1
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Bewersdorf JP, Shallis RM, Sharon E, Park S, Ramaswamy R, Roe CE, Irish JM, Caldwell A, Wei W, Yacoub A, Madanat YF, Zeidner JF, Altman JK, Odenike O, Yerrabothala S, Kovacsovics T, Podoltsev NA, Halene S, Little RF, Piekarz R, Gore SD, Kim TK, Zeidan AM. A multicenter phase Ib trial of the histone deacetylase inhibitor entinostat in combination with pembrolizumab in patients with myelodysplastic syndromes/neoplasms or acute myeloid leukemia refractory to hypomethylating agents. Ann Hematol 2024; 103:105-116. [PMID: 38036712 DOI: 10.1007/s00277-023-05552-4] [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: 09/28/2023] [Accepted: 11/13/2023] [Indexed: 12/02/2023]
Abstract
Patients with myelodysplastic syndromes/neoplasms (MDS) or acute myeloid leukemia (AML) with hypomethylating agent failure have a poor prognosis. Myeloid-derived suppressor cells (MDSCs) can contribute to MDS progression and mediate resistance to anti-PD1 therapy. As histone deacetylase inhibitors (HDACi) decrease MDSCs in preclinical models, we conducted an investigator-initiated, NCI-Cancer Therapy Evaluation Program-sponsored, multicenter, dose escalation, and expansion phase Ib trial (NCT02936752) of the HDACi entinostat and the anti-PD1 antibody pembrolizumab. Twenty-eight patients (25 MDS and 3 AML) were enrolled. During dose escalation (n=13 patients), there was one dose-limiting toxicity (DLT) on dose level (DL) 1 (G5 pneumonia/bronchoalveolar hemorrhage) and two DLTs at DL 2 (G3 pharyngeal mucositis and G3 anorexia). Per the 3 + 3 dose escalation design, DL 1 (entinostat 8 mg PO days 1 and 15 + pembrolizumab 200 mg IV day 1 every 21 days) was expanded and another 15 patients were enrolled. Hematologic adverse events (AEs) were common. The most common non-hematologic ≥G3 AEs were infection (32%), hypoxia/respiratory failure (11%), and dyspnea (11%). There were no protocol-defined responses among the 28 patients enrolled. Two patients achieved a marrow complete remission (mCR). Using a systems immunology approach with mass cytometry and machine learning analysis, mCR patients had increased classical monocytes and macrophages but there was no significant change of MDSCs. In conclusion, combining entinostat with pembrolizumab in patients with advanced MDS and AML was associated with limited clinical efficacy and substantial toxicity. Absence of an effect on MDSCs could be a potential explanation for the limited efficacy of this combination. ClinicalTrial.gov Identifier: NCT02936752.
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Affiliation(s)
- Jan Philipp Bewersdorf
- Section of Hematology, Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, Yale University, New Haven, CT, USA.
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Rory M Shallis
- Section of Hematology, Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Elad Sharon
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, MD, USA
| | - Silvia Park
- Division of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rahul Ramaswamy
- Division of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Caroline E Roe
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Center for Immunobiology, Vanderbilt University, Nashville, TN, USA
| | - Jonathan M Irish
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Center for Immunobiology, Vanderbilt University, Nashville, TN, USA
| | - Anne Caldwell
- Section of Hematology, Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Wei Wei
- Section of Hematology, Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Abdulraheem Yacoub
- The Division of Hematologic Malignancies and Cellular Therapeutics (HMCT), The University of Kansas Cancer Center, Westwood, KS, USA
| | - Yazan F Madanat
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - Joshua F Zeidner
- Lineberger Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jessica K Altman
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA
| | | | | | | | - Nikolai A Podoltsev
- Section of Hematology, Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Stephanie Halene
- Section of Hematology, Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Richard F Little
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, MD, USA
| | - Richard Piekarz
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, MD, USA
| | - Steven D Gore
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, MD, USA
| | - Tae Kon Kim
- Section of Hematology, Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, Yale University, New Haven, CT, USA.
- Division of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA.
- Vanderbilt Center for Immunobiology, Vanderbilt University, Nashville, TN, USA.
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, Yale University, New Haven, CT, USA.
- Hematology Section, Department of Internal Medicine, Yale School of Medicine, Yale University, 333 Cedar Street, PO Box 208028, New Haven, CT, 06520-8028, USA.
