1
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Yang L, Zhang R, Ma H. Sweet syndrome induced by FLT3 inhibitors: case report and literature review. Hematology 2024; 29:2337230. [PMID: 38563968 DOI: 10.1080/16078454.2024.2337230] [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: 10/05/2023] [Accepted: 03/26/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Acute febrile neutrophilic dermatosis, also commonly referred to as Sweet syndrome, is often associated with tumors, infections, immune disorders and medications. FLT3 inhibitor-induced Sweet syndrome is a rare complication. METHODS AND RESULTS We report a patient with relapsed and refractory acute monocytic leukemia harboring high-frequency FLT3-ITD and DNMT3a mutations. The FLT3 inhibitor gilteritinib was administered for reinduction therapy after failure of chemotherapy with a combination of venetoclax, decitabine, aclarubicin, cytarabine and granulocyte colony-stimulating factor. The leukemia patient achieved remission after 1 month of treatment. However, Sweet syndrome induced by gilteritinib, which was confirmed by skin biopsy, developed during induction therapy. Similar cases of Sweet syndrome following FLT3 inhibitor therapy for acute myeloid leukemia were reviewed. CONCLUSION Attention should be given to this rare complication when FLT3 inhibitors are used for acute myeloid leukemia therapy, and appropriate treatments need to be administered in a timely manner.
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Affiliation(s)
- Linhui Yang
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, People's Republic of China
| | - Ran Zhang
- Department of Dermatology, West China Hospital of Sichuan University, Chengdu, People's Republic of China
| | - Hongbing Ma
- Department of Hematology, West China Hospital of Sichuan University, Chengdu, People's Republic of China
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2
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Urrutia S, Takahashi K. Precision medicine in AML: overcoming resistance. Int J Hematol 2024:10.1007/s12185-024-03827-8. [PMID: 39085680 DOI: 10.1007/s12185-024-03827-8] [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: 04/19/2024] [Revised: 07/04/2024] [Accepted: 07/24/2024] [Indexed: 08/02/2024]
Abstract
The development of molecularly targeted therapy for acute myeloid leukemia is progressing at an accelerated pace. Therapies targeting FLT3, IDH1, IDH2, and BCL2 have been approved in the last 5 years. As we exploit these biological vulnerabilities, various mechanisms of resistance arise. Emergence of competing clones with different genetic drivers and acquisition of constitutional mutations in the target renders therapies ineffective, and enzymatic isoform changes can lead to reappearance of the disease phenotype. Understanding the timing and circumstances of resistance origination will allow clinicians to develop combinatorial and sequential therapeutic approaches to deepen responses and improve survival. The objective of this review is to illustrate the biological underpinnings of each therapy and the landscape of resistance mechanisms and discuss strategies to overcome on- and off-target resistance.
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Affiliation(s)
- Samuel Urrutia
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, 1901 East Road, 4SCR6.2085, Houston, TX, 77030-4009, USA
| | - Koichi Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, USA.
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3
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Kowalczyk A, Zarychta J, Lejman M, Latoch E, Zawitkowska J. Clinical Implications of Isocitrate Dehydrogenase Mutations and Targeted Treatment of Acute Myeloid Leukemia with Mutant Isocitrate Dehydrogenase Inhibitors-Recent Advances, Challenges and Future Prospects. Int J Mol Sci 2024; 25:7916. [PMID: 39063158 PMCID: PMC11276768 DOI: 10.3390/ijms25147916] [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: 06/21/2024] [Revised: 07/12/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Despite the better understanding of the molecular mechanisms contributing to the pathogenesis of acute myeloid leukemia (AML) and improved patient survival in recent years, AML therapy still remains a clinical challenge. For this reason, it is important to search for new therapies that will enable the achievement of remission. Recently, the Food and Drug Administration approved three mutant IDH (mIDH) inhibitors for the treatment of AML. However, the use of mIDH inhibitors in monotherapy usually leads to the development of resistance and the subsequent recurrence of the cancer, despite the initial effectiveness of the therapy. A complete understanding of the mechanisms by which IDH mutations influence the development of leukemia, as well as the processes that enable resistance to mIDH inhibitors, may significantly improve the efficacy of this therapy through the use of an appropriate synergistic approach. The aim of this literature review is to present the role of IDH1/IDH2 mutations in the pathogenesis of AML and the results of clinical trials using mIDH1/IDH2 inhibitors in AML and to discuss the challenges related to the use of mIDH1/IDH2 inhibitors in practice and future prospects related to the potential methods of overcoming resistance to these agents.
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Affiliation(s)
- Adrian Kowalczyk
- Student Scientific Society of Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, 20-093 Lublin, Poland; (A.K.); (J.Z.)
| | - Julia Zarychta
- Student Scientific Society of Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, 20-093 Lublin, Poland; (A.K.); (J.Z.)
| | - Monika Lejman
- Independent Laboratory of Genetic Diagnostics, Medical University of Lublin, 20-093 Lublin, Poland;
| | - Eryk Latoch
- Department of Pediatric Oncology and Hematology, Medical University of Bialystok, 15-274 Bialystok, Poland;
| | - Joanna Zawitkowska
- Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, 20-093 Lublin, Poland
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4
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Jen WY, Kantarjian H, Kadia TM, DiNardo CD, Issa GC, Short NJ, Yilmaz M, Borthakur G, Ravandi F, Daver NG. Combination therapy with novel agents for acute myeloid leukaemia: Insights into treatment of a heterogenous disease. Br J Haematol 2024; 205:30-47. [PMID: 38724457 DOI: 10.1111/bjh.19519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/27/2024] [Indexed: 07/13/2024]
Abstract
The treatment landscape of acute myeloid leukaemia (AML) is evolving rapidly. Venetoclax in combination with intensive chemotherapy or doublets or triplets with targeted or immune therapies is the focus of numerous ongoing trials. The development of mutation-targeted therapies has greatly enhanced the treatment armamentarium, with FLT3 inhibitors and isocitrate dehydrogenase inhibitors improving outcomes in frontline and relapsed/refractory (RR) AML, and menin inhibitors showing efficacy in RR NPM1mut and KMT2A-rearranged AML. With so many new drugs approved, the number of potential combinatorial approaches to leverage the maximal benefit of these agents has increased dramatically, while at the same time introducing clinical challenges, such as key preclinical and clinical data supporting the development of combinatorial therapy, how to optimally combine or sequence these novel agents, how to optimise dose and duration to maintain safety while enhancing efficacy, the optimal duration of therapy and the role of measurable residual disease in decision-making in both intensive and low-intensity therapy settings. In this review, we will outline the evidence leading to the approval of key agents in AML, their on-label current approvals and how they may be optimally combined in a safe and deliverable fashion to further improve outcomes in AML.
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Affiliation(s)
- Wei-Ying Jen
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ghayas C Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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5
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Zhang Y, Yan H, Wei Y, Wei X. Decoding mitochondria's role in immunity and cancer therapy. Biochim Biophys Acta Rev Cancer 2024; 1879:189107. [PMID: 38734035 DOI: 10.1016/j.bbcan.2024.189107] [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: 02/08/2024] [Revised: 04/22/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024]
Abstract
The functions of mitochondria, including energy production and biomolecule synthesis, have been known for a long time. Given the rising incidence of cancer, the role of mitochondria in cancer has become increasingly popular. Activated by components released by mitochondria, various pathways interact with each other to induce immune responses to protect organisms from attack. However, mitochondria play dual roles in the progression of cancer. Abnormalities in proteins, which are the elementary structures of mitochondria, are closely linked with oncogenesis. Both the aberrant accumulation of intermediates and mutations in enzymes result in the generation and progression of cancer. Therefore, targeting mitochondria to treat cancer may be a new strategy. Several drugs aimed at inhibiting mutated enzymes and accumulated intermediates have been tested clinically. Here, we discuss the current understanding of mitochondria in cancer and the interactions between mitochondrial functions, immune responses, and oncogenesis. Furthermore, we discuss mitochondria as hopeful targets for cancer therapy, providing insights into the progression of future therapeutic strategies.
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Affiliation(s)
- Yu Zhang
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 17, Block 3, Southern Renmin Road, 610041 Chengdu, Sichuan, PR China
| | - Hong Yan
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 17, Block 3, Southern Renmin Road, 610041 Chengdu, Sichuan, PR China
| | - Yuquan Wei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 17, Block 3, Southern Renmin Road, 610041 Chengdu, Sichuan, PR China.
| | - Xiawei Wei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 17, Block 3, Southern Renmin Road, 610041 Chengdu, Sichuan, PR China.
