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Graff Z, Wachter F, Eapen M, Lehmann L, Cooper T. Navigating Treatment Options and Communication in Relapsed Pediatric AML. Am Soc Clin Oncol Educ Book 2024; 44:e438690. [PMID: 38862135 DOI: 10.1200/edbk_438690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
Despite improved outcomes in newly diagnosed pediatric AML, relapsed disease remains a therapeutic challenge. Factors contributing to slow progress in improving outcomes include inherent challenges in pediatric clinical trial accrual and the scarcity of novel targeted/immunotherapy agents available for pediatric development. This paradigm is changing, however, as international collaboration grows in parallel with the development of promising targeted agents. In this review, we discuss the therapeutic landscape of relapsed pediatric AML, including conventional chemotherapy, targeted therapies, and the challenges of drug approvals in this patient population. We highlight current efforts to improve communication among academia, industry, and regulatory authorities and discuss the importance of international collaboration to improve access to new therapies. Among the therapeutic options, we highlight the approach to second hematopoietic stem cell transplant (HSCT) and discuss which patients are most likely to benefit from this potentially curative intervention. Importantly, we acknowledge the challenges in providing these high-risk interventions to our patients and their families and the importance of shared communication and decision making when considering early-phase clinical trials and second HSCT.
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Affiliation(s)
- Zachary Graff
- Department of Pediatrics, Division of Hematology, Oncology, and BMT, Medical College of Wisconsin, Milwaukee, WI
| | - Franziska Wachter
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Mary Eapen
- Department of Medicine, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Leslie Lehmann
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Todd Cooper
- Department of Pediatrics, Division of Hematology and Oncology, Seattle Children's Hospital, Seattle, WA
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Tarlock K, Gerbing RB, Ries RE, Smith JL, Leonti A, Huang BJ, Kirkey D, Robinson L, Peplinksi JH, Lange B, Cooper TM, Gamis AS, Kolb EA, Aplenc R, Pollard JA, Alonzo TA, Meshinchi S. Prognostic impact of cooccurring mutations in FLT3-ITD pediatric acute myeloid leukemia. Blood Adv 2024; 8:2094-2103. [PMID: 38295280 PMCID: PMC11063409 DOI: 10.1182/bloodadvances.2023011980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/28/2023] [Accepted: 01/11/2024] [Indexed: 02/02/2024] Open
Abstract
ABSTRACT We sought to define the cooccurring mutational profile of FLT3-ITD-positive (ITDpos) acute myeloid leukemia (AML) in pediatric and young adult patients and to define the prognostic impact of cooperating mutations. We identified 464 patients with FLT3-ITD mutations treated on Children's Oncology Group trials with available sequencing and outcome data. Overall survival, event-free survival (EFS), and relapse risk were determined according to the presence of cooccurring risk stratifying mutations. Among the cohort, 79% of patients had cooccurring alterations across 239 different genes that were altered through mutations or fusions. Evaluation of the prognostic impact of the cooccurring mutations demonstrated that patients with ITDpos AML experienced significantly different outcomes according to the cooccurring mutational profile. Patients with ITDpos AML harboring a cooccurring favorable-risk mutation of NPM1, CEBPA, t(8;21), or inv(16) experienced a 5-year EFS of 64%, which was significantly superior to of 22.2% for patients with ITDpos AML and poor-risk mutations of WT1, UBTF, or NUP98::NSD1 as well to 40.9% for those who lacked either favorable-risk or poor-risk mutation (ITDpos intermediate; P < .001 for both). Multivariable analysis demonstrated that cooccurring mutations had significant prognostic impact, whereas allelic ratio had no impact. Therapy intensification, specifically consolidation transplant in remission, resulted in significant improvements in survival for ITDpos AML. However, patients with ITDpos/NUP98::NSD1 continued to have poor outcomes with intensified therapy, including sorafenib. Cooccurring mutational profile in ITDpos AML has significant prognostic impacts and is critical to determining risk stratification and therapeutic allocation. These clinical trials were registered at www.clinicaltrials.gov as NCT00002798, NCT00070174, NCT00372593, and NCT01371981.
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Affiliation(s)
- Katherine Tarlock
- Division of Hematology/Oncology, Seattle Children’s Hospital, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | | | - Rhonda E. Ries
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Jenny L. Smith
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Amanda Leonti
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Benjamin J. Huang
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Danielle Kirkey
- Division of Hematology/Oncology, Seattle Children’s Hospital, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Leila Robinson
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Jack H. Peplinksi
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Beverly Lange
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Todd M. Cooper
- Division of Hematology/Oncology, Seattle Children’s Hospital, Seattle, WA
| | - Alan S. Gamis
- Divisions of Hematology/Oncology, Children’s Mercy Hospital and Clinics, Kansas City, MO
| | - E. Anders Kolb
- Nemours Center for Cancer and Blood Disorders, Alfred I. DuPont Hospital for Children, Wilmington, DE
| | - Richard Aplenc
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jessica A. Pollard
- Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Todd A. Alonzo
- Children’s Oncology Group, Monrovia, CA
- University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Soheil Meshinchi
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
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3
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Russell NH, Wilhelm-Benartzi C, Othman J, Dillon R, Knapper S, Batten LM, Canham J, Hinson EL, Betteridge S, Overgaard UM, Gilkes A, Potter N, Mehta P, Kottaridis P, Cavenagh J, Hemmaway C, Arnold C, Freeman SD, Dennis M. Fludarabine, Cytarabine, Granulocyte Colony-Stimulating Factor, and Idarubicin With Gemtuzumab Ozogamicin Improves Event-Free Survival in Younger Patients With Newly Diagnosed AML and Overall Survival in Patients With NPM1 and FLT3 Mutations. J Clin Oncol 2024:JCO2300943. [PMID: 38215358 DOI: 10.1200/jco.23.00943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 09/07/2023] [Accepted: 10/20/2023] [Indexed: 01/14/2024] Open
Abstract
PURPOSE To determine the optimal induction chemotherapy regimen for younger adults with newly diagnosed AML without known adverse risk cytogenetics. PATIENTS AND METHODS One thousand thirty-three patients were randomly assigned to intensified (fludarabine, cytarabine, granulocyte colony-stimulating factor, and idarubicin [FLAG-Ida]) or standard (daunorubicin and Ara-C [DA]) induction chemotherapy, with one or two doses of gemtuzumab ozogamicin (GO). The primary end point was overall survival (OS). RESULTS There was no difference in remission rate after two courses between FLAG-Ida + GO and DA + GO (complete remission [CR] + CR with incomplete hematologic recovery 93% v 91%) or in day 60 mortality (4.3% v 4.6%). There was no difference in OS (66% v 63%; P = .41); however, the risk of relapse was lower with FLAG-Ida + GO (24% v 41%; P < .001) and 3-year event-free survival was higher (57% v 45%; P < .001). In patients with an NPM1 mutation (30%), 3-year OS was significantly higher with FLAG-Ida + GO (82% v 64%; P = .005). NPM1 measurable residual disease (MRD) clearance was also greater, with 88% versus 77% becoming MRD-negative in peripheral blood after cycle 2 (P = .02). Three-year OS was also higher in patients with a FLT3 mutation (64% v 54%; P = .047). Fewer transplants were performed in patients receiving FLAG-Ida + GO (238 v 278; P = .02). There was no difference in outcome according to the number of GO doses, although NPM1 MRD clearance was higher with two doses in the DA arm. Patients with core binding factor AML treated with DA and one dose of GO had a 3-year OS of 96% with no survival benefit from FLAG-Ida + GO. CONCLUSION Overall, FLAG-Ida + GO significantly reduced relapse without improving OS. However, exploratory analyses show that patients with NPM1 and FLT3 mutations had substantial improvements in OS. By contrast, in patients with core binding factor AML, outcomes were excellent with DA + GO with no FLAG-Ida benefit.
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Affiliation(s)
- Nigel H Russell
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - Jad Othman
- Department of Medical and Molecular Genetics, Kings College London, London, United Kingdom
| | - Richard Dillon
- Department of Medical and Molecular Genetics, Kings College London, London, United Kingdom
| | - Steven Knapper
- School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Leona M Batten
- Centre for Trials Research, Cardiff University, Cardiff, United Kindgom
| | - Joanna Canham
- Centre for Trials Research, Cardiff University, Cardiff, United Kindgom
| | - Emily L Hinson
- Centre for Trials Research, Cardiff University, Cardiff, United Kindgom
| | - Sophie Betteridge
- Centre for Trials Research, Cardiff University, Cardiff, United Kindgom
| | | | - Amanda Gilkes
- School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Nicola Potter
- Department of Medical and Molecular Genetics, Kings College London, London, United Kingdom
| | - Priyanka Mehta
- University Hospitals of Bristol and Weston NHS Trust, Bristol, United Kingdom
| | | | - Jamie Cavenagh
- Department of Haematology, St Bartholomew's Hospital, London, United Kingdom
| | | | | | - Sylvie D Freeman
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Mike Dennis
- The Christie NHS Foundation Trust, Manchester, United Kingdom
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Pawinska-Wasikowska K, Czogala M, Skoczen S, Surman M, Rygielska M, Ksiazek T, Pac A, Wieczorek A, Skalska-Sadowska J, Samborska M, Wachowiak J, Chaber R, Tomaszewska R, Szczepanski T, Zielezinska K, Urasinski T, Moj-Hackemer M, Kalwak K, Kozlowska M, Irga-Jaworska N, Balwierz W, Bukowska-Strakova K. Gemtuzumab ozogamicin for relapsed or primary refractory acute myeloid leukemia in children-the Polish Pediatric Leukemia and Lymphoma Study Group experience. Front Immunol 2023; 14:1268993. [PMID: 38187390 PMCID: PMC10766767 DOI: 10.3389/fimmu.2023.1268993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 12/07/2023] [Indexed: 01/09/2024] Open
Abstract
Background Gemtuzumab ozogamicin (GO), one of the first targeted drugs used in oncology, consists of an anti-cluster of differentiation 33 (CD33) monoclonal antibody bound to a derivative of cytotoxic calicheamicin. After the drug withdrawn in 2010 due to a significantly higher rate of early deaths, GO regained approval in 2017 for the treatment of newly diagnosed, refractory, or relapsed acute myeloid leukemia (AML) in adults and children over 15 years of age. The objective of the study was a retrospective analysis of clinical characteristics, treatment outcomes, and GO toxicity profile in children with primary refractory or relapsed (R/R) AML treated in Poland from 2008 to 2022. Methods Data were collected through the Polish Registry of Acute Myeloid Leukemia. From January 2008 to December 2022, 35 children with R/R AML were treated with GO in seven centers of the Polish Pediatric Leukemia and Lymphoma Study Group. Results Most of the children (30 of 35) received only one GO cycle in combination with various chemotherapy cycles (IDA-FLA, DOXO-FLA, FLA, FLAG, and others). Eighteen children (51%) achieved complete remission (CR), 14 did not respond to treatment, and three progressed. GO therapy was followed by allogeneic hematopoietic stem cell transplantation (allo-HSCT) in 18 children in CR. The 5-year overall survival (OS) after GO therapy was 37.1% ± 8.7% for the total cohort. There was a trend toward a superior outcome in patients with strong expression of CD33 expression (over 50% positive cells) compared with that in patients with lower expression of CD33 (OS, 41.2% ± 11.9% versus 27.8% ± 13.2%; p = 0.5; 5-year event-free survival, 35.4% ± 11.6% versus 25.7% ± 12.3%; p = 0.5, respectively). Children under 15 years have better outcome (OS, 34.9% ± 10.4% versus 30% ± 14.5%, p = 0.3). The most common adverse events were bone marrow aplasia, fever of unknown origin, infections, and elevated liver enzyme elevation. Sinusoidal obstruction syndrome occurred in two children. Conclusions The use of GO in severely pretreated children, including those under 15 years of age, with previous failure of AML treatment is a feasible and effective bridging therapy to allo-HSCT with an acceptable toxicity profile.