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2
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Awada H, Gurnari C, Xie Z, Bewersdorf JP, Zeidan AM. What's Next after Hypomethylating Agents Failure in Myeloid Neoplasms? A Rational Approach. Cancers (Basel) 2023; 15:2248. [PMID: 37190176 PMCID: PMC10137017 DOI: 10.3390/cancers15082248] [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: 03/05/2023] [Revised: 04/07/2023] [Accepted: 04/07/2023] [Indexed: 05/17/2023] Open
Abstract
Hypomethylating agents (HMA) such as azacitidine and decitabine are a mainstay in the current management of patients with myelodysplastic syndromes/neoplasms (MDS) and acute myeloid leukemia (AML) as either single agents or in multidrug combinations. Resistance to HMA is not uncommon, and it can result due to several tumor cellular adaptations. Several clinical and genomic factors have been identified as predictors of HMA resistance. However, the management of MDS/AML patients after the failure of HMA remains challenging in the absence of standardized guidelines. Indeed, this is an area of active research with several potential therapeutic agents currently under development, some of which have demonstrated therapeutic potential in early clinical trials, especially in cases with particular mutational characteristics. Here, we review the latest findings and give a rational approach for such a challenging scenario.
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Affiliation(s)
- Hussein Awada
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Zhuoer Xie
- Department of Hematology, H. Lee Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Jan Philipp Bewersdorf
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Comprehensive Cancer Center, New York, NY 10065, USA
| | - Amer M. Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University and Yale Cancer Center, New Haven, CT 06511, USA
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3
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Mohty R, Al Hamed R, Bazarbachi A, Brissot E, Nagler A, Zeidan A, Mohty M. Treatment of myelodysplastic syndromes in the era of precision medicine and immunomodulatory drugs: a focus on higher-risk disease. J Hematol Oncol 2022; 15:124. [PMID: 36045390 PMCID: PMC9429775 DOI: 10.1186/s13045-022-01346-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/22/2022] [Indexed: 11/22/2022] Open
Abstract
Myelodysplastic syndromes (MDS) are a heterogeneous clonal disease of myeloid neoplasms characterized by ineffective hematopoiesis, variable degree of cytopenias, and an increased risk of progression to acute myeloid leukemia (AML). Molecular and genetic characterization of MDS has led to a better understanding of the disease pathophysiology and is leading to the development of novel therapies. Targeted and immune therapies have shown promising results in different hematologic malignancies. However, their potential use in MDS is yet to be fully defined. Here, we review the most recent advances in therapeutic approaches in MDS, focusing on higher-risk disease. Allogeneic hematopoietic cell transplantation is beyond the scope of this article.
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Affiliation(s)
- Razan Mohty
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Rama Al Hamed
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Eolia Brissot
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, and INSERM, Saint-Antoine Research Centre, 75012, Paris, France
| | - Arnon Nagler
- Hematology and Bone Marrow Transplant Unit, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Amer Zeidan
- Division of Hematology/Oncology, Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, and INSERM, Saint-Antoine Research Centre, 75012, Paris, France.
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4
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Pulte D, Jansen L, Brenner H. Incidence and survival estimates for patients with myelodysplastic syndrome in the early 21st century: no evidence of improvement over time. Leuk Lymphoma 2022; 63:1964-1969. [DOI: 10.1080/10428194.2022.2053529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Dianne Pulte
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DFKZ), Heidelberg, Germany
| | - Lina Jansen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DFKZ), Heidelberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DFKZ), Heidelberg, Germany
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
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5
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Yao Y, Li F, Huang J, Jin J, Wang H. Leukemia stem cell-bone marrow microenvironment interplay in acute myeloid leukemia development. Exp Hematol Oncol 2021; 10:39. [PMID: 34246314 PMCID: PMC8272391 DOI: 10.1186/s40164-021-00233-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/02/2021] [Indexed: 12/18/2022] Open
Abstract
Despite the advances in intensive chemotherapy regimens and targeted therapies, overall survival (OS) of acute myeloid leukemia (AML) remains unfavorable due to inevitable chemotherapy resistance and high relapse rate, which mainly caused by the persistence existence of leukemia stem cells (LSCs). Bone marrow microenvironment (BMM), the home of hematopoiesis, has been considered to play a crucial role in both hematopoiesis and leukemogenesis. When interrupted by the AML cells, a malignant BMM formed and thus provided a refuge for LSCs and protecting them from the cytotoxic effects of chemotherapy. In this review, we summarized the alterations in the bidirectional interplay between hematopoietic cells and BMM in the normal/AML hematopoietic environment, and pointed out the key role of these alterations in pathogenesis and chemotherapy resistance of AML. Finally, we focused on the current potential BMM-targeted strategies together with future prospects and challenges. Accordingly, while further research is necessary to elucidate the underlying mechanisms behind LSC–BMM interaction, targeting the interaction is perceived as a potential therapeutic strategy to eradicate LSCs and ultimately improve the outcome of AML.