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6
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Bruserud Ø, Selheim F, Hernandez-Valladares M, Reikvam H. Monocytic Differentiation in Acute Myeloid Leukemia Cells: Diagnostic Criteria, Biological Heterogeneity, Mitochondrial Metabolism, Resistance to and Induction by Targeted Therapies. Int J Mol Sci 2024; 25:6356. [PMID: 38928061 PMCID: PMC11203697 DOI: 10.3390/ijms25126356] [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: 05/05/2024] [Revised: 05/31/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
We review the importance of monocytic differentiation and differentiation induction in non-APL (acute promyelocytic leukemia) variants of acute myeloid leukemia (AML), a malignancy characterized by proliferation of immature myeloid cells. Even though the cellular differentiation block is a fundamental characteristic, the AML cells can show limited signs of differentiation. According to the French-American-British (FAB-M4/M5 subset) and the World Health Organization (WHO) 2016 classifications, monocytic differentiation is characterized by morphological signs and the expression of specific molecular markers involved in cellular communication and adhesion. Furthermore, monocytic FAB-M4/M5 patients are heterogeneous with regards to cytogenetic and molecular genetic abnormalities, and monocytic differentiation does not have any major prognostic impact for these patients when receiving conventional intensive cytotoxic therapy. In contrast, FAB-M4/M5 patients have decreased susceptibility to the Bcl-2 inhibitor venetoclax, and this seems to be due to common molecular characteristics involving mitochondrial regulation of the cellular metabolism and survival, including decreased dependency on Bcl-2 compared to other AML patients. Thus, the susceptibility to Bcl-2 inhibition does not only depend on general resistance/susceptibility mechanisms known from conventional AML therapy but also specific mechanisms involving the molecular target itself or the molecular context of the target. AML cell differentiation status is also associated with susceptibility to other targeted therapies (e.g., CDK2/4/6 and bromodomain inhibition), and differentiation induction seems to be a part of the antileukemic effect for several targeted anti-AML therapies. Differentiation-associated molecular mechanisms may thus become important in the future implementation of targeted therapies in human AML.
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MESH Headings
- Humans
- Cell Differentiation
- Leukemia, Myeloid, Acute/metabolism
- Leukemia, Myeloid, Acute/pathology
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/genetics
- Mitochondria/metabolism
- Monocytes/metabolism
- Monocytes/pathology
- Drug Resistance, Neoplasm/genetics
- Molecular Targeted Therapy
- Antineoplastic Agents/pharmacology
- Antineoplastic Agents/therapeutic use
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Affiliation(s)
- Øystein Bruserud
- Acute Leukemia Research Group, Department of Clinical Science, University of Bergen, 5007 Bergen, Norway; (M.H.-V.); (H.R.)
- Section for Hematology, Department of Medicine, Haukeland University Hospital, 5009 Bergen, Norway
| | - Frode Selheim
- Proteomics Unit of University of Bergen (PROBE), University of Bergen, Jonas Lies vei 91, 5009 Bergen, Norway;
| | - Maria Hernandez-Valladares
- Acute Leukemia Research Group, Department of Clinical Science, University of Bergen, 5007 Bergen, Norway; (M.H.-V.); (H.R.)
- Department of Physical Chemistry, University of Granada, Avenida de la Fuente Nueva S/N, 18071 Granada, Spain
- Instituto de Investigación Biosanitaria ibs.GRANADA, 18012 Granada, Spain
| | - Håkon Reikvam
- Acute Leukemia Research Group, Department of Clinical Science, University of Bergen, 5007 Bergen, Norway; (M.H.-V.); (H.R.)
- Section for Hematology, Department of Medicine, Haukeland University Hospital, 5009 Bergen, Norway
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7
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Lafarge A, Chean D, Whiting L, Clere-Jehl R. Management of hematological patients requiring emergency chemotherapy in the intensive care unit. Intensive Care Med 2024; 50:849-860. [PMID: 38748265 PMCID: PMC11164740 DOI: 10.1007/s00134-024-07454-z] [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: 02/27/2024] [Accepted: 04/18/2024] [Indexed: 05/30/2024]
Abstract
Hematological malignancies may require rapid-onset treatment because of their short doubling time, notably observed in acute leukemias and specific high-grade lymphomas. Furthermore, in targeted onco-hematological scenarios, chemotherapy is deemed necessary as an emergency measure when facing short-term, life-threatening complications associated with highly chemosensitive hematological malignancies. The risks inherent in the disease itself, or in the initiation of treatment, may then require admission to the intensive care unit (ICU) to optimize monitoring and initial management protocols. Hyperleukocytosis and leukostasis in acute leukemias, tumor lysis syndrome, and disseminated intravascular coagulation are the most frequent onco-hematological complications requiring the implementation of emergency chemotherapy in the ICU. Chemotherapy must also be started urgently in secondary hemophagocytic lymphohistiocytosis. Tumor-induced microangiopathic hemolytic anemia and plasma hyperviscosity due to malignant monoclonal gammopathy represent infrequent yet substantial indications for emergency chemotherapy. In all cases, the administration of emergency chemotherapy in the ICU requires close collaboration between intensivists and hematology specialists. In this review, we provide valuable insights that aid in the identification and treatment of patients requiring emergency chemotherapy in the ICU, offering diagnostic tools and guidance for their overall initial management.
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Affiliation(s)
- Antoine Lafarge
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France.
| | - Dara Chean
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France
| | - Livia Whiting
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France
| | - Raphaël Clere-Jehl
- Médecine Intensive et Réanimation, Hôpital de Hautepierre, University Hospital of Strasbourg, Strasbourg, France
- Laboratoire d'ImmunoRhumatologie Moléculaire, INSERM (French National Institute of Health and Medical Research), UMR_S1109, Centre de Recherche d'Immunologie et d'Hématologie, University of Strasbourg, Strasbourg, France
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8
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Montesinos P, Fathi AT, de Botton S, Stein EM, Zeidan AM, Zhu Y, Prebet T, Vigil CE, Bluemmert I, Yu X, DiNardo CD. Differentiation syndrome associated with treatment with IDH2 inhibitor enasidenib: pooled analysis from clinical trials. Blood Adv 2024; 8:2509-2519. [PMID: 38507688 PMCID: PMC11131052 DOI: 10.1182/bloodadvances.2023011914] [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: 10/13/2023] [Revised: 02/20/2024] [Accepted: 03/01/2024] [Indexed: 03/22/2024] Open
Abstract
ABSTRACT Treatment with enasidenib, a selective mutant isocitrate dehydrogenase isoform 2 (IDH2) inhibitor, has been associated with the development of differentiation syndrome (DS) in patients with acute myeloid leukemia (AML). Studies on the incidence and clinical features of DS are limited in this setting, and diagnosis is challenging because of nonspecific symptoms. This study assessed the incidence, diagnostic criteria, risk factors, and correlation with clinical response of DS based on the pooled analysis of 4 clinical trials in patients with IDH2-mutated AML treated with enasidenib as monotherapy, or in combination with azacitidine or with chemotherapy. Across the total AML population, 67 of 643 (10.4%) had ≥1 any-grade DS event, with highest incidence in patients who received enasidenib plus azacitidine and lowest incidence in patients who received enasidenib plus chemotherapy (13/74 [17.6%] and 2/93 [2.2%]). The most common symptoms of DS were dyspnea/hypoxia (80.6%) and pulmonary infiltrate (73.1%). Median time to onset of first DS event across all studies was 32 days (range, 4-129). Most patients (88.1%) received systemic steroids for treatment of DS. Evaluation of baseline risk factors for DS identified higher levels of bone marrow blasts and lactate dehydrogenase as independent factors associated with increased grade 3 to 5 DS risk. Overall, these results suggest that DS associated with IDH inhibition is manageable, given the benefits of enasidenib treatment in IDH2-mutated AML. We further characterized enasidenib-related DS in these patients and identified risk factors, which could be used for DS management in clinical practice. These trials were registered at www.ClinicalTrials.gov as # NCT01915498, NCT02577406, NCT02677922, and NCT02632708.
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Affiliation(s)
- Pau Montesinos
- Department of Hematology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Amir T. Fathi
- Leukemia Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Eytan M. Stein
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Amer M. Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University and Yale Cancer Center, New Haven, CT
| | - Yue Zhu
- Bristol Myers Squibb, Philadelphia, PA
| | | | | | | | - Xin Yu
- Bristol Myers Squibb, Summit, NJ
| | - Courtney D. DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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9
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Selheim F, Aasebø E, Reikvam H, Bruserud Ø, Hernandez-Valladares M. Monocytic Differentiation of Human Acute Myeloid Leukemia Cells: A Proteomic and Phosphoproteomic Comparison of FAB-M4/M5 Patients with and without Nucleophosmin 1 Mutations. Int J Mol Sci 2024; 25:5080. [PMID: 38791118 PMCID: PMC11121526 DOI: 10.3390/ijms25105080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 04/14/2024] [Accepted: 04/24/2024] [Indexed: 05/26/2024] Open
Abstract
Even though morphological signs of differentiation have a minimal impact on survival after intensive cytotoxic therapy for acute myeloid leukemia (AML), monocytic AML cell differentiation (i.e., classified as French/American/British (FAB) subtypes M4/M5) is associated with a different responsiveness both to Bcl-2 inhibition (decreased responsiveness) and possibly also bromodomain inhibition (increased responsiveness). FAB-M4/M5 patients are heterogeneous with regard to genetic abnormalities, even though monocytic differentiation is common for patients with Nucleophosmin 1 (NPM1) insertions/mutations; to further study the heterogeneity of FAB-M4/M5 patients we did a proteomic and phosphoproteomic comparison of FAB-M4/M5 patients with (n = 13) and without (n = 12) NPM1 mutations. The proteomic profile of NPM1-mutated FAB-M4/M5 patients was characterized by increased levels of proteins involved in the regulation of endocytosis/vesicle trafficking/organellar communication. In contrast, AML cells without NPM1 mutations were characterized by increased levels of several proteins involved in the regulation of cytoplasmic translation, including a large number of ribosomal proteins. The phosphoproteomic differences between the two groups were less extensive but reflected similar differences. To conclude, even though FAB classification/monocytic differentiation are associated with differences in responsiveness to new targeted therapies (e.g., Bcl-2 inhibition), our results shows that FAB-M4/M5 patients are heterogeneous with regard to important biological characteristics of the leukemic cells.
