by the clonal proliferation of malignant myeloid blast cells in the marrow along with impaired normal hematopoiesis. With an almost stagnant approach for the management of patients with AML in the last three decades, the main purpose of this paper is to increase our understanding of recent scientific advancements for the enhanced diagnosis and treatment of AML. Existing research data related to different approaches for a possible improvement in AML management has been collected and discussed. The identification of recurrently mutated genes, such as CCAAT-enhancer-binding proteins α (CEBPα), Fms-related tyrosine kinase 3 (FLT3), and nucleophosmin 1 (NPM1) along with the classic diagnostic karyotype has improved prognostic-risk stratification. Moreover, mutations affecting cellular metabolism like isocitrate dehydrogenase (IDH1), lysine-specific demethylase 1 (LSD 1), and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) have become a huge success by providing targets for novel therapeutic drugs. Checkpoint inhibitors (CPI) and vaccination against tumor-associated antigen are added options considered, which require further trials before their efficacy can be determined. An important tool in monitoring early response to therapy, minimal residual disease (MRD) assays can be further refined by including pretreatment parameters such as cytogenetic and molecular markers. Potential side effects and resistance to treatment remains a huge barrier in completely finding success against AML and work needs to be done to find combinations of immunotherapies to possibly reduce adaptive resistance by AML.