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Affiliation(s)
- Yiyi Yao
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China.,Zhejiang Provincial Key Lab of Hematopoietic Malignancy, Zhejiang University, Hangzhou, 310003, Zhejiang, People's Republic of China
| | - Fenglin Li
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China.,Zhejiang Provincial Key Lab of Hematopoietic Malignancy, Zhejiang University, Hangzhou, 310003, Zhejiang, People's Republic of China
| | - Jiansong Huang
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China.,Zhejiang Provincial Key Lab of Hematopoietic Malignancy, Zhejiang University, Hangzhou, 310003, Zhejiang, People's Republic of China
| | - Jie Jin
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China. .,Zhejiang Provincial Key Lab of Hematopoietic Malignancy, Zhejiang University, Hangzhou, 310003, Zhejiang, People's Republic of China. .,Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, 310000, Zhejiang, People's Republic of China.
| | - Huafeng Wang
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China. .,Zhejiang Provincial Key Lab of Hematopoietic Malignancy, Zhejiang University, Hangzhou, 310003, Zhejiang, People's Republic of China. .,Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, 310000, Zhejiang, People's Republic of China.
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6
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Lewis R, Bewersdorf JP, Zeidan AM. Clinical Management of Anemia in Patients with Myelodysplastic Syndromes: An Update on Emerging Therapeutic Options. Cancer Manag Res 2021; 13:645-657. [PMID: 33531837 PMCID: PMC7846829 DOI: 10.2147/cmar.s240600] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 01/13/2021] [Indexed: 12/18/2022] Open
Abstract
For the majority of patients with lower-risk myelodysplastic syndrome (LR-MDS), one of the primary clinical goals is to alleviate the symptoms associated with the resultant cytopenias and to minimize the transfusion burden. While supportive red blood cell (RBC) transfusions and erythropoiesis-stimulating agents (ESAs) may lead to clinical improvement, frequent transfusions are often complicated by iron overload and decreased quality of life; furthermore, most patients either do not respond to ESAs or will eventually develop resistance. As such, there is a great need for further therapeutic options in the management of anemia related to MDS. Several additional therapeutics are now available in select patients with LR-MDS and symptomatic anemia including luspatercept, lenalidomide, and immunosuppressive therapy. Furthermore, several novel agents are currently in development to address this area of clinical need such as imetelstat and roxadustat. In this article, we review the currently available therapeutic options for symptomatic anemia in LR-MDS as well as review the therapeutic agents in development.
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Affiliation(s)
- Russell Lewis
- Department of Medicine, Section of Hematology, Yale University, New Haven, CT, USA
| | | | - Amer M Zeidan
- Department of Medicine, Section of Hematology, Yale University, New Haven, CT, USA
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7
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Bewersdorf JP, Carraway H, Prebet T. Emerging treatment options for patients with high-risk myelodysplastic syndrome. Ther Adv Hematol 2020; 11:2040620720955006. [PMID: 33240476 PMCID: PMC7675905 DOI: 10.1177/2040620720955006] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/31/2020] [Indexed: 12/20/2022] Open
Abstract
Myelodysplastic syndromes (MDS) are clonal hematopoietic stem cell disorders
characterized by ineffective hematopoiesis with peripheral blood cytopenias,
dysplastic cell morphology, and a variable risk of progression to acute myeloid
leukemia (AML). The hypomethylating agents (HMA) azacitidine and decitabine have
been used for over a decade in MDS treatment and lead to a modest survival
benefit. However, response rates are only around 40% and responses are mostly
transient. For HMA-refractory patients the prognosis is poor and there are no
therapies approved by the United States Food and Drug Administration. Combinations of HMAs, especially along with immune checkpoint inhibitors, have
shown promising signals in both the frontline and HMA-refractory setting.
Several other novel agents including orally available and longer acting HMAs,
the BCL-2 inhibitor venetoclax, oral agents targeting driver mutations
(IDH1/2, FLT3), immunotherapies, and new options for
intensive chemotherapy have been studied with variable success and will be
reviewed herein. Except for the minority of patients with targetable driver
mutations, HMAs – likely as part of combination therapies – will remain the
backbone of frontline MDS treatment. However, the wider use of genetic testing
may enable a more targeted and individualized therapy of MDS patients.