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Affiliation(s)
- Frode Selheim
- Proteomics Unit of University of Bergen (PROBE), University of Bergen, Jonas Lies vei 91, 5009 Bergen, Norway
| | - Elise Aasebø
- Acute Leukemia Research Group, Department of Clinical Science, University of Bergen, Jonas Lies vei 91, 5009 Bergen, Norway; (E.A.); (H.R.); (Ø.B.)
| | - Håkon Reikvam
- Acute Leukemia Research Group, Department of Clinical Science, University of Bergen, Jonas Lies vei 91, 5009 Bergen, Norway; (E.A.); (H.R.); (Ø.B.)
- Section for Hematology, Department of Medicine, Haukeland University Hospital, 5009 Bergen, Norway
| | - Øystein Bruserud
- Acute Leukemia Research Group, Department of Clinical Science, University of Bergen, Jonas Lies vei 91, 5009 Bergen, Norway; (E.A.); (H.R.); (Ø.B.)
- Section for Hematology, Department of Medicine, Haukeland University Hospital, 5009 Bergen, Norway
| | - Maria Hernandez-Valladares
- Proteomics Unit of University of Bergen (PROBE), University of Bergen, Jonas Lies vei 91, 5009 Bergen, Norway
- Department of Physical Chemistry, University of Granada, Avenida de la Fuente Nueva S/N, 18071 Granada, Spain
- Instituto de Investigación Biosanitaria ibs.GRANADA, 18012 Granada, Spain
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10
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Abaza Y, McMahon C, Garcia JS. Advancements and Challenges in the Treatment of AML. Am Soc Clin Oncol Educ Book 2024; 44:e438662. [PMID: 38662975 DOI: 10.1200/edbk_438662] [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: 05/29/2024]
Abstract
The therapeutic arsenal for the management of AML has expanded significantly in recent years. Before 2017, newly diagnosed AML was treated with either standard cytarabine- and anthracycline-based induction chemotherapy (for all fit patients) or a single-agent hypomethylating agent (in unfit patients or those 75 years and older). While assessing patient fitness remains important, characterizing the disease biology has become critical to select the optimal initial therapy for each patient with more options available. FLT3 inhibitors, gemtuzumab ozogamicin, and CPX-351 have been shown to improve outcomes for specific subsets of patients. Venetoclax (VEN) with a hypomethylating agent (HMA) is the standard-of-care frontline regimen for most older patients, except perhaps for those with an IDH1 mutation where ivosidenib with azacitidine may also be considered. On the basis of the success seen with HMA/VEN in older patients, there is now increasing interest in incorporating VEN into frontline regimens in younger patients, with promising data from multiple early phase studies. This article focuses on recent updates and ongoing challenges in the management of AML, with a particular focus on the ongoing challenge of secondary AML and considerations regarding the selection of initial therapy in younger patients. An overview of common side effects and toxicities associated with targeted therapies is also presented here, along with recommended strategies to mitigate these risks.
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Affiliation(s)
- Yasmin Abaza
- Division of Hematology and Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Christine McMahon
- Division of Hematology, University of Colorado School of Medicine, Aurora, CO
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11
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Pourhassan H, Kareem W, Agrawal V, Aldoss I. Important Considerations in the Intensive Care Management of Acute Leukemias. J Intensive Care Med 2024; 39:291-305. [PMID: 37990559 DOI: 10.1177/08850666231193955] [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] [Indexed: 11/23/2023]
Abstract
In the realm of hematologic disorders, acute leukemia is approached as an emergent disease given the multitude of complications and challenges that present both as a result of inherent disease pathology and adverse events associated with antineoplastic therapies and interventions. The heavy burden of leukemic cells may lead to complications including tumor lysis syndrome, hyperleukocytosis, leukostasis, and differentiation syndrome, and the initiation of treatment can further exacerbate these effects. Capillary leak syndrome is observed as a result of antineoplastic agents used in acute leukemia, and L-asparaginase, a bacterial-derived enzyme, has a unique side effect profile including association with thrombosis. Thrombohemorrhagic syndrome and malignancy-associated thrombosis are also commonly observed complications due to direct disequilibrium in coagulant and anticoagulant factors. Due to inherent effects on the white blood cell milieu, leukemia patients are inherently immunocompromised and vulnerable to life-threatening sepsis. Lastly, the advents of newer therapies such as chimeric antigen receptor (CAR) T-cells have clinicians facing the management of related toxicities on unfamiliar territory. This review aims to discuss these acute leukemia-associated complications, their pathology, and management recommendations.
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Affiliation(s)
- Hoda Pourhassan
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Waasil Kareem
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Vaibhav Agrawal
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
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12
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Woods A, Norsworthy KJ, Wang X, Vallejo J, Chiu Yuen Chow E, Li RJ, Sun J, Charlab R, Jiang X, Pazdur R, Theoret MR, de Claro RA. FDA Approval Summary: Ivosidenib in Combination with Azacitidine for Treatment of Patients with Newly Diagnosed Acute Myeloid Leukemia with an IDH1 Mutation. Clin Cancer Res 2024; 30:1226-1231. [PMID: 38010220 PMCID: PMC10984783 DOI: 10.1158/1078-0432.ccr-23-2234] [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: 07/26/2023] [Revised: 09/23/2023] [Accepted: 11/07/2023] [Indexed: 11/29/2023]
Abstract
On May 25, 2022, FDA approved a supplemental application for ivosidenib (Tibsovo; Servier) extending the indication in patients with newly diagnosed IDH1-mutated acute myeloid leukemia (AML) in older adults or those with comorbidities to include the combination with azacitidine. The efficacy of ivosidenib in combination with azacitidine was evaluated in Study AG120-C-009, a phase 3, multicenter, double-blind, randomized (1:1), controlled study of ivosidenib or matched placebo in combination with azacitidine in adults with previously untreated AML with an IDH1 mutation who were 75 years or older or had comorbidities that precluded use of intensive induction chemotherapy. Efficacy was established on the basis of improved event-free survival and overall survival on the ivosidenib + azacitidine arm [HR, 0.35; 95% confidence interval (CI), 0.17-0.72; P = 0.0038, and HR, 0.44; 95% CI, 0.27-0.73; P = 0.0010], respectively. Furthermore, the rate and duration of complete remission (CR) were improved with ivosidenib versus placebo [CR 47% versus 15%, two-sided P < 0.0001; median duration of CR not estimable (NE; 95% CI, 13.0-NE) months versus 11.2 (95% CI, 3.2-NE) months. The safety profile of ivosidenib in combination with azacitidine was consistent with that of ivosidenib monotherapy, with important adverse reactions including differentiation syndrome (15%) and QT interval prolongation (20%).
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Affiliation(s)
- Ashley Woods
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Kelly J Norsworthy
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Xin Wang
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Jonathon Vallejo
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Edwin Chiu Yuen Chow
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Ruo-Jing Li
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Jielin Sun
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Rosane Charlab
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Xiling Jiang
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Richard Pazdur
- Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Marc R Theoret
- Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - R Angelo de Claro
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
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13
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Vakilpour A, Lefebvre B, Lai C, Scherrer-Crosbie M. Heartbreaker: Detection and prevention of cardiotoxicity in hematological malignancies. Blood Rev 2024; 64:101166. [PMID: 38182490 DOI: 10.1016/j.blre.2023.101166] [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: 10/30/2023] [Revised: 12/12/2023] [Accepted: 12/30/2023] [Indexed: 01/07/2024]
Abstract
Cancer survivors are at significant risk of cardiovascular (CV) morbidity and mortality; patients with hematologic malignancies have a higher rate of death due to heart failure compared to all other cancer subtypes. The majority of conventional hematologic cancer treatments is associated with increased risk of acute and long-term CV toxicity. The incidence of cancer therapy induced CV toxicity depends on the combination of patient characteristics and on the type, dose, and duration of the therapy. Early diagnosis of CV toxicity, appropriate referral, more specific cardiac monitoring follow-up and timely interventions in target patients can decrease the risk of CV adverse events, the interruption of oncological therapy, and improve the patient's prognosis. Herein, we summarize the CV effects of conventional treatments used in hematologic malignancies with a focus on definitions and incidence of the most common CV toxicities, guideline recommended early detection approaches, and preventive strategies before and during cancer treatments.