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Affiliation(s)
- Katarzyna Pawinska-Wasikowska
- Department of Pediatric Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
- Department of Pediatric Oncology and Hematology, University Children Hospital of Krakow, Krakow, Poland
| | - Malgorzata Czogala
- Department of Pediatric Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
- Department of Pediatric Oncology and Hematology, University Children Hospital of Krakow, Krakow, Poland
| | - Szymon Skoczen
- Department of Pediatric Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
- Department of Pediatric Oncology and Hematology, University Children Hospital of Krakow, Krakow, Poland
| | - Marta Surman
- Laboratory of Clinical Immunology, University Children’s Hospital of Krakow, Krakow, Poland
| | - Monika Rygielska
- Department of Pediatric Oncology and Hematology, Hematology Laboratory, University Children’s Hospital, Krakow, Poland
| | - Teofila Ksiazek
- Department of Medical Genetics, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Agnieszka Pac
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Aleksandra Wieczorek
- Department of Pediatric Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
- Department of Pediatric Oncology and Hematology, University Children Hospital of Krakow, Krakow, Poland
| | - Jolanta Skalska-Sadowska
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Magdalena Samborska
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Radoslaw Chaber
- Department of Pediatric Oncohematology, Clinical Province Hospital of Rzeszow, Rzeszow, Poland
- Department of Pediatrics, Institute of Medical Sciences, Medical College, University of Rzeszow, Rzeszow, Poland
| | - Renata Tomaszewska
- Department of Pediatric Hematology and Oncology, Zabrze, Medical University of Silesia, Katowice, Poland
| | - Tomasz Szczepanski
- Department of Pediatric Hematology and Oncology, Zabrze, Medical University of Silesia, Katowice, Poland
| | - Karolina Zielezinska
- Department of Pediatrics, Hemato-Oncology and Gastroenterology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Tomasz Urasinski
- Department of Pediatrics, Hemato-Oncology and Gastroenterology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Malgorzata Moj-Hackemer
- Clinical Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland
| | - Krzysztof Kalwak
- Clinical Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland
| | - Marta Kozlowska
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdansk, Gdansk, Poland
| | - Ninela Irga-Jaworska
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdansk, Gdansk, Poland
| | - Walentyna Balwierz
- Department of Pediatric Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
- Department of Pediatric Oncology and Hematology, University Children Hospital of Krakow, Krakow, Poland
| | - Karolina Bukowska-Strakova
- Department of Clinical Immunology, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
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Murphy LA, Winters AC. Emerging and Future Targeted Therapies for Pediatric Acute Myeloid Leukemia: Targeting the Leukemia Stem Cells. Biomedicines 2023; 11:3248. [PMID: 38137469 PMCID: PMC10741170 DOI: 10.3390/biomedicines11123248] [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: 11/13/2023] [Revised: 12/01/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
Acute myeloid leukemia (AML) is a rare subtype of acute leukemia in the pediatric and adolescent population but causes disproportionate morbidity and mortality in this age group. Standard chemotherapeutic regimens for AML have changed very little in the past 3-4 decades, but the addition of targeted agents in recent years has led to improved survival in select subsets of patients as well as a better biological understanding of the disease. Currently, one key paradigm of bench-to-bedside practice in the context of adult AML is the focus on leukemia stem cell (LSC)-targeted therapies. Here, we review current and emerging immunotherapies and other targeted agents that are in clinical use for pediatric AML through the lens of what is known (and not known) about their LSC-targeting capability. Based on a growing understanding of pediatric LSC biology, we also briefly discuss potential future agents on the horizon.
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Affiliation(s)
- Lindsey A. Murphy
- Department of Pediatrics, City of Hope Comprehensive Cancer Center, Duarte, CA 91010, USA;
| | - Amanda C. Winters
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA
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Al-Antary ET, Gupte A, Carter J, Kaafarani M, Howard M, Edwards H, Ge Y, Taub JW. Curing childhood cancer the "Natural" Way: Nature as the source of chemotherapy agents. Biochem Pharmacol 2023; 213:115630. [PMID: 37263301 DOI: 10.1016/j.bcp.2023.115630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/24/2023] [Accepted: 05/24/2023] [Indexed: 06/03/2023]
Abstract
For many centuries, products of natural origin from plants, marine, microbes and soil micro-organisms have been studied by numerous researchers across the world to yield many of the chemotherapeutic agents we use in this modern era. There has been a tremendous gain in knowledge from various screening and separating techniques which led to the discovery of biologically active small molecules from natural products. Preclinical studies testing the antitumor activities of these agents against tumor cell lines and xenograft animal models were the gateway to the clinical trials in humans leading to the approval of these agents that are in clinical use today. This review summarizes how various chemotherapeutic agents were discovered from products of natural origin, their preclinical development, and their indications in both pediatric and adult oncology. Many of these natural products have contributed to the very high cure rates of both pediatric leukemias and solid tumors.
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Affiliation(s)
- Eman T Al-Antary
- Division of Pediatric Hematology/Oncology, Children's Hospital of Michigan, Detroit, MI, USA; Discipline of Pediatrics, Central Michigan University, Mt. Pleasant, MI, USA
| | - Avanti Gupte
- Division of Pediatric Hematology/Oncology, Children's Hospital of Michigan, Detroit, MI, USA; Discipline of Pediatrics, Central Michigan University, Mt. Pleasant, MI, USA
| | - Jenna Carter
- Cancer Biology Graduate Program, Wayne State University School of Medicine, Detroit, MI, USA; MD/PhD Program, Wayne State University School of Medicine, Detroit, MI, USA
| | | | | | - Holly Edwards
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI, USA; Molecular Therapeutics Program, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - Yubin Ge
- Cancer Biology Graduate Program, Wayne State University School of Medicine, Detroit, MI, USA; Department of Oncology, Wayne State University School of Medicine, Detroit, MI, USA; Molecular Therapeutics Program, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - Jeffrey W Taub
- Division of Pediatric Hematology/Oncology, Children's Hospital of Michigan, Detroit, MI, USA; Discipline of Pediatrics, Central Michigan University, Mt. Pleasant, MI, USA; Cancer Biology Graduate Program, Wayne State University School of Medicine, Detroit, MI, USA; Molecular Therapeutics Program, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA; Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA.
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7
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Othman J, Dillon R. Time to add gemtuzumab ozogamicin to intensive chemotherapy for NPM1-mutated acute myeloid leukaemia? Lancet Haematol 2023; 10:e478-e479. [PMID: 37187197 DOI: 10.1016/s2352-3026(23)00092-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Jad Othman
- Department of Medical and Molecular Genetics, King's College, London SE1 9RT, UK; Department of Haematology, Royal North Shore Hospital, Sydney, Australia; Faculty of Medicine and Heath, University of Sydney, Australia
| | - Richard Dillon
- Department of Medical and Molecular Genetics, King's College, London SE1 9RT, UK; Department of Haematology, Guy's and St Thomas' Hospitals NHS Trust, London, UK.
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8
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Wijnen NE, Koedijk JB, Klein K, Luesink M, Goemans BF, Zwaan CM, Kaspers GJL. Treating CD33-Positive de novo Acute Myeloid Leukemia in Pediatric Patients: Focus on the Clinical Value of Gemtuzumab Ozogamicin. Onco Targets Ther 2023; 16:297-308. [PMID: 37153641 PMCID: PMC10155714 DOI: 10.2147/ott.s263829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/20/2023] [Indexed: 05/10/2023] Open
Abstract
Although survival in pediatric acute myeloid leukemia (AML) has increased considerably over the past decades, refractory disease and relapse rates remain high. Refractory and relapsed disease are difficult to treat, with overall survival rates less than 40-50%. Preventing relapse should, therefore, be one of the highest priorities. Current conventional chemotherapy regimens are hard to intensify due to associated toxic complications, hence more effective therapies that do not increase toxicity are needed. A promising targeted agent is the CD33-directed antibody-drug conjugate gemtuzumab ozogamicin (GO). Because CD33 is highly expressed on leukemic cells in the majority of AML patients, GO can be useful for a broad range of patients. Better relapse-free survival (RFS) after therapy including GO has been reported in several pediatric clinical trials; however, ambiguity about the clinical value of GO in newly diagnosed children remains. Treatment with GO in de novo AML patients aged ≥1 month, in combination with standard chemotherapy is approved in the United States, whereas in Europe, GO is only approved for newly diagnosed patients aged ≥15 years. In this review, we aimed to clarify the clinical value of GO for treatment of newly diagnosed pediatric AML patients. Based on current literature, GO seems to have additional value, in terms of RFS, and acceptable toxicity when used in addition to chemotherapy during initial treatment. Moreover, in KMT2A-rearranged patients, the clinical value of GO was even more evident. Also, we addressed predictors of response, being CD33 expression and SNPs, PgP-1 and Annexin A5. The near finalized intent-to-file clinical trial in the MyeChild consortium investigates whether fractionated dosing has additional value for pediatric AML, which may pave the way for a broader application of GO in pediatric AML.
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Affiliation(s)
- Noa E Wijnen
- Pediatric Hemato-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Pediatric Oncology, Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
- Correspondence: Noa E Wijnen, Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, Utrecht, 3584 CS, the Netherlands, Tel +31(0)889727272, Email
| | - Joost B Koedijk
- Pediatric Hemato-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Pediatric Oncology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Kim Klein
- Pediatric Hemato-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Wilhelmina Children’s Hospital/University Medical Center, Utrecht, the Netherlands
| | - Maaike Luesink
- Pediatric Hemato-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Bianca F Goemans
- Pediatric Hemato-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - C Michel Zwaan
- Pediatric Hemato-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Pediatric Oncology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Gertjan J L Kaspers
- Pediatric Hemato-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Pediatric Oncology, Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
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9
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The evolution of targeted therapy in pediatric AML: gemtuzumab ozogamicin, FLT3/IDH/BCL2 inhibitors, and other therapies. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:603-610. [PMID: 36485125 PMCID: PMC9819987 DOI: 10.1182/hematology.2022000358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Despite the maximum intensification of chemotherapy and the increased use of hematopoietic stem cell transplantation (HCT) in pediatric patients with acute myeloid leukemia (AML), nearly 40% of patients still experience relapse, and cure in this setting remains a significant challenge. Recent improvements in AML characterization, including advances in flow cytometry and comprehensive genomic sequencing, have led to a better understanding of AML biology and the identification of multiple potential therapeutic targets. Novel agents targeting genomic lesions, cell surface antigens, and other mechanisms that permit oncogenesis or immune escape are being incorporated into current treatment strategies or are under investigation in efforts to improve outcomes and decrease the toxicities and late effects associated with traditional intensive chemotherapeutic and HCT treatment. However, multiple challenges still exist, including the biologic and immunophenotypic heterogeneity of childhood AML, the differences in underlying biology as compared to adult AML, and the significant potential for on-target/off-tumor toxicity associated with therapies directed at targets common to myeloid cells, both leukemic and normal. This article reviews the current landscape of genomic and cell surface targets for children with AML with a focus on the currently available targeted therapeutic agents, those in active clinical investigation, and those still in development.
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10
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Tecik M, Adan A. Therapeutic Targeting of FLT3 in Acute Myeloid Leukemia: Current Status and Novel Approaches. Onco Targets Ther 2022; 15:1449-1478. [PMID: 36474506 PMCID: PMC9719701 DOI: 10.2147/ott.s384293] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/19/2022] [Indexed: 08/13/2023] Open
Abstract
FMS-like tyrosine kinase 3 (FLT3) is mutated in approximately 30% of acute myeloid leukemia (AML) patients. The presence of FLT3-ITD (internal tandem duplication, 20-25%) mutation and, to a lesser extent, FLT3-TKD (tyrosine kinase domain, 5-10%) mutation is associated with poorer diagnosis and therapy response since the leukemic cells become hyperproliferative and resistant to apoptosis after continuous activation of FLT3 signaling. Targeting FLT3 has been the focus of many pre-clinical and clinical studies. Hence, many small-molecule FLT3 inhibitors (FLT3is) have been developed, some of which are approved such as midostaurin and gilteritinib to be used in different clinical settings, either in combination with chemotherapy or alone. However, many questions regarding the best treatment strategy remain to be answered. On the other hand, various FLT3-dependent and -independent resistance mechanisms could be evolved during FLT3i therapy which limit their clinical impact. Therefore, identifying molecular mechanisms of resistance and developing novel strategies to overcome this obstacle is a current interest in the field. In this review, recent studies of approved FLT3i and knowledge about major resistance mechanisms of clinically approved FLT3i's will be discussed together with novel treatment approaches such as designing novel FLT3i and dual FLT3i and combination strategies including approved FLT3i plus small-molecule agents targeting altered molecules in the resistant cells to abrogate resistance. Moreover, how to choose an appropriate FLT3i for the patients will be summarized based on what is currently known from available clinical data. In addition, strategies beyond FLT3i's including immunotherapeutics, small-molecule FLT3 degraders, and flavonoids will be summarized to highlight potential alternatives in FLT3-mutated AML therapy.