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Affiliation(s)
- Jan Philipp Bewersdorf
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
| | - Hetty Carraway
- Leukemia Program, Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Thomas Prebet
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, 37 College Street, Room 101, New Haven, CT 06511, USA
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8
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Compassionate use of glasdegib in combination with low-dose cytarabine for relapsed, refractory acute myeloid leukemia or high-risk myelodysplastic syndrome. Ann Hematol 2020; 100:837-839. [PMID: 33001280 DOI: 10.1007/s00277-020-04291-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 09/28/2020] [Indexed: 02/03/2023]
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9
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Ossenkoppele GJ, Breems DA, Stuessi G, van Norden Y, Bargetzi M, Biemond BJ, A von dem Borne P, Chalandon Y, Cloos J, Deeren D, Fehr M, Gjertsen B, Graux C, Huls G, Janssen JJJW, Jaspers A, Jongen-Lavrencic M, de Jongh E, Klein SK, van der Klift M, van Marwijk Kooy M, Maertens J, Michaux L, van der Poel MWM, van Rhenen A, Tick L, Valk P, Vekemans MC, van der Velden WJFM, de Weerdt O, Pabst T, Manz M, Löwenberg B. Lenalidomide added to standard intensive treatment for older patients with AML and high-risk MDS. Leukemia 2020; 34:1751-1759. [PMID: 32020044 DOI: 10.1038/s41375-020-0725-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/24/2019] [Accepted: 01/22/2020] [Indexed: 11/09/2022]
Abstract
More effective treatment modalities are urgently needed in patients with acute myeloid leukemia (AML) of older age. We hypothesized that adding lenalidomide to intensive standard chemotherapy might improve their outcome. After establishing a safe lenalidomide, dose elderly patients with AML were randomly assigned in this randomized Phase 2 study (n = 222) to receive standard chemotherapy ("3 + 7") with or without lenalidomide at a dose of 20 mg/day 1-21. In the second cycle, patients received cytarabine 1000 mg/m2 twice daily on days 1-6 with or without lenalidomide (20 mg/day 1-21). The CR/CRi rates in the two arms were not different (69 vs. 66%). Event-free survival (EFS) at 36 months was 19% for the standard arm versus 21% for the lenalidomide arm and overall survival (OS) 35% vs. 30%, respectively. The frequencies and grade of adverse events were not significantly different between the treatment arms. Cardiovascular toxicities were rare and equally distributed between the arms. The results of the present study show that the addition of lenalidomide to standard remission induction chemotherapy does not improve the therapeutic outcome of older AML patients. This trial is registered as number NTR2294 in The NederlandsTrial Register (www.trialregister.nl).
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Affiliation(s)
- G J Ossenkoppele
- Amsterdam University Medical Cente, location VUMC, Amsterdam, Netherlands.
| | | | - G Stuessi
- Bellinzona-IOSI, Bellinzona, Switzerland
| | - Y van Norden
- HOVON Data Center, Erasmus MC- Department of Hematology, Rotterdam, The Netherlands
| | - M Bargetzi
- Aarau- Kantonsspital, Aarau, Switzerland
| | - B J Biemond
- Amsterdam University Medical Center, location AMC, Amsterdam, Netherlands
| | | | - Y Chalandon
- University Hospital and University of Geneva, Genève, Switzerland
| | - J Cloos
- Amsterdam University Medical Cente, location VUMC, Amsterdam, Netherlands
| | - D Deeren
- Roeselare-AZ Delta, Roeselare, Belgium
| | - M Fehr
- St Gallen-Kantonnsspital, St. Gallen, Switzerland
| | - B Gjertsen
- Haukeland University Hospital, Bergen (N), Norway
| | - C Graux
- Yvoir-MontGodinne, Yvoir, Belgium
| | - G Huls
- University Medical Center, Groningen, Netherlands
| | - J J J W Janssen
- Amsterdam University Medical Cente, location VUMC, Amsterdam, Netherlands
| | - A Jaspers
- Hôpital Citadelle, Liège (B), Belgium
| | | | | | - S K Klein
- Meander Medical Center, Amersfoort, Netherlands
| | | | | | - J Maertens
- Hospital Gasthuisberg, Leuven (B), Belgium
| | - L Michaux
- Center for Human Genetics, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | | | | | - L Tick