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Affiliation(s)
- Azin Vakilpour
- Division of Cardiovascular Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Bénédicte Lefebvre
- Division of Cardiovascular Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; The Thalheimer Center for Cardio-oncology, Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Catherine Lai
- Division of Hematology-Oncology, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Marielle Scherrer-Crosbie
- Division of Cardiovascular Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; The Thalheimer Center for Cardio-oncology, Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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14
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Jramne-Saleem Y, Danilenko M. Roles of Glutathione and AP-1 in the Enhancement of Vitamin D-Induced Differentiation by Activators of the Nrf2 Signaling Pathway in Acute Myeloid Leukemia Cells. Int J Mol Sci 2024; 25:2284. [PMID: 38396960 PMCID: PMC10889780 DOI: 10.3390/ijms25042284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 02/04/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024] Open
Abstract
Active vitamin D derivatives (VDDs)-1α,25-dihydroxyvitamin D3/D2 and their synthetic analogs-are well-known inducers of cell maturation with the potential for differentiation therapy of acute myeloid leukemia (AML). However, their dose-limiting calcemic activity is a significant obstacle to using VDDs as an anticancer treatment. We have shown that different activators of the NF-E2-related factor-2/Antioxidant Response Element (Nrf2/ARE) signaling pathway, such as the phenolic antioxidant carnosic acid (CA) or the multiple sclerosis drug monomethyl fumarate (MMF), synergistically enhance the antileukemic effects of various VDDs applied at low concentrations in vitro and in vivo. This study aimed to investigate whether glutathione, the major cellular antioxidant and the product of the Nrf2/ARE pathway, can mediate the Nrf2-dependent differentiation-enhancing activity of CA and MMF in HL60 human AML cells. We report that glutathione depletion using L-buthionine sulfoximine attenuated the enhancing effects of both Nrf2 activators concomitant with downregulating vitamin D receptor (VDR) target genes and the activator protein-1 (AP-1) family protein c-Jun levels and phosphorylation. On the other hand, adding reduced glutathione ethyl ester to dominant negative Nrf2-expressing cells restored both the suppressed differentiation responses and the downregulated expression of VDR protein, VDR target genes, as well as c-Jun and P-c-Jun levels. Finally, using the transcription factor decoy strategy, we demonstrated that AP-1 is necessary for the enhancement by CA and MMF of 1α,25-dihydroxyvitamin D3-induced VDR and RXRα protein expression, transactivation of the vitamin D response element, and cell differentiation. Collectively, our findings suggest that glutathione mediates, at least in part, the potentiating effect of Nrf2 activators on VDDs-induced differentiation of AML cells, likely through the positive regulation of AP-1.
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Affiliation(s)
| | - Michael Danilenko
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 8410501, Israel;
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15
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Fobare S, Elgamal OA, Wunderlich M, Stahl E, Mehmood A, Furby C, Lerma JR, Sesterhenn TM, Pan J, Rai J, Johnstone ME, Abdul-Aziz A, Johnson ML, Rai SN, Byrd JC, Hertlein E. Inhibition of Enhancer of Zeste Homolog 2 Induces Blast Differentiation, Impairs Engraftment and Prolongs Survival in Murine Models of Acute Myeloid Leukemia. Cancers (Basel) 2024; 16:569. [PMID: 38339323 PMCID: PMC10854504 DOI: 10.3390/cancers16030569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/21/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Acute myeloid leukemia (AML) is the malignant proliferation of immature myeloid cells characterized by a block in differentiation. As such, novel therapeutic strategies to promote the differentiation of immature myeloid cells have been successful in AML, although these agents are targeted to a specific mutation that is only present in a subset of AML patients. In the current study, we show that targeting the epigenetic modifier enhancer of zeste homolog 2 (EZH2) can induce the differentiation of immature blast cells into a more mature myeloid phenotype and promote survival in AML murine models. METHODS The EZH2 inhibitor EPZ011989 (EPZ) was studied in AML cell lines, primary in AML cells and normal CD34+ stem cells. A pharmacodynamic assessment of H3K27me3; studies of differentiation, cell growth, and colony formation; and in vivo therapeutic studies including the influence on primary AML cell engraftment were also conducted. RESULTS EPZ inhibited H3K27me3 in AML cell lines and primary AML samples in vitro. EZH2 inhibition reduced colony formation in multiple AML cell lines and primary AML samples, while exhibiting no effect on colony formation in normal CD34+ stem cells. In AML cells, EPZ promoted phenotypic evidence of differentiation. Finally, the pretreatment of primary AML cells with EPZ significantly delayed engraftment and prolonged the overall survival when engrafted into immunodeficient mice. CONCLUSIONS Despite evidence that EZH2 silencing in MDS/MPN can promote AML pathogenesis, our data demonstrate that the therapeutic inhibition of EZH2 in established AML has the potential to improve survival.
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Affiliation(s)
- Sydney Fobare
- Medical Scientist Training Program, The Ohio State University, Columbus, OH 43210, USA;
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45229, USA (J.C.B.)
| | - Ola A. Elgamal
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45229, USA (J.C.B.)
| | - Mark Wunderlich
- Experimental Hematology and Cancer Biology, Cincinnati Children’s Hospital, Cincinnati, OH 45229, USA
| | - Emily Stahl
- Department of Internal Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Abeera Mehmood
- Department of Internal Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Casie Furby
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45229, USA (J.C.B.)
| | - James R. Lerma
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45229, USA (J.C.B.)
| | - Thomas M. Sesterhenn
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45229, USA (J.C.B.)
| | - Jianmin Pan
- Division of Biostatistics and Bioinformatics, Department of Environmental Health and Public Health Sciences, University of Cincinnati, Cincinnati, OH 45267, USA
- The Cancer Data Science Center, Department of Environmental Health and Public Health Sciences, University of Cincinnati, Cincinnati, OH 45267, USA
- Biostatistics and Informatics Shared Resource, University of Cincinnati Cancer Center, Cincinnati, OH 45267, USA
| | - Jayesh Rai
- Division of Biostatistics and Bioinformatics, Department of Environmental Health and Public Health Sciences, University of Cincinnati, Cincinnati, OH 45267, USA
- The Cancer Data Science Center, Department of Environmental Health and Public Health Sciences, University of Cincinnati, Cincinnati, OH 45267, USA
- Biostatistics and Informatics Shared Resource, University of Cincinnati Cancer Center, Cincinnati, OH 45267, USA
| | - Megan E. Johnstone
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45229, USA (J.C.B.)
| | - Amina Abdul-Aziz
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45229, USA (J.C.B.)
| | - Mariah L. Johnson
- Department of Internal Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Shesh N. Rai
- Division of Biostatistics and Bioinformatics, Department of Environmental Health and Public Health Sciences, University of Cincinnati, Cincinnati, OH 45267, USA
- The Cancer Data Science Center, Department of Environmental Health and Public Health Sciences, University of Cincinnati, Cincinnati, OH 45267, USA
- Biostatistics and Informatics Shared Resource, University of Cincinnati Cancer Center, Cincinnati, OH 45267, USA
| | - John C. Byrd
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45229, USA (J.C.B.)
| | - Erin Hertlein
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45229, USA (J.C.B.)
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16
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Selheim F, Aasebø E, Bruserud Ø, Hernandez-Valladares M. High Mitochondrial Protein Expression as a Potential Predictor of Relapse Risk in Acute Myeloid Leukemia Patients with the Monocytic FAB Subtypes M4 and M5. Cancers (Basel) 2023; 16:8. [PMID: 38201437 PMCID: PMC10778527 DOI: 10.3390/cancers16010008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 01/12/2024] Open
Abstract
AML is a highly aggressive and heterogeneous form of hematological cancer. Proteomics-based stratification of patients into more refined subgroups may contribute to a more precise characterization of the patient-derived AML cells. Here, we reanalyzed liquid chromatography-tandem mass spectrometry (LC-MS/MS) generated proteomic and phosphoproteomic data from 26 FAB-M4/M5 patients. The patients achieved complete hematological remission after induction therapy. Twelve of them later developed chemoresistant relapse (RELAPSE), and 14 patients were relapse-free (REL_FREE) long-term survivors. We considered not only the RELAPSE and REL_FREE characteristics but also integrated the French-American-British (FAB) classification, along with considering the presence of nucleophosmin 1 (NPM1) mutation and cytogenetically normal AML. We found a significant number of differentially enriched proteins (911) and phosphoproteins (257) between the various FAB subtypes in RELAPSE patients. Patients with the myeloblastic M1/M2 subtype showed higher levels of RNA processing-related routes and lower levels of signaling related to terms like translation and degranulation when compared with the M4/M5 subtype. Moreover, we found that a high abundance of proteins associated with mitochondrial translation and oxidative phosphorylation, particularly observed in the RELAPSE M4/M5 NPM1 mutated subgroup, distinguishes relapsing from non-relapsing AML patient cells with the FAB subtype M4/M5. Thus, the discovery of subtype-specific biomarkers through proteomic profiling may complement the existing classification system for AML and potentially aid in selecting personalized treatment strategies for individual patients.
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Affiliation(s)
- Frode Selheim
- Proteomics Unit of University of Bergen (PROBE), University of Bergen, Jonas Lies vei 91, 5009 Bergen, Norway
| | - Elise Aasebø
- Acute Leukemia Research Group, Department of Clinical Science, University of Bergen, Jonas Lies vei 91, 5009 Bergen, Norway; (E.A.); (Ø.B.)
| | - Øystein Bruserud
- Acute Leukemia Research Group, Department of Clinical Science, University of Bergen, Jonas Lies vei 91, 5009 Bergen, Norway; (E.A.); (Ø.B.)