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Affiliation(s)
- Melisa Tecik
- Bioengineering Program, Graduate School of Engineering and Science, Abdullah Gul University, Kayseri, Turkey
| | - Aysun Adan
- Department of Molecular Biology and Genetics, Faculty of Life and Natural Sciences, Abdullah Gul University, Kayseri, Turkey
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Knight TE, Edwards H, Meshinchi S, Taub JW, Ge Y. "FLipping" the Story: FLT3-Mutated Acute Myeloid Leukemia and the Evolving Role of FLT3 Inhibitors. Cancers (Basel) 2022; 14:3398. [PMID: 35884458 PMCID: PMC9315611 DOI: 10.3390/cancers14143398] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/07/2022] [Accepted: 07/11/2022] [Indexed: 12/19/2022] Open
Abstract
The treatment of many types of cancers, including acute myeloid leukemia (AML), has been revolutionized by the development of therapeutics targeted at crucial molecular drivers of oncogenesis. In contrast to broad, relatively indiscriminate conventional chemotherapy, these targeted agents precisely disrupt key pathways within cancer cells. FMS-like tyrosine kinase 3 (FLT3)-encoding a critical regulator of hematopoiesis-is the most frequently mutated gene in patients with AML, and these mutations herald reduced survival and increased relapse in these patients. Approximately 30% of newly diagnosed AML carries an FLT3 mutation; of these, approximately three-quarters are internal tandem duplication (ITD) mutations, and the remainder are tyrosine kinase domain (TKD) mutations. In contrast to its usual, tightly controlled expression, FLT3-ITD mutants allow constitutive, "run-away" activation of a large number of key downstream pathways which promote cellular proliferation and survival. Targeted inhibition of FLT3 is, therefore, a promising therapeutic avenue. In April 2017, midostaurin became both the first FLT3 inhibitor and the first targeted therapy of any kind in AML to be approved by the US FDA. The use of FLT3 inhibitors has continued to grow as clinical trials continue to demonstrate the efficacy of this class of agents, with an expanding number available for use as both experimental standard-of-care usage. This review examines the biology of FLT3 and its downstream pathways, the mechanism of FLT3 inhibition, the development of the FLT3 inhibitors as a class and uses of the agents currently available clinically, and the mechanisms by which resistance to FLT3 inhibition may both develop and be overcome.
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Affiliation(s)
- Tristan E. Knight
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, Seattle, WA 98105, USA;
- Division of Hematology and Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98105, USA
| | - Holly Edwards
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI 48202, USA; (H.E.); (Y.G.)
- Molecular Therapeutics Program, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Soheil Meshinchi
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, Seattle, WA 98105, USA;
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Jeffrey W. Taub
- Division of Hematology/Oncology, Children’s Hospital of Michigan, Detroit, MI 48201, USA;
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI 48202, USA
- Department of Pediatrics, Central Michigan University, Mt. Pleasant, MI 48859, USA
| | - Yubin Ge
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI 48202, USA; (H.E.); (Y.G.)
- Molecular Therapeutics Program, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI 48201, USA
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12
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Tomizawa D, Tsujimoto SI, Tanaka S, Matsubayashi J, Aoki T, Iwamoto S, Hasegawa D, Nagai K, Nakashima K, Kawaguchi K, Deguchi T, Kiyokawa N, Ohki K, Hiramatsu H, Shiba N, Terui K, Saito AM, Kato M, Taga T, Koshinaga T, Adachi S. A phase III clinical trial evaluating efficacy and safety of minimal residual disease-based risk stratification for children with acute myeloid leukemia, incorporating a randomized study of gemtuzumab ozogamicin in combination with post-induction chemotherapy for non-low-risk patients (JPLSG-AML-20). Jpn J Clin Oncol 2022; 52:1225-1231. [PMID: 35809896 DOI: 10.1093/jjco/hyac105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/06/2022] [Indexed: 11/14/2022] Open
Abstract
The purpose of this study is to establish a treatment with appropriate intensity for children (<16 years old at diagnosis) with de novo acute myeloid leukemia (excluding acute promyelocytic leukemia and myeloid leukemia associated with Down syndrome) according to a risk stratification based on recurrent leukemic cytogenetic abnormalities and flow-cytometric minimal residual disease at end of initial induction chemotherapy and to validate the safety and efficacy of gemtuzumab ozogamicin (GO)-combined post-induction chemotherapy for the non-low-risk (non-LR) patients. The primary endpoint of this phase III study is three-year disease-free survival rate, which will be compared between the GO and non-GO arms of the non-LR (intermediate-risk and high-risk [HR]) patients. All HR patients will be allocated to allogeneic hematopoietic stem cell transplantation in first remission. This trial has been registered at the Japan Registry of Clinical Trials (jRCTs041210015).
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Affiliation(s)
- Daisuke Tomizawa
- Division of Leukemia and Lymphoma, Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Shin-Ichi Tsujimoto
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Shiro Tanaka
- Department of Clinical Biostatistics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Jun Matsubayashi
- Center for Clinical Research and Advanced Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Takahiro Aoki
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shotaro Iwamoto
- Department of Pediatrics, Mie University Graduate School of Medicine, Tsu, Japan
| | - Daisuke Hasegawa
- Department of Pediatrics, St. Luke's International Hospital, Tokyo, Japan
| | - Kozo Nagai
- Department of Pediatric Hematology/Oncology, Shikoku Medical Center for Children and Adults, Zentsuji, Japan
| | - Kentaro Nakashima
- Department of Pediatrics, University of Occupational and Environmental Health, Kita-Kyushu, Japan
| | - Koji Kawaguchi
- Department of Hematology and Oncology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Takao Deguchi
- Division of Cancer Immunodiagnostics, Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Nobutaka Kiyokawa
- Department of Pediatric Hematology and Oncology Research, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Kentaro Ohki
- Department of Pediatric Hematology and Oncology Research, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Hidefumi Hiramatsu
- Department of Pediatrics, Graduate School of Medicine Kyoto University, Kyoto, Japan
| | - Norio Shiba
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kiminori Terui
- Department of Pediatrics, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Akiko Moriya Saito
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Motohiro Kato
- Department of Pediatrics, University of Tokyo, Tokyo, Japan
| | - Takashi Taga
- Department of Pediatrics, Shiga University of Medical Science, Otsu, Japan
| | - Tsugumichi Koshinaga
- Department of Pediatric Surgery, Nihon University School of Medicine, Tokyo, Japan
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Poor outcome of pediatric patients with acute myeloid leukemia harboring high FLT3/ITD allelic ratios. Nat Commun 2022; 13:3679. [PMID: 35760968 PMCID: PMC9237020 DOI: 10.1038/s41467-022-31489-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 06/17/2022] [Indexed: 11/08/2022] Open
Abstract
Activating FLT3 mutations are the most common mutations in acute myeloid leukemia (AML), but the optimal threshold of FLT3/ITD allelic ratio (AR) among pediatric AML patients remains controversial. Here, we present the outcome and prognostic significance of FLT3/ITD AR analysis among pediatric patients with AML from the TARGET dataset. Applying fitting curve models and threshold effect analysis using the restrictive cubic spline function following Cox proportional hazards models identifies the cut-off value of 0.5 on FLT3/ITD AR. Moreover, we observe that high FLT3/ITD AR patients have an inferior outcome when compared to low AR patients. Our study also demonstrates that stem cell transplantation may improve the outcome in pediatric AML patients with high FLT3/ITD AR and may be further improved when combined with additional therapies such as Gemtuzumab Ozogamicin. These findings underline the importance of individualized treatment of pediatric AML. Activating FLT3 mutations are the most common mutations in AML. Here, the authors explore the relationship between the FLT3/ITD allelic ratio and prognosis in pediatric AML patients and identify an optimal threshold to stratify patients.
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14
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High-Risk Acute Myeloid Leukemia: A Pediatric Prospective. Biomedicines 2022; 10:biomedicines10061405. [PMID: 35740427 PMCID: PMC9220202 DOI: 10.3390/biomedicines10061405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/19/2022] [Accepted: 05/31/2022] [Indexed: 11/16/2022] Open
Abstract
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.
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15
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Teicher BA, Morris J. Antibody-Drug Conjugate Targets, Drugs and Linkers. Curr Cancer Drug Targets 2022; 22:463-529. [PMID: 35209819 DOI: 10.2174/1568009622666220224110538] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/22/2021] [Accepted: 11/09/2021] [Indexed: 11/22/2022]
Abstract
Antibody-drug conjugates offer the possibility of directing powerful cytotoxic agents to a malignant tumor while sparing normal tissue. The challenge is to select an antibody target expressed exclusively or at highly elevated levels on the surface of tumor cells and either not all or at low levels on normal cells. The current review explores 78 targets that have been explored as antibody-drug conjugate targets. Some of these targets have been abandoned, 9 or more are the targets of FDA-approved drugs, and most remain active clinical interest. Antibody-drug conjugates require potent cytotoxic drug payloads, several of these small molecules are discussed, as are the linkers between the protein component and small molecule components of the conjugates. Finally, conclusions regarding the elements for the successful antibody-drug conjugate are discussed.
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Affiliation(s)
- Beverly A Teicher
- Developmental Therapeutics Program, DCTD, National Cancer Institute, Bethesda, MD 20892,United States
| | - Joel Morris
- Developmental Therapeutics Program, DCTD, National Cancer Institute, Bethesda, MD 20892,United States
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Liu J, Tong J, Yang H. Targeting CD33 for acute myeloid leukemia therapy. BMC Cancer 2022; 22:24. [PMID: 34980040 PMCID: PMC8722076 DOI: 10.1186/s12885-021-09116-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/15/2021] [Indexed: 12/25/2022] Open
Abstract
Background The aim of this study was to analyze the level of CD33 expression in patients with newly diagnosed AML and determine its correlation with clinical characteristics. Methods Samples were collected for analysis from AML patients at diagnosis. We evaluated the level of CD33 expression by flow cytometry analysis of bone marrow. Chi-square or t- tests were used to assess the association between the high and low CD33 expression groups. Survival curves were generated by the Kaplan-Meier and Cox regression model method. Results In this study we evaluated the level of CD33 expression in de novo patients diagnosed from November 2013 until January 2019. The mean value of 73.4% was used as the cutoff for the two groups. Statistical analysis revealed that 53 of the 86 (61.2%) AML patients were above the mean. Although there was no statistical significance between CD33 expression level and gene mutation, FLT3 mutation (P = 0.002) and NPM1 mutation (P = 0.001) were more likely to be seen in the high CD33 group. The overall survival (OS) was worse in the high CD33 group (39.0 m vs. 16.7 m, x2 = 13.06, P < 0.001). The Cox survival regression display that the CD33 is independent prognostic marker (HR =0.233,p = 0.008). Univariate analysis showed that the high expression of CD33 was an unfavorable prognostic factor. Of the 86 patients, CD33-high was closely related to the patients with normal karyotype (x2 = 4.891,P = 0.027), high white blood cell count (WBC, t = 2.804, P = 0.007), and a high ratio of primitive cells (t = 2.851, P = 0.005). Conclusions These findings provide a strong rationale for targeting CD33 in combination with chemotherapy, which can be considered a promising therapeutic strategy for AML. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-09116-5.
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Affiliation(s)
- Jingjing Liu
- Department of Hematology, First Affiliated Hospital of Henan University of Science and Technology, 636 Guanlin Road, Luoyang, Henan, 471000, P.R. China
| | - Jiayin Tong
- Department of Hematology, First Affiliated Hospital of Henan University of Science and Technology, 636 Guanlin Road, Luoyang, Henan, 471000, P.R. China
| | - Haiping Yang
- Department of Hematology, First Affiliated Hospital of Henan University of Science and Technology, 636 Guanlin Road, Luoyang, Henan, 471000, P.R. China.