- MaximaMC Eindhoven, Eindhoven, Netherlands
| | - P Valk
- Hôpital Citadelle, Liège (B), Belgium
| | | | | | - O de Weerdt
- St Antonius Hospital, Nieuwegein, Netherlands
| | - T Pabst
- Department of Oncology, University Hospital, Inselspital and University of Bern, Bern, Switzerland
| | - M Manz
- University Hospital, Zurich, Switzerland
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10
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Immunomodulation with pomalidomide at early lymphocyte recovery after induction chemotherapy in newly diagnosed AML and high-risk MDS. Leukemia 2020; 34:1563-1576. [PMID: 31900407 DOI: 10.1038/s41375-019-0693-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 11/24/2019] [Accepted: 12/06/2019] [Indexed: 11/09/2022]
Abstract
An immunosuppressive microenvironment promoting leukemia cell immune escape plays an important role in the pathogenesis of AML. Through its interaction with cereblon, a substrate receptor for the E3 ubiquitin ligase complex, pomalidomide leads to selective ubiquitination of transcription factors Aiolos and Ikaros thereby promoting immune modulation. In this phase I trial, 51 newly diagnosed non-favorable risk AML and high-risk MDS patients were enrolled and treated with AcDVP16 (cytarabine 667 mg/m2/day IV continuous infusion days 1-3, daunorubicin 45 mg/m2 IV days 1-3, etoposide 400 mg/m2 IV days 8-10) induction therapy followed by dose- and duration-escalation pomalidomide beginning at early lymphocyte recovery. Forty-three patients (AML: n = 39, MDS: n = 4) received pomalidomide. The maximum tolerated dose of pomalidomide was 4 mg for 21 consecutive days. The overall complete remission (CR + CRi) rate, median overall survival, and disease-free survival were 75%, 27.1 and 20.6 months, respectively. Subset analyses revealed 86% CR/CRi rate in AML patients with unfavorable-risk karyotype treated with pomalidomide. Pomalidomide significantly decreased Aiolos expression in both CD4+ and CD8+ peripheral blood and bone marrow T cells, promoted T cell differentiation, proliferation, and heightened their cytokine production. Finally, pomalidomide induced distinct gene expression changes in immune function-related ontologies in CD4+ and CD8+ T cells.
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11
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Bewersdorf JP, Stahl M, Zeidan AM. One plus one does not always equal two, especially with regard to hypomethylating agents: the question of synergy of azacitidine and lenalidomide for treatment of relapsed acute myeloid leukemia and myelodysplastic syndromes post allogeneic hematopoietic stem cell transplant. Expert Rev Hematol 2019; 12:575-578. [PMID: 31225770 DOI: 10.1080/17474086.2019.1635005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Key paper evaluation: Craddock C, et al. Combination Lenalidomide and Azacitidine: A Novel Salvage Therapy in Patients Who Relapse After Allogeneic Stem-Cell Transplantation for Acute Myeloid Leukemia. J Clin Oncol. 2019; 37: 580-8. Allogeneic hematopoietic stem cell transplant (allo-HSCT) is the only potentially curative treatment for acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS). However, most patients relapse after allo-HSCT and treatment options are limited. Craddock et al. reported recently in the Journal of Clinical Oncology results from a small phase Ib study combining azacitidine (AZA) and lenalidomide (LEN) for treatment of 29 patients (24 AML and 5 MDS patients) who relapsed after allo-HSCT. Overall response rate was 24%. Patients who received ≥3 cycles of treatment had a higher response rate and responders had a better survival compared to non-responders (27 months vs. 10 months; p = 0.004). Combination treatment was well tolerated with three cases of graft-versus-host disease. While this study suggests a potential synergistic effect of LEN + AZA combination therapy, many questions remain. Efficacy and safety should be confirmed in larger, ideally randomized, studies. Further research on mechanism of action of this combination, comparison with other treatment combinations (e.g. AZA + venetoclax) and use during other disease stages are needed.
