Emerging pharmacotherapies for elderly acute myeloid leukemia patients

"Losing the Brakes"-Suppressed Inhibitors Triggering Uncontrolled Wnt/ß-Catenin Signaling May Provide a Potential Therapeutic Target in Elderly Acute Myeloid Leukemia

Dysregulated Wnt/β-catenin signal transduction is implicated in initiation, propagation, and poor prognosis in AML. Epigenetic inactivation is central to Wnt/β-catenin hyperactivity, and Wnt/β-catenin inhibitors are being investigated as targeted therapy. Dysregulated Wnt/β-catenin signaling has also been linked to accelerated aging. Since AML is a disease of old age (>60 yrs), we hypothesized age-related differential activity of Wnt/β-catenin signaling in AML patients. We probed Wnt/β-catenin expression in a series of AML in the elderly (>60 yrs) and compared it to a cohort of pediatric AML (<18 yrs). RNA from diagnostic bone marrow biopsies (n = 101) were evaluated for key Wnt/β-catenin molecule expression utilizing the NanoString platform. Differential expression of significance was defined as >2.5-fold difference (p < 0.01). A total of 36 pediatric AML (<18 yrs) and 36 elderly AML (>60 yrs) were identified in this cohort. Normal bone marrows (n = 10) were employed as controls. Wnt/β-catenin target genes (MYC, MYB, and RUNX1) showed upregulation, while Wnt/β-catenin inhibitors (CXXR, DKK1-4, SFRP1-4, SOST, and WIFI) were suppressed in elderly AML compared to pediatric AML and controls. Our data denote that suppressed inhibitor expression (through mutation or hypermethylation) is an additional contributing factor in Wnt/β-catenin hyperactivity in elderly AML, thus supporting Wnt/β-catenin inhibitors as potential targeted therapy.

Treatment Pattern, Financial Burden and Outcomes in Elderly Patients with Acute Myeloid Leukemia in Korea: A Nationwide Cohort Study

Although approximately 50% of patients with acute myeloid leukemia (AML) are diagnosed over the age of 60 years, there is currently no established consensus on the treatment of elderly AML patients. Herein, we aimed to explore the incidence, medical expenditure, treatment, and outcomes of elderly AML patients in Korea by analyzing a nationwide cohort. We employed the Korean National Health Insurance Service-Senior cohort, which represents 10% of a random selection from a total of 5.5 million subjects aged 60 years or older. AML patients were identified according to the main diagnostic criteria of acute leukemia. Treatment for AML was divided into high- (high-dose cytarabine ± idarubicin) and low- (low-dose cytarabine or hypomethylating agents) intensity chemo-therapy and classified according to the chemotherapeutics protocol. We analyzed the survival outcomes and medical expenditures. Among 558,147 elderly patients, 471 were diagnosed with AML, and 195 (41.4%) were treated with chemotherapy. The median age was 65 years, and the median overall survival (OS) was 4.93 months (95% confidence interval, 4.47–5.43). Median OS was longer in patients undergoing chemotherapy than those in the best supportive care group (6.28 vs. 3.45 months, p < 0.001), and the difference was prominent in patients aged < 70 years. Twenty-eight (5.9%) patients received high-intensity chemotherapy, while 146 (31.0%) received low-intensity chemotherapy. The difference in median OS according to dose intensity was 4.6 months, which was longer in the high-intensity chemotherapy group (9.8 vs. 5.2 months in low-intensity group); however, the difference was not statistically significant. Patients who received high-intensity chemotherapy recorded longer hospital stays and incurred greater expenses on initial hospitalization. Elderly AML patients in Korea exhibited clinical benefits from chemotherapy. Although patients should be carefully selected for intensive treatment, chemotherapy, including low-intensity treatment, can be considered in elderly patients. Moreover, prospective studies on new agents or new treatment strategies are needed.

Therapeutic targeting of chromatin: status and opportunities

The molecular characterization of mechanisms underlying transcriptional control and epigenetic inheritance since the 1990s has paved the way for the development of targeted therapies that modulate these pathways. In the past two decades, cancer genome sequencing approaches have uncovered a plethora of mutations in chromatin modifying enzymes across tumor types, and systematic genetic screens have identified many of these proteins as specific vulnerabilities in certain cancers. Now is the time when many of these basic and translational efforts start to bear fruit and more and more chromatin-targeting drugs are entering the clinic. At the same time, novel pharmacological approaches harbor the potential to modulate chromatin in unprecedented fashion, thus generating entirely novel opportunities. Here, we review the current status of chromatin targets in oncology and describe a vision for the epigenome-modulating drugs of the future.

Recent Clinical Update of Acute Myeloid Leukemia: Focus on Epigenetic Therapies

Acute myeloid leukemia (AML) is a complicated disease characterized by genetic heterogeneity and simultaneous alterations in multiple genes. For decades, its only curative method has been intensive induction chemotherapy with or without allogeneic hematopoietic stem cell transplantation, and this approach cannot be applied to elderly patients, who make up more than 50% of AML patients. Recent advances in genomics facilitated the elucidation of various mutations related to AML, and the most frequent mutations were discovered in epigenetic regulators. Alterations to epigenetic modifications that are essential for normal cell biology, including DNA methylation and histone acetylation, have been identified. As epigenetic dysregulation is an important carcinogenic mechanism and some epigenetic changes are reversible, these epigenetic alterations have become targets for novel drug development against AML. This review summarizes the recent advances in epigenetic therapies for AML and discusses future research directions.

Current clinical strategies and emergent treatment landscapes in leukemic transformation of Philadelphia-negative myeloproliferative neoplasms

Introduction: Transformation to acute myeloid leukemia (AML) of Philadelphia chromosome-negative (Ph-) chronic myeloproliferative neoplasms (MPN) represents a challenging medical concern and an unmet clinical need, since it charts a very poor outcome and a low rate of response to standard treatments with the exception of allogeneic hematopoietic stem cell transplantation (HSCT). Recent novel insights into the molecular disease pathways and the genomic features characterizing the transformation of Ph-MPN have led to new therapeutic individualized approaches with the potential to modify the clinical management of these difficult-to-treat patients. Areas covered: Literature review (MeSH headings/PubMed) of risk factors of MPNs progression and treatment options for transformed disease with traditional standard approaches, and novel and investigational agents was performed. One or combinations of related subject headings like transformed MPN, epigenetics, molecular alterations, HSCT, ruxolitinib, azacytidine, decitabine, gliterinib, novel agents, personalized therapy was screened. Informative papers were selected by the appropriate actual evidence and suggesting strategies for improving outcomes in the future. Expert opinion: Current and emerging treatments for transformed Ph-MPN, are presented. Novel targeted or experimental agents to be used both before HSCT, to induce blast-free state, or to modify the disease prognosis and improve survival and quality of life are critically reviewed.