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17
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Varotto E, Munaretto E, Stefanachi F, Della Torre F, Buldini B. Diagnostic challenges in acute monoblastic/monocytic leukemia in children. Front Pediatr 2022; 10:911093. [PMID: 36245718 PMCID: PMC9554480 DOI: 10.3389/fped.2022.911093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 09/01/2022] [Indexed: 11/13/2022] Open
Abstract
Acute monoblastic/monocytic leukemia (AMoL), previously defined as M5 according to FAB classification, is one of the most common subtypes of Acute Myeloid Leukemia (AML) in children, representing ~15-24% of all pediatric AMLs. Currently, the characterization of monocytic-lineage neoplasia at diagnosis includes cytomorphology, cytochemistry, immunophenotyping by multiparametric flow cytometry, cytogenetics, and molecular biology. Moreover, measurable residual disease (MRD) detection is critical in recognizing residual blasts refractory to chemotherapy. Nonetheless, diagnosis and MRD detection may still be challenging in pediatric AMoL since the morphological and immunophenotypic features of leukemic cells potentially overlap with those of normal mature monocytic compartment, as well as differential diagnosis can be troublesome, particularly with Juvenile Myelomonocytic Leukemia and reactive monocytosis in infants and young children. A failure or delay in diagnosis and inaccuracy in MRD assessment may worsen the AMoL prognosis. Therefore, improving diagnosis and monitoring techniques is mandatory to stratify and tailor therapies to the risk profile. This Mini Review aims to provide an updated revision of the scientific evidence on pediatric AMoL diagnostic tools.
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Affiliation(s)
- Elena Varotto
- Pediatric Hematology Oncology and Stem Cell Transplant Division, Maternal and Child Health Department, Padua University, Padua, Italy
| | - Eleonora Munaretto
- Pediatric Hematology Oncology and Stem Cell Transplant Division, Maternal and Child Health Department, Padua University, Padua, Italy
| | - Francesca Stefanachi
- Pediatric Hematology Oncology and Stem Cell Transplant Division, Maternal and Child Health Department, Padua University, Padua, Italy
| | - Fiammetta Della Torre
- Pediatric Hematology Oncology and Stem Cell Transplant Division, Maternal and Child Health Department, Padua University, Padua, Italy
| | - Barbara Buldini
- Pediatric Hematology Oncology and Stem Cell Transplant Division, Maternal and Child Health Department, Padua University, Padua, Italy
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Montefiori LE, Mullighan CG. Redefining the biological basis of lineage-ambiguous leukemia through genomics: BCL11B deregulation in acute leukemias of ambiguous lineage. Best Pract Res Clin Haematol 2021; 34:101329. [PMID: 34865701 DOI: 10.1016/j.beha.2021.101329] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Acute leukemias of ambiguous lineage (ALAL), including mixed phenotype acute leukemia (MPAL) and related entities such as early T-cell precursor acute leukemia (ETP-ALL), remain diagnostic and clinical challenges due to limited understanding of pathogenesis, reliance of immunophenotyping to classify disease, and the lack of a rational approach to guide selection of appropriate therapy. Recent studies utilizing genomic sequencing and complementary approaches have provided key insights that are changing the way in which such leukemias are classified, and potentially, treated. Several recurrent genomic alterations define leukemias that straddle immunophenotypic entities, such as ZNF384-rearranged childhood B-ALL and B/myeloid MPAL, and BCL11B-rearranged T/myeloid MPAL, ETP-ALL and AML. In contrast, some cases of MPAL represent canonical ALL/AML entities exhibiting lineage aberrancy. For many cases of ALAL, experimental approaches indicate lineage aberrancy arises from acquisition of a founding genetic alteration into a hematopoietic stem or progenitor cell. Determination of optimal therapeutic approach requires genomic characterization of uniformly treated ALAL patients in prospective studies, but several approaches, including kinase inhibitors and BH3 mimetics may be efficacious in subsets of ALAL.
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Affiliation(s)
- Lindsey E Montefiori
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Charles G Mullighan
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA.
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Huo Y, Guan XM, Dou Y, Wen XH, Guo YX, Shen YL, An XZ, Yu J. Prognostic significance of measurable residual disease based on multiparameter flow cytometry in childhood acute myeloid leukemia. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:1111-1118. [PMID: 34753542 DOI: 10.7499/j.issn.1008-8830.2106102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To study the prognostic value of measurable residual disease (MRD) for childhood acute myeloid leukemia (AML) by analyzing MRD-guided risk stratification therapy. METHODS A total of 93 children with AML were prospectively enrolled in this study. Chemotherapy with the 2015-AML-03 regimen was completed according to the risk stratification determined by genetic abnormality at initial diagnosis and MRD and bone marrow cytology after induction therapy I. Multiparameter flow cytometry was used to dynamically monitor MRD and analyze the prognostic effect of MRD on 3-year cumulative incidence of recurrence (CIR) rate, event-free survival (EFS) rate, and overall survival (OS) rate. RESULTS The 93 children with AML had a 3-year CIR rate of 48%±6%, a median time to recurrence of 11 months (range 2-32 months), a 3-year OS rate of 65%±6%, and a 3-year EFS rate of 50%±5%. After induction therapy I and intensive therapy I, the MRD-positive children had a significantly higher 3-year CIR rate and significantly lower 3-year EFS and OS rates than the MRD-negative children (P<0.05). There were no significant differences in 3-year CIR, EFS, and OS rates between the MRD-positive children with a low risk at initial diagnosis and the MRD-negative children after adjustment of chemotherapy intensity (P>0.05). The multivariate analysis showed that positive MRD after intensive treatment I was a risk factor for 3-year OS rate in children with AML (P<0.05). CONCLUSIONS MRD has predictive value for the prognosis of children with AML. Based on the MRD-guided risk stratification therapy, reasonable application of chemotherapy may improve the overall prognosis of children with AML.
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Affiliation(s)
- Ya Huo
- Department of Hematology and Oncology, Children's Hospital Affiliated to Chongqing Medical University/Ministry of Education Key Laboratory of Child Development and Disorders/National Children's Health and Disease Clinical Medicine Research Center/National International Science and Technology Cooperation Base for Critical Child Developmental Diseases/Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China (Yu J, 1808106657@qq. com)
| | - Xian-Min Guan
- Department of Hematology and Oncology, Children's Hospital Affiliated to Chongqing Medical University/Ministry of Education Key Laboratory of Child Development and Disorders/National Children's Health and Disease Clinical Medicine Research Center/National International Science and Technology Cooperation Base for Critical Child Developmental Diseases/Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China (Yu J, 1808106657@qq. com)
| | - Ying Dou
- Department of Hematology and Oncology, Children's Hospital Affiliated to Chongqing Medical University/Ministry of Education Key Laboratory of Child Development and Disorders/National Children's Health and Disease Clinical Medicine Research Center/National International Science and Technology Cooperation Base for Critical Child Developmental Diseases/Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China (Yu J, 1808106657@qq. com)
| | - Xian-Hao Wen
- Department of Hematology and Oncology, Children's Hospital Affiliated to Chongqing Medical University/Ministry of Education Key Laboratory of Child Development and Disorders/National Children's Health and Disease Clinical Medicine Research Center/National International Science and Technology Cooperation Base for Critical Child Developmental Diseases/Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China (Yu J, 1808106657@qq. com)
| | - Yu-Xia Guo
- Department of Hematology and Oncology, Children's Hospital Affiliated to Chongqing Medical University/Ministry of Education Key Laboratory of Child Development and Disorders/National Children's Health and Disease Clinical Medicine Research Center/National International Science and Technology Cooperation Base for Critical Child Developmental Diseases/Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China (Yu J, 1808106657@qq. com)
| | - Ya-Li Shen
- Department of Hematology and Oncology, Children's Hospital Affiliated to Chongqing Medical University/Ministry of Education Key Laboratory of Child Development and Disorders/National Children's Health and Disease Clinical Medicine Research Center/National International Science and Technology Cooperation Base for Critical Child Developmental Diseases/Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China (Yu J, 1808106657@qq. com)
| | - Xi-Zhou An
- Department of Hematology and Oncology, Children's Hospital Affiliated to Chongqing Medical University/Ministry of Education Key Laboratory of Child Development and Disorders/National Children's Health and Disease Clinical Medicine Research Center/National International Science and Technology Cooperation Base for Critical Child Developmental Diseases/Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China (Yu J, 1808106657@qq. com)
| | - Jie Yu
- Department of Hematology and Oncology, Children's Hospital Affiliated to Chongqing Medical University/Ministry of Education Key Laboratory of Child Development and Disorders/National Children's Health and Disease Clinical Medicine Research Center/National International Science and Technology Cooperation Base for Critical Child Developmental Diseases/Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China (Yu J, 1808106657@qq. com)
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Gottardi M, Simonetti G, Sperotto A, Nappi D, Ghelli Luserna di Rorà A, Padella A, Norata M, Giannini MB, Musuraca G, Lanza F, Cerchione C, Martinelli G. Therapeutic Targeting of Acute Myeloid Leukemia by Gemtuzumab Ozogamicin. Cancers (Basel) 2021; 13:cancers13184566. [PMID: 34572794 PMCID: PMC8469571 DOI: 10.3390/cancers13184566] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 11/16/2022] Open
Abstract
Acute myeloid leukemia (AML) is a complex hematological malignancy characterized by genetic and clinical heterogeneity and high mortality. Despite the recent introduction of novel pharmaceutical agents in hemato-oncology, few advancements have been made in AML for decades. In the last years, the therapeutic options have rapidly changed, with the approval of innovative compounds that provide new opportunities, together with new challenges for clinicians: among them, on 1 September, 2017 the Food and Drug Administration granted approval for Gemtuzumab Ozogamicin (GO) in combination with daunorubicin and cytarabine for the treatment of adult patients affected by newly diagnosed CD33+ AML. Benefits of GO-based regimens were also reported in the pre- and post-transplantation settings. Moreover, several biomarkers of GO response have been suggested, including expression of CD33 and multidrug resistance genes, cytogenetic and molecular profiles, minimal residual disease and stemness signatures. Among them, elevated CD33 expression on blast cells and non-adverse cytogenetic or molecular risk represent largely validated predictors of good response.
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Affiliation(s)
- Michele Gottardi
- Onco Hematology, Department of Oncology, Veneto Institute of Oncology IOV, IRCCS, 31033 Padua, Italy
| | - Giorgia Simonetti
- Biosciences Laboratory, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", 47014 Meldola (FC), Italy
| | - Alessandra Sperotto
- Hematology and Transplant Center Unit, Dipartimento di Area Medica (DAME), Udine University Hospital, 33100 Udine, Italy
| | - Davide Nappi
- Department of Hematology and Cell Bone Marrow Transplantation (CBMT), Ospedale di Bolzano, 39100 Bolzano, Italy
| | - Andrea Ghelli Luserna di Rorà
- Biosciences Laboratory, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", 47014 Meldola (FC), Italy
| | - Antonella Padella
- Biosciences Laboratory, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", 47014 Meldola (FC), Italy
| | - Marianna Norata
- Hematology Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", 47014 Meldola (FC), Italy
| | - Maria Benedetta Giannini
- Hematology Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", 47014 Meldola (FC), Italy
| | - Gerardo Musuraca
- Hematology Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", 47014 Meldola (FC), Italy
| | - Francesco Lanza
- Hematology Unit & Romagna Transplant Network, Ravenna Hospital, 48121 Ravenna, Italy
| | - Claudio Cerchione
- Hematology Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", 47014 Meldola (FC), Italy
| | - Giovanni Martinelli
- Scientific Directorate, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", 47014 Meldola (FC), Italy
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Abstract
The outcomes associated with pediatric acute myeloid leukemia (AML) have improved over the last few decades, with the implementation of intensive chemotherapy, hematopoietic stem cell transplant, and improved supportive care. However, even with intensive therapy and the use of HSCT, both of which carry significant risks of short- and long-term side effects, approximately 30% of children are not able to be cured. The characterization of AML in pediatrics has evolved over time and it currently involves use of a variety of diagnostic tools, including flow cytometry and comprehensive genomic sequencing. Given the adverse effects of chemotherapy and the need for additional therapeutic options to improve outcomes in these patients, the genomic and molecular architecture is being utilized to inform selection of targeted therapies in pediatric AML. This review provides a summary of current, targeted therapy options in pediatric AML.