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Affiliation(s)
- Jan Philipp Bewersdorf
- a Department of Internal Medicine, Section of Hematology, Yale School of Medicine , New Haven , CT , USA
| | - Maximilian Stahl
- b Leukemia Service, Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Amer M Zeidan
- a Department of Internal Medicine, Section of Hematology, Yale School of Medicine , New Haven , CT , USA.,c Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University , New Haven , CT , USA
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12
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Horibata S, Gui G, Lack J, DeStefano CB, Gottesman MM, Hourigan CS. Heterogeneity in refractory acute myeloid leukemia. Proc Natl Acad Sci U S A 2019; 116:10494-10503. [PMID: 31064876 PMCID: PMC6535032 DOI: 10.1073/pnas.1902375116] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Successful clinical remission to therapy for acute myeloid leukemia (AML) is required for long-term survival to be achieved. Despite trends in improved survival due to better supportive care, up to 40% of patients will have refractory disease, which has a poorly understood biology and carries a dismal prognosis. The development of effective treatment strategies has been hindered by a general lack of knowledge about mechanisms of chemotherapy resistance. Here, through transcriptomic analysis of 154 cases of treatment-naive AML, three chemorefractory patient groups with distinct expression profiles are identified. A classifier, four key refractory gene signatures (RG4), trained based on the expression profile of the highest risk refractory patients, validated in an independent cohort (n = 131), was prognostic for overall survival (OS) and refined an established 17-gene stemness score. Refractory subpopulations have differential expression in pathways involved in cell cycle, transcription, translation, metabolism, and/or stem cell properties. Ex vivo drug sensitivity to 122 small-molecule inhibitors revealed effective group-specific targeting of pathways among these three refractory groups. Gene expression profiling by RNA sequencing had a suboptimal ability to correctly predict those individuals resistant to conventional cytotoxic induction therapy, but could risk-stratify for OS and identify subjects most likely to have superior responses to a specific alternative therapy. Such personalized therapy may be studied prospectively in clinical trials.
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Affiliation(s)
- Sachi Horibata
- Laboratory of Cell Biology, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892;
| | - Gege Gui
- Laboratory of Myeloid Malignancies, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20814
| | - Justin Lack
- NIAID Collaborative Bioinformatics Resource, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892
- Advanced Biomedical Computational Science, Frederick National Laboratory for Cancer Research sponsored by the National Cancer Institute, Frederick, MD 21702
| | - Christin B DeStefano
- Laboratory of Myeloid Malignancies, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20814
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
| | - Michael M Gottesman
- Laboratory of Cell Biology, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892;
| | - Christopher S Hourigan
- Laboratory of Myeloid Malignancies, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20814;
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13
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Retuning the immune system in myelodysplastic syndromes: from immunomodulatory approaches to vaccination strategies and non myeloablative hemopoietic cell transplant. Crit Rev Oncol Hematol 2019; 133:112-119. [DOI: 10.1016/j.critrevonc.2018.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/09/2018] [Accepted: 11/05/2018] [Indexed: 12/24/2022] Open
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14
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How I treat MDS after hypomethylating agent failure. Blood 2018; 133:521-529. [PMID: 30545832 DOI: 10.1182/blood-2018-03-785915] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 12/04/2018] [Indexed: 12/20/2022] Open
Abstract
Hypomethylating agents (HMA) azacitidine and decitabine are standard of care for myelodysplastic syndrome (MDS). Response to these agents occurs in ∼50% of treated patients, and duration of response, although variable, is transient. Prediction of response to HMAs is possible with clinical and molecular parameters, but alternative approved treatments are not available, and in the case of HMA failure, there are no standard therapeutic opportunities. It is important to develop a reasoned choice of therapy after HMA failure. This choice should be based on evaluation of type of resistance (primary vs secondary, progression of disease [acute leukemia or higher risk MDS] vs absence of hematological improvement) as well as on molecular and cytogenetic characteristics reassessed at the moment of HMA failure. Rescue strategies may include stem-cell transplantation, which remains the only curative option, and chemotherapy, both of which are feasible in only a minority of cases, and experimental agents. Patients experiencing HMA failure should be recruited to clinical experimental trials as often as possible. Several novel agents with different mechanisms of action are currently being tested in this setting. Drugs targeting molecular alterations (IDH2 mutations, spliceosome gene mutations) or altered signaling pathways (BCL2 inhibitors) seem to be the most promising.