- Section for Hematology, Department of Medicine, Haukeland University Hospital, 5009 Bergen, Norway
| | - Maria Hernandez-Valladares
- Proteomics Unit of University of Bergen (PROBE), University of Bergen, Jonas Lies vei 91, 5009 Bergen, Norway
- Department of Physical Chemistry, Institute of Biotechnology, Excellence Unit in Chemistry Applied to Biomedicine and Environment, School of Sciences, University of Granada, Campus Fuentenueva s/n, 18071 Granada, Spain
- Instituto de Investigación Biosanitaria ibs.GRANADA, 18012 Granada, Spain
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17
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Papadopoulou V, Schoumans J, Basset V, Solly F, Pasquier J, Blum S, Spertini O. Single-center, observational study of AML/MDS-EB with IDH1/2 mutations: genetic profile, immunophenotypes, mutational kinetics and outcomes. Hematology 2023; 28:2180704. [PMID: 36815747 DOI: 10.1080/16078454.2023.2180704] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVE IDH1/2 mutations, intervening in epigenetic procedures, are frequently encountered in acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS). Knowledge of the genetics, immunophenotypes, and mutational kinetics of IDH1/2-mutated AML can contribute to the understanding of AML clonal architecture and inform therapeutics and monitoring. METHODS We retrospectively analyzed 50 IDH1/2-mutated AML/MDS-EB cases of our institution, to identify recurrent co-mutations, immunophenotypes, patterns of co-variance of IDH1/2 allele burdens with those of recurrent co-mutations, frequency of persistent IDH1/2 mutation as clonal hematopoiesis of indeterminate potential (CHIP) in remission and response to hypomethylating agents. RESULTS Most frequently co-mutated genes were DNMT3A, SRSF2 and NPM1. Most cases with co-existent IDH1/2 and NPM1 mutations (11/13) showed an 'APL-like' immunophenotype (CD34-HLADR-). Allele burdens of mutated IDH1/2 were identical to mutated SRSF2 allele burdens at diagnosis and remission, but not always to mutated NPM1 allele burden in remission. We show persistence of significant mutIDH1/2 allele burden in approximately one-fourth of patients with deep remissions. IDH1/2 mutations were significantly more frequent among responders to first-line HMA-based regimens than among non-responders, in patients treated for myeloid neoplasms with excess blasts. CONCLUSIONS IDH1/2 mutations are most frequently accompanied by DNMT3A, SRSF2 and NPM1 mutations. NPM1-IDH1/2 mutated AML has a mature phenotype possibly amenable to differentiation therapies. IDH1/2 and SRSF2 mutations probably arise at the same developmental stage of the disease, as their allele burdens covariate. IDH1/2 mutation represents CHIP in a substantial proportion of cases and is therefore no reliable residual disease marker. The preferential presence of IDH1/2 mutations among HMA-responders could inform therapeutic decisions if confirmed in larger series.
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Affiliation(s)
- Vasiliki Papadopoulou
- Service and Laboratory of Hematology, Department of Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Jacqueline Schoumans
- Service and Laboratory of Hematology, Department of Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Valentin Basset
- Service and Laboratory of Hematology, Department of Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Françoise Solly
- Service and Laboratory of Hematology, Department of Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Jérôme Pasquier
- Center for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
| | - Sabine Blum
- Service and Laboratory of Hematology, Department of Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Olivier Spertini
- Service and Laboratory of Hematology, Department of Oncology, Lausanne University Hospital, Lausanne, Switzerland
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18
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Alsouqi A, Geramita E, Im A. Treatment of Acute Myeloid Leukemia in Older Adults. Cancers (Basel) 2023; 15:5409. [PMID: 38001669 PMCID: PMC10670451 DOI: 10.3390/cancers15225409] [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: 09/14/2023] [Revised: 10/27/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
Acute Myeloid Leukemia (AML) is an aggressive myeloid malignancy predominantly affecting older adults. Despite the advancements in new therapies for AML, older and medically unfit patients continue to suffer from poor outcomes due to disease-related factors such as the mutational profile and patient-related factors such as comorbidities and performance status. In this review, we discuss a spectrum of therapeutic options for older patients with AML starting with a historical perspective and ending with therapies being investigated in clinical trials. We review the standard of care treatment options including combination venetoclax and hypomethylating agents, in addition to targeted therapies such as FLT3 and IDH inhibitors. Lastly, we shed light on challenges facing the care of older adults and their representation in clinical trials.
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Affiliation(s)
| | | | - Annie Im
- Hillman Cancer Center, Division of Hematology and Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA; (A.A.); (E.G.)
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19
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Woods AC, Norsworthy KJ. Differentiation Syndrome in Acute Leukemia: APL and Beyond. Cancers (Basel) 2023; 15:4767. [PMID: 37835461 PMCID: PMC10571864 DOI: 10.3390/cancers15194767] [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: 08/14/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
Differentiation syndrome (DS) is a frequent and potentially life-threatening clinical syndrome first recognized with the advent of targeted therapeutics for acute promyelocytic leukemia (APL). DS was subsequently observed more broadly with targeted therapeutics for acute myeloid leukemia (AML). DS is typically characterized by fever, dyspnea, hypotension, weight gain, pleural or pericardial effusions, and acute renal failure. The incidence in patients with APL ranges from 2 to 37%, with the wide variation likely attributed to different diagnostic criteria, use of prophylactic treatment, and different treatment regimens. Treatment with corticosteroids +/- cytoreductive therapy should commence as soon as DS is suspected to reduce DS-related morbidity and mortality. The targeted anti-leukemic therapy should be discontinued in patients with severe DS. Here, we discuss the pathogenesis of DS, clinical presentations, diagnostic criteria, management strategies, and implementation of prospective tracking on clinical trials.
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Affiliation(s)
- Ashley C. Woods
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20903, USA
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20
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Wei Q, Yao K, Yang J, Zhou Q, Liu P, Chen J, Liu H, Lai Y, Cao P. Structure-Based Drug Design of Novel Triaminotriazine Derivatives as Orally Bioavailable IDH2 R140Q Inhibitors with High Selectivity and Reduced hERG Inhibitory Activity for the Treatment of Acute Myeloid Leukemia. J Med Chem 2023; 66:12894-12910. [PMID: 37706660 DOI: 10.1021/acs.jmedchem.3c00835] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Neomorphic IDH2R140Q mutation is commonly found in acute myeloid leukemia (AML), and inhibiting its activity has been validated as an effective treatment for AML. Herein, we report a series of highly potent and selective IDH2R140Q inhibitors. Among them, compound 36 was identified as the most promising inhibitor, with an IC50 value of 29 nM and more than 490-fold selectivity over wild-type IDH2. The compound significantly suppressed D2HG production (IC50 = 10 nM) and induced differentiation in TF-1/IDH2R140Q cells. Furthermore, it showed reasonable pharmacokinetic properties with high bioavailability (F = 90.3%) and an appropriate half-life (T1/2 = 6.4 h). In vivo, oral administration of compound 36 at a dose of 25 mg/kg effectively reduced D2HG levels in the tumor of TF-1/IDH2R140Q xenograft mouse model. Besides, compound 36 displayed little effect on the hERG current. These results suggest that compound 36 has the potential to be an efficacious treatment for AML.
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Affiliation(s)
- Qingyun Wei
- Jiangsu Provincial Medical Innovation Center, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing 210028, China
- Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing 210028, China
| | - Kun Yao
- State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Drug Discovery for Metabolic Diseases, Center of Drug Discovery, China Pharmaceutical University, Nanjing 210009, China
| | - Jie Yang
- Jiangsu Provincial Medical Innovation Center, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing 210028, China
- Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing 210028, China
| | - Qian Zhou
- Jiangsu Provincial Medical Innovation Center, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing 210028, China
- Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing 210028, China
| | - Pengyu Liu
- State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Drug Discovery for Metabolic Diseases, Center of Drug Discovery, China Pharmaceutical University, Nanjing 210009, China
| | - Jiao Chen
- Jiangsu Provincial Medical Innovation Center, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing 210028, China
- Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing 210028, China
| | - Haipeng Liu
- State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Drug Discovery for Metabolic Diseases, Center of Drug Discovery, China Pharmaceutical University, Nanjing 210009, China
| | - Yisheng Lai
- State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Drug Discovery for Metabolic Diseases, Center of Drug Discovery, China Pharmaceutical University, Nanjing 210009, China
| | - Peng Cao
- Jiangsu Provincial Medical Innovation Center, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing 210028, China
- School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, China
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21
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Tangella AV, Gajre A, Kantheti VV. Isocitrate Dehydrogenase 1 Mutation and Ivosidenib in Patients With Acute Myeloid Leukemia: A Comprehensive Review. Cureus 2023; 15:e44802. [PMID: 37692182 PMCID: PMC10483130 DOI: 10.7759/cureus.44802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 09/12/2023] Open
Abstract
Acute myeloid leukemia (AML) arises from immature myeloid progenitors, resulting in a stem-cell-like proliferative state. This leads to excessive pools of immature cells that cannot function, which usually happens at the cost of the production of mature functional cells, leading to deleterious consequences. The management of AML has intensified as newer targeted therapies have come into existence owing to deeper genetic analysis of the disease and patients. Isocitrate dehydrogenase (IDH) is a cytosolic enzyme that is a part of the Krebs cycle and is extremely important in maintaining the homeostasis of the cell. It is produced by two different genes: IDH1 and IDH2. Ivosidenib has been associated with IDH1 inhibition and has been studied in numerous cancers. This review highlights the studies that have dealt with ivosidenib, an IDH1 inhibitor, in AML, the side effect profile, and the possible future course of the drug. After a scoping review of the available literature, we have identified that studies have consistently shown positive outcomes and that ivosidenib is a promising avenue for the management of AML. But it also has to be kept in mind that resistance to IDH inhibitors is on the rise, and the need to identify ways to circumvent this is to be addressed.