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The Role of Allogeneic Hematopoietic Stem Cell Transplantation in Pediatric Leukemia. J Clin Med 2021; 10:jcm10173790. [PMID: 34501237 PMCID: PMC8432223 DOI: 10.3390/jcm10173790] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/08/2021] [Accepted: 08/19/2021] [Indexed: 02/07/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) offers potentially curative treatment for many children with high-risk or relapsed acute leukemia (AL), thanks to the combination of intense preparative radio/chemotherapy and the graft-versus-leukemia (GvL) effect. Over the years, progress in high-resolution donor typing, choice of conditioning regimen, graft-versus-host disease (GvHD) prophylaxis and supportive care measures have continuously improved overall transplant outcome, and recent successes using alternative donors have extended the potential application of allotransplantation to most patients. In addition, the importance of minimal residual disease (MRD) before and after transplantation is being increasingly clarified and MRD-directed interventions may be employed to further ameliorate leukemia-free survival after allogeneic HSCT. These advances have occurred in parallel with continuous refinements in chemotherapy protocols and the development of targeted therapies, which may redefine the indications for HSCT in the coming years. This review discusses the role of HSCT in childhood AL by analysing transplant indications in both acute lymphoblastic and acute myeloid leukemia, together with current and most promising strategies to further improve transplant outcome, including optimization of conditioning regimen and MRD-directed interventions.
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Xu Q, He S, Yu L. Clinical Benefits and Safety of Gemtuzumab Ozogamicin in Treating Acute Myeloid Leukemia in Various Subgroups: An Updated Systematic Review, Meta-Analysis, and Network Meta-Analysis. Front Immunol 2021; 12:683595. [PMID: 34484181 PMCID: PMC8415423 DOI: 10.3389/fimmu.2021.683595] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 07/27/2021] [Indexed: 01/11/2023] Open
Abstract
Background Previous trials demonstrated evidence involving the total effects of gemtuzumab ozogamicin (GO), an anti-CD33 humanized antibody, on treating acute myeloid leukemia (AML). In this updated systematic review, meta-analysis, and network meta-analysis (NMA), we aimed to comprehensively explore the clinical benefits and safety of GO in various subtypes of AML. Methods PubMed, Embase, Cochrane, and Chinese databases were filtered to search randomized controlled trials (RCTs) and retrospective cohort studies that compared clinical efficiency and toxicity of GO with non-GO groups in AML. Random-effects models were used to calculate pooled effect sizes and 95% confidence intervals (CIs). Relative risk (RR) was used for estimating complete remission (CR), early death, and toxicity. Hazard risk (HR) was accomplished to evaluate survival. Results Fifteen RCTs and 15 retrospective cohort studies were identified (GO: 4,768; Control: 6,466). GO tended to improve CR (RR 0.95, p = 0.084), followed by significantly improved survival (overall survival: HR 0.86, p = 0.003; event-free survival: HR 0.86, p = 0.015; relapse-free survival: HR 0.83, p = 0.001; cumulative incidence of relapse: HR 0.82, p < 0.001). GO benefits of CR and survival were evident in favorable- and intermediate-risk karyotypes (p ≤ 0.023). GO advantages were also associated with nucleophosmin 1 mutations (p ≤ 0.04), wild-type FMS-like tyrosine kinase 3 internal tandem duplication gene (p ≤ 0.03), age of <70 years (p < 0.05), de novo AML (p ≤ 0.017), and CD33(+) (p ≤ 0.021). Both adding GO into induction therapy (p ≤ 0.011) and a lower (<6 mg/m2) dose of GO (p ≤ 0.03) enhanced survival. Prognosis of combined regimens with GO was heterogeneous in both meta-analysis and NMA, with several binding strategies showing improved prognosis. Additionally, GO was related to increased risk of early death at a higher dose (≥6 mg/m2) (RR 2.01, p = 0.005), hepatic-related adverse effects (RR 1.29, p = 0.02), and a tendency of higher risk for hepatic veno-occlusive disease or sinusoidal obstruction syndrome (RR 1.56, p = 0.072). Conclusions These data indicated therapeutic benefits and safety of GO in AML, especially in some subtypes, for which further head-to-head RCTs are warranted. Systematic Review Registration [PROSPERO: https://www.crd.york.ac.uk/prospero/], identifier [CRD42020158540].
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MESH Headings
- Antineoplastic Agents, Immunological/administration & dosage
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Agents, Immunological/therapeutic use
- Biomarkers, Tumor
- Gemtuzumab/administration & dosage
- Gemtuzumab/adverse effects
- Gemtuzumab/therapeutic use
- Humans
- Karyotype
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/etiology
- Leukemia, Myeloid, Acute/mortality
- Molecular Targeted Therapy
- Mutation
- Prognosis
- Sialic Acid Binding Ig-like Lectin 3/antagonists & inhibitors
- Treatment Outcome
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Affiliation(s)
- Qingyu Xu
- Department of Hematology and Oncology, International Cancer Center, Shenzhen Key Laboratory, Shenzhen University General Hospital, Shenzhen University Clinical Medical Academy, Shenzhen University Health Science Center, Shenzhen, China
- Department of Hematology and Oncology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Shujiao He
- Department of Hematology and Oncology, International Cancer Center, Shenzhen Key Laboratory, Shenzhen University General Hospital, Shenzhen University Clinical Medical Academy, Shenzhen University Health Science Center, Shenzhen, China
| | - Li Yu
- Department of Hematology and Oncology, International Cancer Center, Shenzhen Key Laboratory, Shenzhen University General Hospital, Shenzhen University Clinical Medical Academy, Shenzhen University Health Science Center, Shenzhen, China
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24
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Stokke JL, Bhojwani D. Antibody-Drug Conjugates for the Treatment of Acute Pediatric Leukemia. J Clin Med 2021; 10:3556. [PMID: 34441852 PMCID: PMC8396964 DOI: 10.3390/jcm10163556] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 12/31/2022] Open
Abstract
The clinical development of antibody-drug conjugates (ADCs) has gained momentum in recent years and these agents are gradually moving into frontline regimens for pediatric acute leukemias. ADCs consist of a monoclonal antibody attached to a cytotoxic payload by a cleavable linker. This structure allows for highly cytotoxic agents to be directly delivered to leukemia cells leading to cell death and avoids excessive off-tumor toxicity. Near universal expression on B-cell acute lymphoblastic leukemia (ALL) blasts and the ability of rapid internalization has rendered CD22 an ideal target for ADC in B-ALL. Inotuzumab ozogamicin, the anti-CD22 antibody linked to calicheamicin led to complete remission rates of 60-80% in patients with relapsed/refractory B-ALL. In acute myeloid leukemia (AML), the CD33 targeting gemtuzumab ozogamicin has demonstrated modest improvements in survival and is the only ADC currently licensed in the United States for pediatric patients with de novo AML. Several other ADCs have been developed and tested clinically for leukemia but have achieved limited success to date. The search for additional leukemia-specific targets and optimization of ADC structure and specificity are ongoing efforts to improve their therapeutic window. This review provides a comprehensive overview of ADCs in acute leukemias, with a focus on pediatric ALL and AML.
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Affiliation(s)
- Jamie L. Stokke
- Division of Hematology-Oncology, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA;
| | - Deepa Bhojwani
- Division of Hematology-Oncology, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA;
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA 90033, USA
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25
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CD33 Expression and Gentuzumab Ozogamicin in Acute Myeloid Leukemia: Two Sides of the Same Coin. Cancers (Basel) 2021; 13:cancers13133214. [PMID: 34203180 PMCID: PMC8268215 DOI: 10.3390/cancers13133214] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/17/2021] [Accepted: 06/23/2021] [Indexed: 01/10/2023] Open
Abstract
Simple Summary Roughly 85–90% of adult and pediatric acute myeloid leukemia (AML) are CD33-positive. Gemtuzumab ozogamicin (GO), a humanized murine IgG4 anti-CD33 antibody, is the first target therapy approved in AML therapeutic scenario. This review focuses on current biological information and clinical data from several studies investigating the use of GO in patients with AML. Over the years, flow cytometry, cytogenetics, molecular techniques, and genotyping studies of CD33 SNPs have provided a comprehensive analysis of promising biomarkers for GO responses and have potentially helped to identify subgroups of patients that may benefit from GO addition to standard chemotherapies. Increased understanding of molecular mutations, altered intracellular pathways, and their potential relationship with CD33 expression may open new therapeutic landscapes based on combinatorial regimens in an AML scenario. Abstract Acute myeloid leukemia (AML), the most frequent acute leukemia in adults, has been historically treated with infusional cytarabine (ara-c) + daunorubicin (3 + 7) for at least 40 years. The first “target therapy” to be introduced was the monoclonal anti-CD33 gemtuzumab ozogamicin (GO) in 2004. Unfortunately, in 2010 it was voluntarily withdrawn from the market both for safety reasons related to potential liver toxicity and veno-occlusive disease (VOD) and because clinical studies failed to confirm the clinical benefit during induction and maintenance. Seven years later, GO was re-approved based on new data, including insights into its mechanism of action on its target receptor CD33 expressed on myeloid cells. The present review focuses on current biological information and clinical data from several studies investigating GO. Cytogenetic, molecular, and immunophenotypic data are now able to predict the potential positive advantages of GO, with the exception of high-risk AML patients who do not seem to benefit. GO can be considered a ‘repurposed drug’ that could be beneficial for some patients with AML, mostly in combination with new drugs already approved or currently in testing.
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26
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Pollard JA, Guest E, Alonzo TA, Gerbing RB, Loken MR, Brodersen LE, Kolb EA, Aplenc R, Meshinchi S, Raimondi SC, Hirsch B, Gamis AS. Gemtuzumab Ozogamicin Improves Event-Free Survival and Reduces Relapse in Pediatric KMT2A-Rearranged AML: Results From the Phase III Children's Oncology Group Trial AAML0531. J Clin Oncol 2021; 39:3149-3160. [PMID: 34048275 DOI: 10.1200/jco.20.03048] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE We investigated the impact of the CD33-targeted agent gemtuzumab ozogamicin (GO) on survival in pediatric patients with KMT2A-rearranged (KMT2A-r) acute myeloid leukemia (AML) enrolled in the Children's Oncology Group trial AAML0531 (NCT01407757). METHODS Patients with KMT2A-r AML were identified and clinical characteristics described. Five-year overall survival (OS), event-free survival (EFS), disease-free survival (DFS), and relapse risk (RR) were determined overall and for higher-risk versus not high-risk translocation partners. GO's impact on response was determined and outcomes based on consolidation approach (hematopoietic stem cell transplant [HSCT] v chemotherapy) described. RESULTS Two hundred fifteen (21%) of 1,022 patients enrolled had KMT2A-r AML. Five-year EFS and OS from study entry were 38% and 58%, respectively. EFS was superior with GO treatment (EFS 48% with GO v 29% without, P = .003), although OS was comparable (63% v 53%, P = .054). For patients with KMT2A-r AML who achieved complete remission, GO was associated with lower RR (40% GO v 66% patients who did not receive GO [No-GO], P = .001) and improved 5-year DFS (GO 57% v No-GO 33%, P = .002). GO benefit was observed in both higher-risk and not high-risk KMT2A-r subsets. For patients who underwent HSCT, prior GO exposure was associated with decreased relapse (5-year RR: 28% GO and HSCT v 73% No-GO and HSCT, P = .006). In multivariable analysis, GO was independently associated with improved EFS, improved DFS, and reduced RR. CONCLUSION GO added to conventional chemotherapy improved outcomes for KMT2A-r AML; consolidation with HSCT may further enhance outcomes. Future clinical trials should study CD33-targeted agents in combination with HSCT for pediatric KMT2A-r AML.