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15
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SOHO State of the Art and Next Questions: Management of Myelodysplastic Syndromes With Deletion 5q. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:629-635. [DOI: 10.1016/j.clml.2018.07.293] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 07/25/2018] [Indexed: 12/17/2022]
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16
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Hütter-Krönke ML, Fiedler W, Kündgen A, Krauter J, von Lilienfeld-Toal M, Döhner H, Schlenk RF. Continuous high dosing of lenalidomide in relapsed, refractory or older newly diagnosed acute myeloid leukemia patients not suitable for other treatment options - results from a phase I study. Haematologica 2018; 104:e63-e64. [PMID: 30171028 DOI: 10.3324/haematol.2018.199794] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
| | - Walter Fiedler
- Department of Internal Medicine II, University Hospital Hamburg-Eppendorf, Hamburg
| | - Andrea Kündgen
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine University Düsseldorf
| | - Jürgen Krauter
- Department of Internal Medicine III, Hospital Braunschweig.,Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Germany
| | | | | | - Richard F Schlenk
- Department of Internal Medicine III, University of Ulm.,National Center for Tumor Diseases, Heidelberg
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17
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Shallis RM, Chokr N, Stahl M, Pine AB, Zeidan AM. Immunosuppressive therapy in myelodysplastic syndromes: a borrowed therapy in search of the right place. Expert Rev Hematol 2018; 11:715-726. [PMID: 30024293 DOI: 10.1080/17474086.2018.1503049] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Myelodysplastic syndromes (MDS) encompass a heterogenous collection of clonal hematopoietic stem cell disorders defined by dysregulated hematopoiesis, peripheral cytopenias, and a risk of leukemic progression. Increasing data support the role of innate and adaptive immune pathways in the pathogenesis and disease course of MDS. The role of immunosuppressive therapy has an established role in the treatment of other hematologic diseases, such as aplastic anemia whose pathogenesis is postulated to reflect that of MDS with regards to many aspects of immune activation. Areas covered: This paper discusses the current understanding of immune dysregulation as it pertains to MDS, the clinical experience with immunosuppressive therapy in the management of MDS, as well as future prospects which will likely improve therapeutic options and outcomes for patients with MDS. Expert commentary: Though limited by paucity of high quality data, immunomodulatory and immunosuppressive therapies for the treatment of MDS have shown meaningful clinical activity in selected patients. Continued clarification of the immune pathways that are dysregulated in MDS and establishing predictors for clinical benefit of immunosuppressive therapy are vital to improve the use and outcomes with these therapies.
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Affiliation(s)
- Rory M Shallis
- a Division of Hematology/Medical Oncology, Department of Medicine , Yale University School of Medicine , New Haven , USA
| | - Nora Chokr
- a Division of Hematology/Medical Oncology, Department of Medicine , Yale University School of Medicine , New Haven , USA
| | - Maximilian Stahl
- a Division of Hematology/Medical Oncology, Department of Medicine , Yale University School of Medicine , New Haven , USA
| | - Alexander B Pine
- a Division of Hematology/Medical Oncology, Department of Medicine , Yale University School of Medicine , New Haven , USA
| | - Amer M Zeidan
- a Division of Hematology/Medical Oncology, Department of Medicine , Yale University School of Medicine , New Haven , USA.,b Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center , Yale University , New Haven , USA
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18
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Shallis RM, Zeidan AM. Lenalidomide in non-deletion 5q lower-risk myelodysplastic syndromes: a glass quarter full or three quarters empty? Leuk Lymphoma 2018; 59:2015-2017. [PMID: 29411698 DOI: 10.1080/10428194.2018.1430797] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Rory M Shallis
- a Department of Internal Medicine School of Medicine , Yale University , New Haven , USA
| | - Amer M Zeidan
- a Department of Internal Medicine School of Medicine , Yale University , New Haven , USA.,b Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University , New Haven , USA
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19
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Uy N, Singh A, Gore SD, Prebet T. Hypomethylating agents (HMA) treatment for myelodysplastic syndromes: alternatives in the frontline and relapse settings. Expert Opin Pharmacother 2017; 18:1213-1224. [PMID: 28675065 PMCID: PMC6121132 DOI: 10.1080/14656566.2017.1349100] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 06/27/2017] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Hypomethylating agents (HMA) have played a pivotal role for treating myelodysplastic syndromes (MDS) over the past decade, inducing sustained hematological responses and delaying progression to leukemia. However, a vast majority of patients will experience treatment failure within 2 years, with poor prognoses and limited options, and management of this growing patient population remains unclear. Areas covered: With the introduction of new agents in the MDS field, a better understanding of the biology of MDS, and updated information on standard of care options (including allogeneic transplantation), we re-evaluate the global treatment strategy in MDS via novel agents, focusing in particular on investigational approaches for patients who fail to respond to HMA when applicable. This review aims to address two questions: what are reasonable alternatives to HMA in MDS, and what strategies can be used for patients experiencing HMA failure. Expert opinion/commentary: HMA therapy remains a mainstay of treatment, even if additional research is still warranted to maximize its benefits for the different groups of patients. The outcome of patients experiencing HMA failure remains grim, without standard of care, but several new approaches seem promising, as there is an increasing focus on studying treatments for patients refractory to HMA treatment.