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Affiliation(s)
| | - Ashwin Gajre
- Internal Medicine, Lokmanya Tilak Municipal Medical College, Mumbai, IND
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22
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de Botton S, Cluzeau T, Vigil C, Cook RJ, Rousselot P, Rizzieri DA, Liesveld JL, Fenaux P, Braun T, Banos A, Jurcic JG, Sekeres MA, Savona MR, Roboz GJ, Bixby D, Madigan K, Volkert A, Stephens K, Kang-Fortner Q, Baker K, Paul S, McKeown M, Carulli J, Eaton M, Hodgson G, Fiore C, Kelly MJ, Roth DA, Stein EM. Targeting RARA overexpression with tamibarotene, a potent and selective RARα agonist, is a novel approach in AML. Blood Adv 2023; 7:1858-1870. [PMID: 36477975 PMCID: PMC10165187 DOI: 10.1182/bloodadvances.2022008806] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/24/2022] [Accepted: 11/08/2022] [Indexed: 12/12/2022] Open
Abstract
A superenhancer at the retinoic acid receptor alpha (RARA) gene is associated with RARA mRNA overexpression in ∼30% of non-acute promyelocytic leukemia acute myeloid leukemia (AML) and in ∼50% of myelodysplastic syndromes (MDS). RARA overexpression is an actionable target for treatment with tamibarotene, an oral potent and selective RARα agonist. Sensitivity to the RARα agonist tamibarotene was demonstrated in RARA-high but not RARA-low preclinical AML models. The combination of oral tamibarotene plus azacitidine was evaluated in a phase 2 clinical study in 51 newly diagnosed unfit patients with AML identified as RARA-positive (n = 22) or RARA-negative (n = 29) for RARA mRNA overexpression in peripheral blasts using a blood-based biomarker test. In 18 response-evaluable RARA-positive patients, complete remission (CR)/CR with incomplete hematologic recovery rate was 61%, CR rate was 50%, and time to initial composite CR was rapid at 1.2 months. Transfusion independence was attained by 72% of RARA-positive patients. In contrast, 28 response-evaluable RARA-negative patients had response rates that were consistent with azacitidine monotherapy. Tamibarotene in combination with azacitidine was well tolerated. The majority of nonhematologic adverse events were low grade and hematologic adverse events were comparable to single-agent azacitidine, demonstrating that there was no additional myelosuppression when tamibarotene was combined with azacitidine. These results support further evaluation of tamibarotene-based treatment strategies in patients with AML or MDS with RARA overexpression to provide a targeted approach with the goal of improving patient outcomes. This trial was registered at www.clinicaltrials.gov as #NCT02807558.
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Affiliation(s)
| | - Thomas Cluzeau
- Côte d’Azur Université, Centre Hospitalier Universitaire de Nice Hôpital, Nice, France
| | - Carlos Vigil
- Robert H Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Rachel J. Cook
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR
| | - Philippe Rousselot
- Hôpital André Mignot, Centre Hospitalier de Versailles, Le Chesnay, France
| | | | | | | | - Thorsten Braun
- Centre Hospitalier Universitaire Hôpital Avicenne, Bobigny, France
| | - Anne Banos
- Centre Hospitalier de la Côte Basque, Bayonne, France
| | | | | | - Michael R. Savona
- Vanderbilt Ingram Cancer Center, Vanderbilt University School of Medicine, Vanderbilt University, Nashville, TN
| | | | - Dale Bixby
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI
| | | | | | | | | | | | - Sofia Paul
- Syros Pharmaceuticals, Inc, Cambridge, MA
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23
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Anipindi M, Kacarow J, Bitetto D. Systemic Capillary Leak Syndrome (SCLS) Presentation in Patients Receiving Anti-cancer Treatments. Cureus 2023; 15:e38335. [PMID: 37261188 PMCID: PMC10228707 DOI: 10.7759/cureus.38335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2023] [Indexed: 06/02/2023] Open
Abstract
Systemic capillary leak syndrome (SCLS) is due to increased capillary permeability to proteins and fluid extravasation from blood vessels into surrounding tissues and body cavities. This fluid extravasation leads to hypotension, generalized anasarca, pleural effusions, and pericardial effusions -- the more severe cases of SCLS can cause multiorgan dysfunction, including cardiovascular collapse, shock, and death. The treatment includes corticosteroids, diuretics, albumin, immunoglobulins, and crystalloids. SCLS is potentially fatal. Recognizing signs and symptoms early and treating the patients is essential as this condition is fatal. It sometimes is a diagnosis of exclusion, being very challenging to diagnose and treat. The lack of understanding of the underlying mechanisms causing SCLS and proper treatment guidelines, especially in cancer patients, made diagnosing and treating this condition hard. Reports show that many cancers and anti-cancer treatments, including newer immunotherapy, cause SCLS. The mortality rate of SCLS associated with cytotoxic chemotherapy is 24% at five years. This review focuses on the cancers and anti-cancer drugs causing SCLS, treating acute SCLS, and available preventive regimens. The fundamental purpose of this review is to help clinicians recognize SCLS early to avoid delays in diagnosis and treatment. We also would like to elaborate on the fact that research on cancer-related SCLS is critical for developing staging criteria, useful diagnostic markers, prevention, and treatment strategies for anti-cancer drug-induced SCLS to prevent early discontinuation of anti-cancer drugs.
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Affiliation(s)
- Manasa Anipindi
- Internal Medicine, Einstein Medical Center Montgomery, East Norriton, USA
| | - Justyna Kacarow
- Internal Medicine, Einstein Medical Center Montgomery, East Norriton, USA
| | - Daniel Bitetto
- Hospital Medicine, Einstein Medical Center Montgomery, East Norriton, USA
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24
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Issa GC, Aldoss I, DiPersio J, Cuglievan B, Stone R, Arellano M, Thirman MJ, Patel MR, Dickens DS, Shenoy S, Shukla N, Kantarjian H, Armstrong SA, Perner F, Perry JA, Rosen G, Bagley RG, Meyers ML, Ordentlich P, Gu Y, Kumar V, Smith S, McGeehan GM, Stein EM. The menin inhibitor revumenib in KMT2A-rearranged or NPM1-mutant leukaemia. Nature 2023; 615:920-924. [PMID: 36922593 PMCID: PMC10060155 DOI: 10.1038/s41586-023-05812-3] [Citation(s) in RCA: 111] [Impact Index Per Article: 111.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 02/08/2023] [Indexed: 03/17/2023]
Abstract
Targeting critical epigenetic regulators reverses aberrant transcription in cancer, thereby restoring normal tissue function1-3. The interaction of menin with lysine methyltransferase 2A (KMT2A), an epigenetic regulator, is a dependence in acute leukaemia caused by either rearrangement of KMT2A or mutation of the nucleophosmin 1 gene (NPM1)4-6. KMT2A rearrangements occur in up to 10% of acute leukaemias and have an adverse prognosis, whereas NPM1 mutations occur in up to 30%, forming the most common genetic alteration in acute myeloid leukaemia7,8. Here, we describe the results of the first-in-human phase 1 clinical trial investigating revumenib (SNDX-5613), a potent and selective oral inhibitor of the menin-KMT2A interaction, in patients with relapsed or refractory acute leukaemia (ClinicalTrials.gov, NCT04065399). We show that therapy with revumenib was associated with a low frequency of grade 3 or higher treatment-related adverse events and a 30% rate of complete remission or complete remission with partial haematologic recovery (CR/CRh) in the efficacy analysis population. Asymptomatic prolongation of the QT interval on electrocardiography was identified as the only dose-limiting toxicity. Remissions occurred in leukaemias refractory to multiple previous lines of therapy. We demonstrate clearance of residual disease using sensitive clinical assays and identify hallmarks of differentiation into normal haematopoietic cells, including differentiation syndrome. These data establish menin inhibition as a therapeutic strategy for susceptible acute leukaemia subtypes.