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Affiliation(s)
- Jessica A Pollard
- Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - Todd A Alonzo
- University of Southern California Keck School of Medicine, Los Angeles, CA.,Children's Oncology Group, Monrovia, CA
| | | | | | | | | | | | - Soheil Meshinchi
- Fred Hutchinson Cancer Research Center, Seattle, WA.,University of Washington School of Medicine, Seattle, WA
| | | | - Betsy Hirsch
- University of Minnesota Cancer Center, Minneapolis, MN
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27
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Zahnreich S, Schmidberger H. Childhood Cancer: Occurrence, Treatment and Risk of Second Primary Malignancies. Cancers (Basel) 2021; 13:cancers13112607. [PMID: 34073340 PMCID: PMC8198981 DOI: 10.3390/cancers13112607] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/20/2021] [Accepted: 05/22/2021] [Indexed: 12/14/2022] Open
Abstract
Cancer represents the leading cause of disease-related death and treatment-associated morbidity in children with an increasing trend in recent decades worldwide. Nevertheless, the 5-year survival of childhood cancer patients has been raised impressively to more than 80% during the past decades, primarily attributed to improved diagnostic technologies and multiagent cytotoxic regimens. This strong benefit of more efficient tumor control and prolonged survival is compromised by an increased risk of adverse and fatal late sequelae. Long-term survivors of pediatric tumors are at the utmost risk for non-carcinogenic late effects such as cardiomyopathies, neurotoxicity, or pneumopathies, as well as the development of secondary primary malignancies as the most detrimental consequence of genotoxic chemo- and radiotherapy. Promising approaches to reducing the risk of adverse late effects in childhood cancer survivors include high precision irradiation techniques like proton radiotherapy or non-genotoxic targeted therapies and immune-based treatments. However, to date, these therapies are rarely used to treat pediatric cancer patients and survival rates, as well as incidences of late effects, have changed little over the past two decades in this population. Here we provide an overview of the epidemiology and etiology of childhood cancers, current developments for their treatment, and therapy-related adverse late health consequences with a special focus on second primary malignancies.
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28
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Alexander TB, Orgel E. Mixed Phenotype Acute Leukemia: Current Approaches to Diagnosis and Treatment. Curr Oncol Rep 2021; 23:22. [PMID: 33544265 DOI: 10.1007/s11912-020-01010-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Mixed phenotype acute leukemia (MPAL) is a rare subtype of acute leukemia with features of both acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML). The review examines current definitions and controversies in classification of MPAL, new insights into genomic drivers and pathogenesis, recent evidence to support treatment recommendations, and opportunities for future research. RECENT FINDINGS Recent collaborative efforts have made progress in understanding the genomic landscape and optimal therapy for MPAL. The preponderance of retrospective data supports beginning therapy with ALL directed regimens. Differences in prognosis for adult and children with MPAL have led to divergent approaches for therapy intensity, including use of stem cell transplantation consolidation. MPAL remains a challenging leukemia to understand, research, and treat due to low incidence, shifting and subjective approaches to classification, and innate biological heterogeneity. Ongoing research hopes to surmount these obstacles through prospective studies within large cooperative groups to provide new insight into targetable biology and further refine optimal therapy.
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Affiliation(s)
- Thomas B Alexander
- University of North Carolina, 170 Manning Drive, 1185A Physicians Office Building, CB # 7236, Chapel Hill, NC, 27599, USA.
| | - Etan Orgel
- Children's Hospital Los Angeles, 4650 Sunset Blvd, MS 54, Los Angeles, CA, 90027, USA
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29
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Conneely SE, Stevens AM. Acute Myeloid Leukemia in Children: Emerging Paradigms in Genetics and New Approaches to Therapy. Curr Oncol Rep 2021; 23:16. [PMID: 33439382 PMCID: PMC7806552 DOI: 10.1007/s11912-020-01009-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Acute myeloid leukemia (AML) in children remains a challenging disease to cure with suboptimal outcomes particularly when compared to the more common lymphoid leukemias. Recent advances in the genetic characterization of AML have enhanced understanding of individualized patient risk, which has also led to the development of new therapeutic strategies. Here, we review key cytogenetic and molecular features of pediatric AML and how new therapies are being used to improve outcomes. RECENT FINDINGS Recent studies have revealed an increasing number of mutations, including WT1, CBFA2T3-GLIS2, and KAT6A fusions, DEK-NUP214 and NUP98 fusions, and specific KMT2A rearrangements, which are associated with poor outcomes. However, outcomes are starting to improve with the addition of therapies such as gemtuzumab ozogamicin and FLT3 inhibitors, initially developed in adult AML. The combination of advanced risk stratification and ongoing improvements and innovations in treatment strategy will undoubtedly lead to better outcomes for children with AML.
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Affiliation(s)
- Shannon E Conneely
- Department of Pediatric Hematology/Oncology, Baylor College of Medicine/Texas Children's Hospital, 6701 Fannin, Suite 1510, Houston, TX, 77030, USA.
| | - Alexandra M Stevens
- Department of Pediatric Hematology/Oncology, Baylor College of Medicine/Texas Children's Hospital, 6701 Fannin, Suite 1510, Houston, TX, 77030, USA
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30
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Shi W, Jin W, Xia L, Hu Y. Novel agents targeting leukemia cells and immune microenvironment for prevention and treatment of relapse of acute myeloid leukemia after allogeneic hematopoietic stem cell transplantation. Acta Pharm Sin B 2020; 10:2125-2139. [PMID: 32837873 PMCID: PMC7326461 DOI: 10.1016/j.apsb.2020.06.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/27/2020] [Accepted: 06/05/2020] [Indexed: 12/20/2022] Open
Abstract
Relapse remains the worst life-threatening complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT) in patients with acute myeloid leukemia (AML), whose prognosis has been historically dismal. Given the rapid development of genomics and immunotherapies, the interference strategies for AML recurrence have been changing these years. More and more novel targeting agents that have received the U.S. Food and Drug Administration (FDA) approval for de novo AML treatment have been administrated in the salvage or maintenance therapy of post-HSCT relapse. Targeted strategies that regulate the immune microenvironment of and optimize the graft versus leukemia (GVL) effect of immune cells are gradually improved. Such agents not only have been proven to achieve clinical benefits from a single drug, but if combined with classic therapies, can significantly improve the poor prognosis of AML patients who relapse after allo-HSCT. This review will focus on currently available and promising upcoming agents and also discuss the challenges and limitations of targeted therapies in the allogeneic hematopoietic stem cell transplantation community.
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Affiliation(s)
- Wei Shi
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024, USA
| | - Weiwei Jin
- Department of Cardiovascular, Optical Valley School District, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan 430061, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan 430074, China
| | - Linghui Xia
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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31
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Walcher L, Kistenmacher AK, Suo H, Kitte R, Dluczek S, Strauß A, Blaudszun AR, Yevsa T, Fricke S, Kossatz-Boehlert U. Cancer Stem Cells-Origins and Biomarkers: Perspectives for Targeted Personalized Therapies. Front Immunol 2020; 11:1280. [PMID: 32849491 PMCID: PMC7426526 DOI: 10.3389/fimmu.2020.01280] [Citation(s) in RCA: 454] [Impact Index Per Article: 113.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 05/20/2020] [Indexed: 02/06/2023] Open
Abstract
The use of biomarkers in diagnosis, therapy and prognosis has gained increasing interest over the last decades. In particular, the analysis of biomarkers in cancer patients within the pre- and post-therapeutic period is required to identify several types of cells, which carry a risk for a disease progression and subsequent post-therapeutic relapse. Cancer stem cells (CSCs) are a subpopulation of tumor cells that can drive tumor initiation and can cause relapses. At the time point of tumor initiation, CSCs originate from either differentiated cells or adult tissue resident stem cells. Due to their importance, several biomarkers that characterize CSCs have been identified and correlated to diagnosis, therapy and prognosis. However, CSCs have been shown to display a high plasticity, which changes their phenotypic and functional appearance. Such changes are induced by chemo- and radiotherapeutics as well as senescent tumor cells, which cause alterations in the tumor microenvironment. Induction of senescence causes tumor shrinkage by modulating an anti-tumorigenic environment in which tumor cells undergo growth arrest and immune cells are attracted. Besides these positive effects after therapy, senescence can also have negative effects displayed post-therapeutically. These unfavorable effects can directly promote cancer stemness by increasing CSC plasticity phenotypes, by activating stemness pathways in non-CSCs, as well as by promoting senescence escape and subsequent activation of stemness pathways. At the end, all these effects can lead to tumor relapse and metastasis. This review provides an overview of the most frequently used CSC markers and their implementation as biomarkers by focussing on deadliest solid (lung, stomach, liver, breast and colorectal cancers) and hematological (acute myeloid leukemia, chronic myeloid leukemia) cancers. Furthermore, it gives examples on how the CSC markers might be influenced by therapeutics, such as chemo- and radiotherapy, and the tumor microenvironment. It points out, that it is crucial to identify and monitor residual CSCs, senescent tumor cells, and the pro-tumorigenic senescence-associated secretory phenotype in a therapy follow-up using specific biomarkers. As a future perspective, a targeted immune-mediated strategy using chimeric antigen receptor based approaches for the removal of remaining chemotherapy-resistant cells as well as CSCs in a personalized therapeutic approach are discussed.
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Affiliation(s)
- Lia Walcher
- Department of Immunology, Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Ann-Kathrin Kistenmacher
- Department of Immunology, Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Huizhen Suo
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Reni Kitte
- Department of Immunology, Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Sarah Dluczek
- Department of Immunology, Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Alexander Strauß
- Department of Immunology, Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - André-René Blaudszun
- Department of Immunology, Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Tetyana Yevsa
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Stephan Fricke
- Department of Immunology, Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Uta Kossatz-Boehlert
- Department of Immunology, Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
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32
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Fenwarth L, Fournier E, Cheok M, Boyer T, Gonzales F, Castaigne S, Boissel N, Lambert J, Dombret H, Preudhomme C, Duployez N. Biomarkers of Gemtuzumab Ozogamicin Response for Acute Myeloid Leukemia Treatment. Int J Mol Sci 2020; 21:E5626. [PMID: 32781546 PMCID: PMC7460695 DOI: 10.3390/ijms21165626] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 08/03/2020] [Indexed: 11/27/2022] Open
Abstract
Gemtuzumab ozogamicin (GO, Mylotarg®) consists of a humanized CD33-targeted antibody-drug conjugated to a calicheamicin derivative. Growing evidence of GO efficacy in acute myeloid leukemia (AML), demonstrated by improved outcomes in CD33-positive AML patients across phase I to III clinical trials, led to the Food and Drug Administration (FDA) approval on 1 September 2017 in CD33-positive AML patients aged 2 years and older. Discrepancies in GO recipients outcome have raised significant efforts to characterize biomarkers predictive of GO response and have refined the subset of patients that may strongly benefit from GO. Among them, CD33 expression levels, favorable cytogenetics (t(8;21), inv(16)/t(16;16), t(15;17)) and molecular alterations, such as NPM1, FLT3-internal tandem duplications and other signaling mutations, represent well-known candidates. Additionally, in depth analyses including minimal residual disease monitoring, stemness expression (LSC17 score), mutations or single nucleotide polymorphisms in GO pathway genes (CD33, ABCB1) and molecular-derived scores, such as the recently set up CD33_PGx6_Score, represent promising markers to enhance GO response prediction and improve patient management.