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Affiliation(s)
- Natalie Uy
- a Section of Hematology, Department of Internal Medicine , Yale School of Medicine , New Haven , CT , USA
| | - Abhay Singh
- a Section of Hematology, Department of Internal Medicine , Yale School of Medicine , New Haven , CT , USA
| | - Steven D Gore
- a Section of Hematology, Department of Internal Medicine , Yale School of Medicine , New Haven , CT , USA
| | - Thomas Prebet
- a Section of Hematology, Department of Internal Medicine , Yale School of Medicine , New Haven , CT , USA
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20
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Talati C, Sallman D, List A. Lenalidomide: Myelodysplastic syndromes with del(5q) and beyond. Semin Hematol 2017; 54:159-166. [PMID: 28958290 DOI: 10.1053/j.seminhematol.2017.06.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 06/19/2017] [Indexed: 01/18/2023]
Abstract
Myelodysplastic syndrome (MDS) with deletion 5q (del(5q)) is a distinct clinical and pathological disease subset that is exquisitely sensitive to lenalidomide for the treatment of red blood cell transfusion-dependent anemia. Although lenalidomide has erythropoeitic promoting activity in MDS without del(5q) (non-del(5q) MDS), the frequency of response to treatment is lower and relates to biologically separate drug effects. In del(5q) MDS, lenalidomide suppresses the malignant clone to restore effective erythropoiesis by virtue of synthetic lethality, arising from cereblon-dependent degradation of haplodeficient proteins encoded within the commonly deleted region of the chromosome 5q deletion. In contrast, in non-del(5q) MDS, lenalidomide restores effective erythropoiesis via enhancement of erythropoietin (EPO) receptor-initiated transcriptional response arising from the assembly of signaling-competent receptor complexes within membrane lipid raft domains. Recently, large phase III clinical studies have explored the role of lenalidomide, alone and in combination with, erythropoiesis-stimulating agents showing additive improvement in erythroid responses. Herein, we will describe the mechanisms of lenalidomide action in MDS and pivotal clinical studies testing the benefit of lenalidomide in both del(5q) and non-del(5q) MDS. Furthermore, we discuss evidence-based strategies to incorporate lenalidomide into the treatment algorithm for patients with MDS.
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Affiliation(s)
- Chetasi Talati
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | - David Sallman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL.
| | - Alan List
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
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21
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Stahl M, Zeidan AM. Lenalidomide use in myelodysplastic syndromes: Insights into the biologic mechanisms and clinical applications. Cancer 2017; 123:1703-1713. [PMID: 28192601 DOI: 10.1002/cncr.30585] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 12/30/2016] [Accepted: 01/01/2017] [Indexed: 12/13/2022]
Abstract
Myelosysplastic syndromes (MDS) include a heterogeneous group of clonal myeloid neoplasms characterized by ineffective hematopoiesis leading to blood cytopenias and a variable risk of progression into acute myeloid leukemia (AML). Although the hypomethylating agent azacitidine prolongs survival among patients with higher risk (HR)-MDS compared with conventional care, no drug has been shown conclusively to prolong survival or delay progression to AML among patients with lower-risk MDS (LR-MDS). Lenalidomide is the drug with the most impressive clinical activity in the subset of anemic LR-MDS patients who harbor a deletion of the long arm of chromosome 5 (5q-), where it leads to high rates of transfusion independence and cytogenetic responses. Furthermore, lenalidomide delays progression to AML and prolongs survival among responders. In this article, we review the recently recognized mechanisms of action of lenalidomide and discuss the most recent clinical data regarding its use in patients with both 5q- MDS as well as non-5q- MDS. Finally, we forecast the future directions to improve the efficacy of lenalidomide in MDS with and without 5q-. Cancer 2017;123:1703-1713. © 2017 American Cancer Society.
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Affiliation(s)
- Maximilian Stahl
- Yale Cancer Center, New Haven, Connecticut.,Section of Hematology, Department of Internal Medicine Yale University, New Haven, Connecticut
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine Yale University, New Haven, Connecticut
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