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Affiliation(s)
- Ghayas C Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | | | - John DiPersio
- Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Branko Cuglievan
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Martha Arellano
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Manish R Patel
- Florida Cancer Specialists/Sarah Cannon Research Institute, Sarasota, FL, USA
| | | | - Shalini Shenoy
- Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Neerav Shukla
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Florian Perner
- Dana-Farber Cancer Institute, Boston, MA, USA
- Greifswald University Medical Center, Greifswald, Germany
| | | | | | | | | | | | - Yu Gu
- Syndax Pharmaceuticals, Waltham, MA, USA
| | | | | | | | - Eytan M Stein
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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25
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Issa GC, Aldoss I, DiPersio J, Cuglievan B, Stone R, Arellano M, Thirman MJ, Patel MR, Dickens DS, Shenoy S, Shukla N, Kantarjian H, Armstrong SA, Perner F, Perry JA, Rosen G, Bagley RG, Meyers ML, Ordentlich P, Gu Y, Kumar V, Smith S, McGeehan GM, Stein EM. The menin inhibitor revumenib in KMT2A-rearranged or NPM1-mutant leukaemia. Nature 2023. [PMID: 36922593 DOI: 10.1038/s411586-023-05755-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Targeting critical epigenetic regulators reverses aberrant transcription in cancer, thereby restoring normal tissue function1-3. The interaction of menin with lysine methyltransferase 2A (KMT2A), an epigenetic regulator, is a dependence in acute leukaemia caused by either rearrangement of KMT2A or mutation of the nucleophosmin 1 gene (NPM1)4-6. KMT2A rearrangements occur in up to 10% of acute leukaemias and have an adverse prognosis, whereas NPM1 mutations occur in up to 30%, forming the most common genetic alteration in acute myeloid leukaemia7,8. Here, we describe the results of the first-in-human phase 1 clinical trial investigating revumenib (SNDX-5613), a potent and selective oral inhibitor of the menin-KMT2A interaction, in patients with relapsed or refractory acute leukaemia (ClinicalTrials.gov, NCT04065399). We show that therapy with revumenib was associated with a low frequency of grade 3 or higher treatment-related adverse events and a 30% rate of complete remission or complete remission with partial haematologic recovery (CR/CRh) in the efficacy analysis population. Asymptomatic prolongation of the QT interval on electrocardiography was identified as the only dose-limiting toxicity. Remissions occurred in leukaemias refractory to multiple previous lines of therapy. We demonstrate clearance of residual disease using sensitive clinical assays and identify hallmarks of differentiation into normal haematopoietic cells, including differentiation syndrome. These data establish menin inhibition as a therapeutic strategy for susceptible acute leukaemia subtypes.
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Affiliation(s)
- Ghayas C Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | | | - John DiPersio
- Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Branko Cuglievan
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Martha Arellano
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Manish R Patel
- Florida Cancer Specialists/Sarah Cannon Research Institute, Sarasota, FL, USA
| | | | - Shalini Shenoy
- Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Neerav Shukla
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Florian Perner
- Dana-Farber Cancer Institute, Boston, MA, USA
- Greifswald University Medical Center, Greifswald, Germany
| | | | | | | | | | | | - Yu Gu
- Syndax Pharmaceuticals, Waltham, MA, USA
| | | | | | | | - Eytan M Stein
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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26
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DiNardo CD, Hochhaus A, Frattini MG, Yee K, Zander T, Krämer A, Chen X, Ji Y, Parikh NS, Choi J, Wei AH. A phase 1 study of IDH305 in patients with IDH1 R132-mutant acute myeloid leukemia or myelodysplastic syndrome. J Cancer Res Clin Oncol 2023; 149:1145-1158. [PMID: 35353219 DOI: 10.1007/s00432-022-03983-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/10/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Isocitrate dehydrogenase enzyme 1 (IDH1) mutations at 132nd amino acid residue (R132*) result in the cellular accumulation of the oncometabolite, 2-hydroxyglutarate (2-HG). IDH305 is an orally bioavailable, brain-penetrant, mutant-selective allosteric IDH1 inhibitor demonstrating target engagement in preclinical models. This first-in human study was designed to identify the recommended dose for expansion/maximum tolerated dose of IDH305 in patients with IDH1R132-mutant acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS). METHODS IDH305 was given at doses 75-750 mg twice daily in 41 patients with IDH1R132-mutant AML/MDS. Dose escalation was designed using Bayesian hierarchical model with overdose control principle and relationship with dose-limiting toxicity. RESULTS IDH305 exhibited rapid absorption with mean T1/2 approximately 4-10 h across doses. Interpatient variability was moderate and exposure increased with dose in a less than dose proportional manner. Most patients (35/41) demonstrated target engagement with reduction in 2-HG concentration at all doses. Complete remission (CR) or CR with incomplete count recovery occurred in 10/37 (27%) patients with AML and 1/ 4 patients with MDS. Adverse events (AEs) suspected to be related to study drug were reported in 53.7% of patients: increased blood bilirubin (14.6%), nausea (14.6%), increased alanine aminotransferase and aspartate aminotransferase (12.2%, each); most frequent grade 3 or 4 AEs were differentiation syndrome and tumor lysis syndrome (n = 3; 7.3%, each). Hepatotoxicity was manageable with dose modification. CONCLUSION Due to potentially narrow therapeutic window, the study was prematurely halted and recommended phase 2 dose could not be declared. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT02381886.
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Affiliation(s)
- Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Andreas Hochhaus
- Klinik für Innere Medizin II, Hämatologie/Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Mark G Frattini
- Hematology/Oncology Division, Columbia University Medical Center, New York City, NY, USA
| | - Karen Yee
- Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Thomas Zander
- Department of Internal Medicine I, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; Gastrointestinal Cancer Group Cologne (GCGC), University of Cologne, Cologne, Germany
| | - Alwin Krämer
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Xueying Chen
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Yan Ji
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Nehal S Parikh
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Joanne Choi
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Andrew H Wei
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, VIC, Australia
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27
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Shimony S, Stahl M, Stone RM. Acute myeloid leukemia: 2023 update on diagnosis, risk-stratification, and management. Am J Hematol 2023; 98:502-526. [PMID: 36594187 DOI: 10.1002/ajh.26822] [Citation(s) in RCA: 57] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/01/2022] [Accepted: 12/15/2022] [Indexed: 01/04/2023]
Abstract
DISEASE OVERVIEW Acute myeloid leukemia (AML) is a frequently fatal bone marrow stem cell cancer characterized by unbridled proliferation of malignant marrow stem cells with associated infection, anemia, and bleeding. An improved understanding of pathophysiology, improvements in measurement technology and at least 10 recently approved therapies have led to revamping the diagnostic, prognostic, and therapeutic landscape of AML. DIAGNOSIS One updated and one new classification system were published in 2022, both emphasizing the integration of molecular analysis into daily practice. Differences between the International Consensus Classification and major revisions from the previous 2016 WHO system provide both challenges and opportunities for care and clinical research. RISK ASSESSMENT AND MONITORING The European Leukemia Net 2022 risk classification integrates knowledge from novel molecular findings and recent trial results, as well as emphasizing dynamic risk based on serial measurable residual disease assessment. However, how to leverage our burgeoning ability to measure a small number of potentially malignant myeloid cells into therapeutic decision making is controversial. RISK ADAPTED THERAPY The diagnostic and therapeutic complexity plus the availability of newly approved agents requires a nuanced therapeutic algorithm which should integrate patient goals of care, comorbidities, and disease characteristics including the specific mutational profile of the patient's AML. The framework we suggest only represents the beginning of the discussion.
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Affiliation(s)
- Shai Shimony
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Rabin Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Maximilian Stahl
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Richard M Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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28
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Liu Y, Xu W, Li M, Yang Y, Sun D, Chen L, Li H, Chen L. The regulatory mechanisms and inhibitors of isocitrate dehydrogenase 1 in cancer. Acta Pharm Sin B 2023; 13:1438-1466. [PMID: 37139412 PMCID: PMC10149907 DOI: 10.1016/j.apsb.2022.12.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/07/2022] [Accepted: 11/18/2022] [Indexed: 02/04/2023] Open
Abstract
Reprogramming of energy metabolism is one of the basic characteristics of cancer and has been proved to be an important cancer treatment strategy. Isocitrate dehydrogenases (IDHs) are a class of key proteins in energy metabolism, including IDH1, IDH2, and IDH3, which are involved in the oxidative decarboxylation of isocitrate to yield α-ketoglutarate (α-KG). Mutants of IDH1 or IDH2 can produce d-2-hydroxyglutarate (D-2HG) with α-KG as the substrate, and then mediate the occurrence and development of cancer. At present, no IDH3 mutation has been reported. The results of pan-cancer research showed that IDH1 has a higher mutation frequency and involves more cancer types than IDH2, implying IDH1 as a promising anti-cancer target. Therefore, in this review, we summarized the regulatory mechanisms of IDH1 on cancer from four aspects: metabolic reprogramming, epigenetics, immune microenvironment, and phenotypic changes, which will provide guidance for the understanding of IDH1 and exploring leading-edge targeted treatment strategies. In addition, we also reviewed available IDH1 inhibitors so far. The detailed clinical trial results and diverse structures of preclinical candidates illustrated here will provide a deep insight into the research for the treatment of IDH1-related cancers.
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29
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Fortin J, Chiang MF, Meydan C, Foox J, Ramachandran P, Leca J, Lemonnier F, Li WY, Gams MS, Sakamoto T, Chu M, Tobin C, Laugesen E, Robinson TM, You-Ten A, Butler DJ, Berger T, Minden MD, Levine RL, Guidos CJ, Melnick AM, Mason CE, Mak TW. Distinct and opposite effects of leukemogenic Idh and Tet2 mutations in hematopoietic stem and progenitor cells. Proc Natl Acad Sci U S A 2023; 120:e2208176120. [PMID: 36652477 PMCID: PMC9942850 DOI: 10.1073/pnas.2208176120] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Mutations in IDH1, IDH2, and TET2 are recurrently observed in myeloid neoplasms. IDH1 and IDH2 encode isocitrate dehydrogenase isoforms, which normally catalyze the conversion of isocitrate to α-ketoglutarate (α-KG). Oncogenic IDH1/2 mutations confer neomorphic activity, leading to the production of D-2-hydroxyglutarate (D-2-HG), a potent inhibitor of α-KG-dependent enzymes which include the TET methylcytosine dioxygenases. Given their mutual exclusivity in myeloid neoplasms, IDH1, IDH2, and TET2 mutations may converge on a common oncogenic mechanism. Contrary to this expectation, we observed that they have distinct, and even opposite, effects on hematopoietic stem and progenitor cells in genetically engineered mice. Epigenetic and single-cell transcriptomic analyses revealed that Idh2R172K and Tet2 loss-of-function have divergent consequences on the expression and activity of key hematopoietic and leukemogenic regulators. Notably, chromatin accessibility and transcriptional deregulation in Idh2R172K cells were partially disconnected from DNA methylation alterations. These results highlight unanticipated divergent effects of IDH1/2 and TET2 mutations, providing support for the optimization of genotype-specific therapies.