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Affiliation(s)
- Laurène Fenwarth
- UMR 9020–UMR-S 1277–Canther–Cancer Heterogeneity, Plasticity and Resistance to Therapies, Institut de Recherche contre le Cancer de Lille, University Lille, CNRS, Inserm, CHU Lille, F-59000 Lille, France; (E.F.); (M.C.); (F.G.); (C.P.); (N.D.)
| | - Elise Fournier
- UMR 9020–UMR-S 1277–Canther–Cancer Heterogeneity, Plasticity and Resistance to Therapies, Institut de Recherche contre le Cancer de Lille, University Lille, CNRS, Inserm, CHU Lille, F-59000 Lille, France; (E.F.); (M.C.); (F.G.); (C.P.); (N.D.)
| | - Meyling Cheok
- UMR 9020–UMR-S 1277–Canther–Cancer Heterogeneity, Plasticity and Resistance to Therapies, Institut de Recherche contre le Cancer de Lille, University Lille, CNRS, Inserm, CHU Lille, F-59000 Lille, France; (E.F.); (M.C.); (F.G.); (C.P.); (N.D.)
| | - Thomas Boyer
- Laboratory of Hematology, CHU Amiens, F-80054 Amiens, France;
| | - Fanny Gonzales
- UMR 9020–UMR-S 1277–Canther–Cancer Heterogeneity, Plasticity and Resistance to Therapies, Institut de Recherche contre le Cancer de Lille, University Lille, CNRS, Inserm, CHU Lille, F-59000 Lille, France; (E.F.); (M.C.); (F.G.); (C.P.); (N.D.)
| | - Sylvie Castaigne
- Department of Hematology, CH Versailles, F-78157 Le Chesnay, France; (S.C.); (J.L.)
| | - Nicolas Boissel
- Adolescent and Young Adult Hematology Unit, Hôpital Saint-Louis, AP-HP, Université de Paris, F-75010 Paris, France;
| | - Juliette Lambert
- Department of Hematology, CH Versailles, F-78157 Le Chesnay, France; (S.C.); (J.L.)
| | - Hervé Dombret
- Department of Hematology, Hôpital Saint-Louis, AP-HP, Université de Paris, F-75010 Paris, France;
| | - Claude Preudhomme
- UMR 9020–UMR-S 1277–Canther–Cancer Heterogeneity, Plasticity and Resistance to Therapies, Institut de Recherche contre le Cancer de Lille, University Lille, CNRS, Inserm, CHU Lille, F-59000 Lille, France; (E.F.); (M.C.); (F.G.); (C.P.); (N.D.)
| | - Nicolas Duployez
- UMR 9020–UMR-S 1277–Canther–Cancer Heterogeneity, Plasticity and Resistance to Therapies, Institut de Recherche contre le Cancer de Lille, University Lille, CNRS, Inserm, CHU Lille, F-59000 Lille, France; (E.F.); (M.C.); (F.G.); (C.P.); (N.D.)
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Immune Landscape in Tumor Microenvironment: Implications for Biomarker Development and Immunotherapy. Int J Mol Sci 2020; 21:ijms21155521. [PMID: 32752264 PMCID: PMC7432816 DOI: 10.3390/ijms21155521] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/31/2020] [Accepted: 07/31/2020] [Indexed: 02/06/2023] Open
Abstract
Integration of the tumor microenvironment as a fundamental part of the tumorigenic process has undoubtedly revolutionized our understanding of cancer biology. Increasing evidence indicates that neoplastic cells establish a dependency relationship with normal resident cells in the affected tissue and, furthermore, develop the ability to recruit new accessory cells that aid tumor development. In addition to normal stromal and tumor cells, this tumor ecosystem includes an infiltrated immune component that establishes complex interactions that have a critical effect during the natural history of the tumor. The process by which immune cells modulate tumor progression is known as immunoediting, a dynamic process that creates a selective pressure that finally leads to the generation of immune-resistant cells and the inability of the immune system to eradicate the tumor. In this context, the cellular and functional characterization of the immune compartment within the tumor microenvironment will help to understand tumor progression and, ultimately, will serve to create novel prognostic tools and improve patient stratification for cancer treatment. Here we review the impact of the immune system on tumor development, focusing particularly on its clinical implications and the current technologies used to analyze immune cell diversity within the tumor.
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Kim H. Treatments for children and adolescents with AML. Blood Res 2020; 55:S5-S13. [PMID: 32719170 PMCID: PMC7386885 DOI: 10.5045/br.2020.s002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/30/2020] [Accepted: 02/14/2020] [Indexed: 12/12/2022] Open
Abstract
In recent decades, survival rates for childhood acute myeloid leukemia have remarkably improved, owing to chemotherapy intensification, allogeneic hematopoietic stem cell transplantation, and improved supportive care. Furthermore, treatment protocols have evolved and are currently better matched to prognostic factors and treatment responses. Recently, new molecular prognostic factors were discovered via leukemia genomic studies. Moreover, new tumor subtypes with independent gene expression profiles have been characterized. To broaden the therapeutic options for patients with poor prognoses, therapies that target specific candidate mutations are being identified. Additionally, new drugs are undergoing clinical trials, and immunotherapy is attracting significant interest as a treatment option for recurrent or refractory childhood acute myeloid leukemia.
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Affiliation(s)
- Hyery Kim
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children’s Hospital, Seoul, Korea
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Pearson ADJ, Zwaan CM, Kolb EA, Karres D, Guillot J, Kim SY, Marshall L, Tasian SK, Smith M, Cooper T, Adamson PC, Barry E, Benettaib B, Binlich F, Borgman A, Brivio E, Capdeville R, Delgado D, Faller D, Fogelstrand L, Fraenkel PG, Hasle H, Heenen D, Kaspers G, Kieran M, Klusmann JH, Lesa G, Ligas F, Mappa S, Mohamed H, Moore A, Morris J, Nottage K, Reinhardt D, Scobie N, Simko S, Winkler T, Norga K, Reaman G, Vassal G. Paediatric Strategy Forum for medicinal product development for acute myeloid leukaemia in children and adolescents: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration. Eur J Cancer 2020; 136:116-129. [PMID: 32688206 PMCID: PMC7789799 DOI: 10.1016/j.ejca.2020.04.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 12/18/2022]
Abstract
Purpose: The current standard-of-care for front-line therapy for acute myeloid leukaemia (AML) results in short-term and long-term toxicity, but still approximately 40% of children relapse. Therefore, there is a major need to accelerate the evaluation of innovative medicines, yet drug development continues to be adult-focused. Furthermore, the large number of competing agents in rare patient populations requires coordinated prioritisation, within the global regulatory framework and cooperative group initiatives. Methods: The fourth multi-stakeholder Paediatric Strategy Forum focused on AML in children and adolescents. Results: CD123 is a high priority target and the paediatric development should be accelerated as a proof-of-concept. Efforts must be coordinated, however, as there are a limited number of studies that can be delivered. Studies of FLT3 inhibitors in agreed paediatric investigation plans present challenges to be completed because they require enrolment of a larger number of patients than actually exist. A consensus was developed by industry and academia of optimised clinical trials. For AML with rare mutations that are more frequent in adolescents than in children, adult trials should enrol adolescents and when scientifically justified, efficacy data could be extrapolated. Methodologies and definitions of minimal residual disease need to be standardised internationally and validated as a new response criterion. Industry supported, academic sponsored platform trials could identify products to be further developed. The Leukaemia and Lymphoma Society PedAL/EUpAL initiative has the potential to be a major advance in the field. Conclusion: These initiatives continue to accelerate drug development for children with AML and ultimately improve clinical outcomes.
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Affiliation(s)
| | - C Michel Zwaan
- Princess Máxima Center, Utrecht, the Netherlands; Erasmus MC, Rotterdam, the Netherlands; ITCC, the Netherlands
| | | | | | - Julie Guillot
- Fred Hutchinson Cancer Research Center, Leukaemia Lymphoma Society, Target Paediatric AML, USA
| | | | - Lynley Marshall
- Royal Marsden Hospital, The Institute of Cancer Research, UK
| | - Sarah K Tasian
- Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, USA
| | - Malcolm Smith
- National Institutes of Health, National Cancer Institute, USA
| | | | - Peter C Adamson
- Sanofi US, Emeritus Professor of Paediatrics & Pharmacology, Perelman School of Medicine, University of Pennsylvania, USA
| | | | | | | | | | - Erica Brivio
- Princess Máxima Center, Utrecht, the Netherlands; Erasmus MC, Rotterdam, the Netherlands; ITCC, the Netherlands
| | | | | | | | - Linda Fogelstrand
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | | | - Henrik Hasle
- Department of Paediatrics, Aarhus University Hospital, Denmark
| | | | - Gertjan Kaspers
- Princess Máxima Center, Utrecht, the Netherlands; Erasmus MC, Rotterdam, the Netherlands; ITCC, the Netherlands
| | | | | | - Giovanni Lesa
- European Medicines Agency, Amsterdam, the Netherlands
| | - Franca Ligas
- European Medicines Agency, Amsterdam, the Netherlands
| | | | | | - Andrew Moore
- Queensland Children's Hospital, Brisbane, Australia
| | | | | | | | | | | | | | - Koen Norga
- Universitair Ziekenhuis Antwerpen, FAMHP, Belgium
| | | | - Gilles Vassal
- ACCELERATE/ITCC, Belgium; Gustave Roussy Cancer Centre, France
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Lyon-University Hospital Experience with Gemtuzumab Ozogamicin Therapy in Acute Myeloid Leukemia: a 'Real-Life' Study. Mediterr J Hematol Infect Dis 2020; 12:e2020020. [PMID: 32395209 PMCID: PMC7202336 DOI: 10.4084/mjhid.2020.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/17/2020] [Indexed: 11/14/2022] Open
Abstract
Ninety-four adults with newly diagnosed or relapsed/refractory acute myeloid leukemia (AML) were treated with fractionated doses of gemtuzumab ozogamicin (GO) at one-single French center over ten years. We attempted to define predictive factors for response and survival. The overall response rate was 70% (86% in newly diagnosed and 65% in relapsed/refractory AML). Mortality during induction was 6%. Disease-free survival (DFS) and overall survival at three years after GO treatment was 36% and 31%, respectively. Median DFS in relapsed/refractory patients was eight months with a 3-year DFS at 34%. Among remitters, allogeneic hematopoietic stem cell transplantation (HSCT) can be performed in 28 cases (42%), including two patients in first-line therapy and 26 in further line. In relapsed/refractory patients undergoing allogeneic HSCT after responding to GO therapy, the median DFS was not reached. Incidences of transplant-related mortality, grade ≥ 3 acute graft-versus-host (GvH) disease, and extensive chronic GvH disease were 11%, 14%, and 25%, respectively. No sinusoidal obstruction syndromes were reported among allografted patients as among the other patients in the studied cohort. GO-based chemotherapy is a viable option for the treatment of relapsed/refractory AML patients and is a feasible schedule as a bridge to allogeneic transplant.
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37
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Bosse KR, Majzner RG, Mackall CL, Maris JM. Immune-Based Approaches for the Treatment of Pediatric Malignancies. ANNUAL REVIEW OF CANCER BIOLOGY-SERIES 2020; 4:353-370. [PMID: 34113750 PMCID: PMC8189419 DOI: 10.1146/annurev-cancerbio-030419-033436] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Immune-based therapies have now been credentialed for pediatric cancers with the robust efficacy of chimeric antigen receptor (CAR) T cells for pediatric B cell acute lymphocytic leukemia (ALL), offering a chance of a cure for children with previously lethal disease and a potentially more targeted therapy to limit treatment-related morbidities. The developmental origins of most pediatric cancers make them ideal targets for immune-based therapies that capitalize on the differential expression of lineage-specific cell surface molecules such as antibodies, antibody-drug conjugates, or CAR T cells, while the efficacy of other therapies that depend on tumor immunogenicity such as immune checkpoint inhibitors has been limited to date. Here we review the current status of immune-based therapies for childhood cancers, discuss challenges to developing immunotherapeutics for these diseases, and outline future directions of pediatric immunotherapy discovery and development.
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Affiliation(s)
- Kristopher R Bosse
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Robbie G Majzner
- Department of Pediatrics and Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Crystal L Mackall
- Department of Pediatrics and Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California 94305, USA
| | - John M Maris
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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Tarlock K, Alonzo TA, Wang YC, Gerbing RB, Ries R, Loken MR, Pardo L, Hylkema T, Joaquin J, Sarukkai L, Raimondi SC, Hirsch B, Sung L, Aplenc R, Bernstein I, Gamis AS, Meshinchi S, Pollard JA. Functional Properties of KIT Mutations Are Associated with Differential Clinical Outcomes and Response to Targeted Therapeutics in CBF Acute Myeloid Leukemia. Clin Cancer Res 2019; 25:5038-5048. [PMID: 31182436 DOI: 10.1158/1078-0432.ccr-18-1897] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 01/03/2019] [Accepted: 05/31/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE KIT mutations (KIT +) are common in core binding factor (CBF) AML and have been associated with varying prognostic significance. We sought to define the functional and clinical significance of distinct KIT mutations in CBF pediatric AML. EXPERIMENTAL DESIGN Following transfection of exon 17 (E17) and exon 8 (E8) mutations into HEK293 and Ba/F3 cells, KIT phosphorylation, cytokine-independent growth, and response to tyrosine kinase inhibitors (TKI) were evaluated. Clinical outcomes of patients treated on COG AAML0531 (NCT01407757), a phase III study of gemtuzumab ozogamicin (GO), were analyzed according to mutation status [KIT + vs. wild-type KIT (KIT -)] and mutation location (E8 vs. E17). RESULTS KIT mutations were detected in 63 of 205 patients (31%); 22 (35%) involved only E8, 32 (51%) only E17, 6 (10%) both exons, and 3 (5%) alternative exons. Functional studies demonstrated that E17, but not E8, mutations result in aberrant KIT phosphorylation and growth. TKI exposure significantly affected growth of E17, but not E8, transfected cells. Patients with KIT + CBF AML had overall survival similar to those with KIT - (78% vs. 81%, P = 0.905) but higher relapse rates (RR = 43% vs. 21%; P = 0.005). E17 KIT + outcomes were inferior to KIT - patients [disease-free survival (DFS), 51% vs. 73%, P = 0.027; RR = 21% vs. 46%, P = 0.007)], although gemtuzumab ozogamicin abrogated this negative prognostic impact. E8 mutations lacked significant prognostic effect, and GO failed to significantly improve outcome. CONCLUSIONS E17 mutations affect prognosis in CBF AML, as well as response to GO and TKIs; thus, clinical trials using both agents should be considered for KIT + patients.
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Affiliation(s)
- Katherine Tarlock
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington. .,Division of Hematology/Oncology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Todd A Alonzo
- University of Southern California Keck School of Medicine, Los Angeles, California.,Children's Oncology Group, Monrovia, California
| | | | | | - Rhonda Ries
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | - Tiffany Hylkema
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Jason Joaquin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Leela Sarukkai
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Betsy Hirsch
- University of Minnesota Cancer Center, Minneapolis, Minnesota
| | - Lillian Sung
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Richard Aplenc
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Irwin Bernstein
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Division of Hematology/Oncology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Alan S Gamis
- Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Soheil Meshinchi
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Division of Hematology/Oncology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Jessica A Pollard
- Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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Clinical and Radiographic Response of Extramedullary Leukemia in Patients Treated With Gemtuzumab Ozogamicin. J Pediatr Hematol Oncol 2019; 41:e174-e176. [PMID: 29734213 DOI: 10.1097/mph.0000000000001201] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Extramedullary leukemia (EML) is common in pediatric acute leukemia and can present at diagnosis or relapse. CD33 is detected on the surface of myeloid blasts in many patients with acute myelogenous leukemia and is the target of the antibody drug conjugate gemtuzumab ozogamicin (GO). Here we present 2 patients with CD33 EML treated with GO. They achieved significant response, with reduction of EML on both clinical and radiographic exams, specifically fluorine fluorodeoxyglucose positron emission tomography/computed tomography, demonstrating potential for targeted therapy with GO as a means of treating EML in patients with CD33 leukemia and the utility of fluorine fluorodeoxyglucose positron emission tomography/computed tomography monitoring in EML.
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40
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Bonifant CL, Velasquez MP, Gottschalk S. Advances in immunotherapy for pediatric acute myeloid leukemia. Expert Opin Biol Ther 2017; 18:51-63. [PMID: 28945115 DOI: 10.1080/14712598.2018.1384463] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Achieving better disease control in patients diagnosed with acute myeloid leukemia (AML) has proven challenging. Overall survival has been impacted by addressing treatment related mortality with focused supportive care measures. Despite this improvement, it remains difficult to induce durable leukemia remissions despite aggressive chemotherapeutic regimens. The addition of hematopoietic stem cell transplants (HSCT) has allowed further treatment intensification and provided the benefit of graft-versus-leukemia (GVL) effect. However, HSCT carries the risk of transplant related morbidities, particularly GVHD, and anti-tumor responsiveness is still suboptimal. Thus, there is a need for alternate therapies. Immunotherapy has the potential to address this need. Areas covered: Expert opinion: The elusiveness of an ideal surface antigen target together with an immunosuppressive leukemic microenvironment add to the already difficult challenge in developing AML-targeted immunotherapies. Though many hurdles remain, recent translational discovery and progressive clinical advances anticipate exciting future developments. AREAS COVERED This review highlights promises and challenges to immune-based therapies for AML. It aims to summarize immunotherapeutic strategies trialed in AML patients to date, inclusive of: antibodies, vaccines, and cellular therapy. It emphasizes those being used in the pediatric population, but also includes adult clinical trials and translational science that may ultimately extend to pediatric patients.
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Affiliation(s)
- Challice L Bonifant
- a Department of Pediatrics and Communicable Diseases , University of Michigan , Ann Arbor , MI , USA
| | - Mireya Paulina Velasquez
- b Department of Bone Marrow Transplantation and Cellular Therapy , St. Jude Children's Research Hospital , Memphis , TN , USA
| | - Stephen Gottschalk
- b Department of Bone Marrow Transplantation and Cellular Therapy , St. Jude Children's Research Hospital , Memphis , TN , USA
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41
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Wang NN, Ye QD. [Advances in targeted therapy for childhood acute myeloid leukemia]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:832-836. [PMID: 28697841 PMCID: PMC7389918 DOI: 10.7499/j.issn.1008-8830.2017.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 03/09/2017] [Indexed: 06/07/2023]
Abstract
At present, acute myeloid leukemia (AML) accounts for about 15%-20% of childhood acute leukemia. Although overall survival rate is increasing with the help of risk stratification, stratification of chemotherapy, and supportive treatment, conventional pharmacotherapy still has a limited clinical effect and certain limitations in improving remission rate in previously untreated patients and reducing recurrence after remission. With the development of precision medicine, the mechanisms of targeted therapy, including abnormal activation of AML-related signaling pathways and epigenetic modification, have been found in recent years. Molecular-targeted drugs can therefore act on specific receptors and target genes to improve clinical effect and the prognosis of AML patients.
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Affiliation(s)
- Ni-Na Wang
- Department of Hematology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China.
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42
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Gemtuzumab ozogamicin in acute myeloid leukemia. Leukemia 2017; 31:1855-1868. [PMID: 28607471 DOI: 10.1038/leu.2017.187] [Citation(s) in RCA: 141] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 05/26/2017] [Accepted: 05/31/2017] [Indexed: 12/13/2022]
Abstract
CD33 is variably expressed on leukemia blasts in almost all patients with acute myeloid leukemia (AML) and possibly leukemia stem cells in some. Efforts to target CD33 therapeutically have focused on gemtuzumab ozogamicin (GO; Mylotarg), an antibody-drug conjugate delivering a DNA-damaging calicheamicin derivative. GO is most effective in acute promyelocytic leukemia but induces remissions in other AML types and received accelerated approval in the US in 2000. However, because a large follow-up study showed no survival improvement and increased early deaths the drug manufacturer voluntarily withdrew the US New Drug Application in 2010. More recently, a meta-analysis of data from several trials reported better survival in adults with favorable- and intermediate-risk cytogenetics but not adverse-risk AML randomized to receive GO along with intensive induction chemotherapy. As a result, GO is being re-evaluated by regulatory agencies. Responses to GO are diverse and predictive biological response markers are needed. Besides cytogenetic risk, ATP-binding cassette transporter activity and possibly CD33 display on AML blasts may predict response, but established clinical assays and prospective validation are lacking. Single-nucleotide polymorphisms in CD33 may also be predictive, most notably rs12459419 where the minor T-allele leads to decreased display of full-length CD33 and preferential translation of a splice variant not recognized by GO. Data from retrospective analyses suggest only patients with the rs12459419 CC genotype may benefit from GO therapy but confirmation is needed. Most important may be markers for AML cell sensitivity to calicheamicin, which varies over 100 000-fold, but useful assays are unavailable. Novel CD33-targeted drugs may overcome some of GO's limitations but it is currently unknown whether such drugs will be more effective in patients benefitting from GO and/or improve outcomes in patients not benefitting from GO, and what the supportive care requirements will be to enable their safe use.
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43
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Sexauer AN, Tasian SK. Targeting FLT3 Signaling in Childhood Acute Myeloid Leukemia. Front Pediatr 2017; 5:248. [PMID: 29209600 PMCID: PMC5702014 DOI: 10.3389/fped.2017.00248] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/06/2017] [Indexed: 11/13/2022] Open
Abstract
Acute myeloid leukemia (AML) is the second most common leukemia of childhood and is associated with high rates of chemotherapy resistance and relapse. Clinical outcomes for children with AML treated with maximally intensive multi-agent chemotherapy lag far behind those of children with the more common acute lymphoblastic leukemia, demonstrating continued need for new therapeutic approaches to decrease relapse risk and improve long-term survival. Mutations in the FMS-like tyrosine kinase-3 receptor gene (FLT3) occur in approximately 25% of children and adults with AML and are associated with particularly poor prognoses. Identification and development of targeted FLT3 inhibitors represents a major precision medicine paradigm shift in the treatment of patients with AML. While further development of many first-generation FLT3 inhibitors was hampered by limited potency and significant toxicity due to effects upon other kinases, the more selective second- and third-generation FLT3 inhibitors have demonstrated excellent tolerability and remarkable efficacy in the relapsed/refractory and now de novo FLT3-mutated AML settings. While these newest and most promising inhibitors have largely been studied in the adult population, pediatric investigation of FLT3 inhibitors with chemotherapy is relatively recently ongoing or planned. Successful development of FLT3 inhibitor-based therapies will be essential to improve outcomes in children with this high-risk subtype of AML.
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Affiliation(s)
- Amy N Sexauer
- Dana-Farber Cancer Institute, Boston, MA, United States.,Boston Children's Hospital, Department of Pediatrics, Division of Pediatric Hematology/Oncology/Stem Cell Transplant, Boston, MA, United States
| | - Sarah K Tasian
- Children's Hospital of Philadelphia, Division of Oncology, Center for Childhood Cancer Research, Philadelphia, PA, United States.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Bautista F, Van der Lugt J, Kearns PR, Mussai FJ, Zwaan CM, Moreno L. The development of targeted new agents to improve the outcome for children with leukemia. Expert Opin Drug Discov 2016; 11:1111-1122. [PMID: 27670965 DOI: 10.1080/17460441.2016.1237939] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Survival rates in pediatric leukemia have greatly improved in the last decades but still a substantial number of patients will relapse and die. New agents are necessary to overcome the limitations of conventional chemotherapy and hematopoietic stem cell transplantation and to reduce their undesirable long-term toxicities. The identification of driving molecular alterations of leukemogenesis in subsets of patients will allow the incorporation of new-targeted therapies. Areas covered: In this article the authors present a detailed review of the most recent advances in targeted therapies for pediatric leukemias. A comprehensive description of the biological background, adult data and early clinical trials in pediatrics is provided. Expert opinion: Clinical trials are the way to evaluate new agents in pediatric cancer. The development of new drugs in pediatric leukemia must be preceded by a solid biological rationale. Agents in development exploit all possible vulnerabilities of leukemic cells. Drugs targeting cell surface antigens, intracellular signaling pathways and cell cycle inhibitors or epigenetic regulators are most prominent. Major advances have occurred thanks to new developments in engineering leading to optimized molecules such as anti-CD19 bi-specific T-cell engagers (e.g. blinatumomab) and antibody-drug conjugates. The integration of new-targeted therapies in pediatric chemotherapy-based regimens will lead to improved outcomes.
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Affiliation(s)
- Francisco Bautista
- a Department of Pediatric Oncology, Hematology and Stem Cell Transplantation , Hospital Niño Jesús , Madrid , Spain
| | - Jasper Van der Lugt
- b Department of Pediatric Oncology/Hematology , Erasmus-MC Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Pamela R Kearns
- c Cancer Research UK Clinical Trials Unit, School of Cancer Sciences , University of Birmingham , Birmingham , UK
| | - Francis J Mussai
- c Cancer Research UK Clinical Trials Unit, School of Cancer Sciences , University of Birmingham , Birmingham , UK
| | - C Michel Zwaan
- b Department of Pediatric Oncology/Hematology , Erasmus-MC Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Lucas Moreno
- a Department of Pediatric Oncology, Hematology and Stem Cell Transplantation , Hospital Niño Jesús , Madrid , Spain
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