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Affiliation(s)
- Jerome Fortin
- aPrincess Margaret Cancer Centre, University Health Network, Toronto, ONM5G 2C1, Canada
- 2To whom correspondence may be addressed. , , or
| | - Ming-Feng Chiang
- aPrincess Margaret Cancer Centre, University Health Network, Toronto, ONM5G 2C1, Canada
| | - Cem Meydan
- bDepartment of Physiology and Biophysics, Weill Cornell Medicine, New York, NY10065
- cThe HRH Prince Alwaleed Bin Talal Bin Abdulaziz Al-Saud Institute for Computational Biomedicine, Weill Cornell Medicine, New York, NY10065
- dWorldQuant Initiative for Quantitative Prediction, Weill Cornell Medicine, New York, NY10065
| | - Jonathan Foox
- bDepartment of Physiology and Biophysics, Weill Cornell Medicine, New York, NY10065
- cThe HRH Prince Alwaleed Bin Talal Bin Abdulaziz Al-Saud Institute for Computational Biomedicine, Weill Cornell Medicine, New York, NY10065
| | | | - Julie Leca
- aPrincess Margaret Cancer Centre, University Health Network, Toronto, ONM5G 2C1, Canada
| | - François Lemonnier
- aPrincess Margaret Cancer Centre, University Health Network, Toronto, ONM5G 2C1, Canada
- eInstitut Mondor de Recherche Biomédicale, INSERMU955, Université Paris Est Créteil, Créteil94010, France
| | - Wanda Y. Li
- aPrincess Margaret Cancer Centre, University Health Network, Toronto, ONM5G 2C1, Canada
- fCentre for Oncology and Immunology, Hong Kong Science Park, Hong Kong SAR, China
| | - Miki S. Gams
- gDepartment of Immunology, The Hospital for Sick Children Research Institute, University of Toronto, Toronto, ONM5G 0A4, Canada
| | - Takashi Sakamoto
- aPrincess Margaret Cancer Centre, University Health Network, Toronto, ONM5G 2C1, Canada
- hDepartment of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto606-8501, Japan
| | - Mandy Chu
- aPrincess Margaret Cancer Centre, University Health Network, Toronto, ONM5G 2C1, Canada
| | - Chantal Tobin
- aPrincess Margaret Cancer Centre, University Health Network, Toronto, ONM5G 2C1, Canada
| | - Eric Laugesen
- aPrincess Margaret Cancer Centre, University Health Network, Toronto, ONM5G 2C1, Canada
| | - Troy M. Robinson
- iHuman Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY10065
- jLouis V. Gerstner, Jr. Graduate School of Biomedical Sciences, Memorial Sloan Kettering Cancer Center, New York, NY10065
| | - Annick You-Ten
- aPrincess Margaret Cancer Centre, University Health Network, Toronto, ONM5G 2C1, Canada
| | - Daniel J. Butler
- bDepartment of Physiology and Biophysics, Weill Cornell Medicine, New York, NY10065
| | - Thorsten Berger
- aPrincess Margaret Cancer Centre, University Health Network, Toronto, ONM5G 2C1, Canada
| | - Mark D. Minden
- aPrincess Margaret Cancer Centre, University Health Network, Toronto, ONM5G 2C1, Canada
| | - Ross L. Levine
- iHuman Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY10065
- kCenter for Epigenetics Research, Memorial Sloan Kettering Cancer Center, New York, NY10065
- lCenter for Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY10065
| | - Cynthia J. Guidos
- gDepartment of Immunology, The Hospital for Sick Children Research Institute, University of Toronto, Toronto, ONM5G 0A4, Canada
| | - Ari M. Melnick
- mDepartment of Medicine, Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY10021
| | - Christopher E. Mason
- bDepartment of Physiology and Biophysics, Weill Cornell Medicine, New York, NY10065
- cThe HRH Prince Alwaleed Bin Talal Bin Abdulaziz Al-Saud Institute for Computational Biomedicine, Weill Cornell Medicine, New York, NY10065
- dWorldQuant Initiative for Quantitative Prediction, Weill Cornell Medicine, New York, NY10065
| | - Tak W. Mak
- aPrincess Margaret Cancer Centre, University Health Network, Toronto, ONM5G 2C1, Canada
- fCentre for Oncology and Immunology, Hong Kong Science Park, Hong Kong SAR, China
- nDepartment of Pathology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- 2To whom correspondence may be addressed. , , or
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30
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de Botton S, Montesinos P, Schuh AC, Papayannidis C, Vyas P, Wei AH, Ommen H, Semochkin S, Kim HJ, Larson RA, Koprivnikar J, Frankfurt O, Thol F, Chromik J, Byrne J, Pigneux A, Thomas X, Salamero O, Vidriales MB, Doronin V, Döhner H, Fathi AT, Laille E, Yu X, Hasan M, Martin-Regueira P, DiNardo CD. Enasidenib vs conventional care in older patients with late-stage mutant-IDH2 relapsed/refractory AML: a randomized phase 3 trial. Blood 2023; 141:156-167. [PMID: 35714312 PMCID: PMC10644040 DOI: 10.1182/blood.2021014901] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/07/2022] [Accepted: 05/04/2022] [Indexed: 01/22/2023] Open
Abstract
This open-label, randomized, phase 3 trial (NCT02577406) compared enasidenib, an oral IDH2 (isocitrate dehydrogenase 2) inhibitor, with conventional care regimens (CCRs) in patients aged ≥60 years with late-stage, mutant-IDH2 acute myeloid leukemia (AML) relapsed/refractory (R/R) to 2 or 3 prior AML-directed therapies. Patients were first preselected to a CCR (azacitidine, intermediate-dose cytarabine, low-dose cytarabine, or supportive care) and then randomized (1:1) to enasidenib 100 mg per day or CCR. The primary endpoint was overall survival (OS). Secondary endpoints included event-free survival (EFS), time to treatment failure (TTF), overall response rate (ORR), hematologic improvement (HI), and transfusion independence (TI). Overall, 319 patients were randomized to enasidenib (n = 158) or CCR (n = 161). The median age was 71 years, median (range) enasidenib exposure was 142 days (3 to 1270), and CCR was 36 days (1 to 1166). One enasidenib (0.6%) and 20 CCR (12%) patients received no randomized treatment, and 30% and 43%, respectively, received subsequent AML-directed therapies during follow-up. The median OS with enasidenib vs CCR was 6.5 vs 6.2 months (HR [hazard ratio], 0.86; P = .23); 1-year survival was 37.5% vs 26.1%. Enasidenib meaningfully improved EFS (median, 4.9 vs 2.6 months with CCR; HR, 0.68; P = .008), TTF (median, 4.9 vs 1.9 months; HR, 0.53; P < .001), ORR (40.5% vs 9.9%; P <.001), HI (42.4% vs 11.2%), and red blood cell (RBC)-TI (31.7% vs 9.3%). Enasidenib safety was consistent with prior reports. The primary study endpoint was not met, but OS was confounded by early dropout and subsequent AML-directed therapies. Enasidenib provided meaningful benefits in EFS, TTF, ORR, HI, and RBC-TI in this heavily pretreated older mutant-IDH2 R/R AML population.
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Affiliation(s)
| | - Pau Montesinos
- Hospital Universitari i Politecnic La Fe, Valencia, Spain
| | | | - Cristina Papayannidis
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
| | - Paresh Vyas
- Oxford Biomedical Research Centre and Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Andrew H. Wei
- The Alfred Hospital, Melbourne, VIC, Australia
- Monash University, Melbourne, VIC, Australia
| | - Hans Ommen
- Aarhus University Hospital, Århus, Denmark
| | - Sergey Semochkin
- Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | - Hee-Je Kim
- Catholic Hematology Hospital, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | | | - Jaime Koprivnikar
- John Theurer Cancer Center at Hackensack University Medical Center, Hackensack, NJ
| | - Olga Frankfurt
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Felicitas Thol
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Medizinische Hochschule Hannover, Hanover, Germany
| | - Jörg Chromik
- Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Jenny Byrne
- Nottingham University Hospitals Trust, Nottingham, United Kingdom
| | - Arnaud Pigneux
- Bordeaux Haut-Leveque University Hospital, Pessac, France
| | - Xavier Thomas
- Centre Hospitalier Universitaire de Lyon-Sud, Lyon, France
| | - Olga Salamero
- Vall d’Hebron Hospital Universitari, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Maria Belen Vidriales
- University Hospital of Salamanca and Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
| | - Vadim Doronin
- City Clinical Hospital No. 40, Moscow, Russian Federation
| | | | - Amir T. Fathi
- Massachusetts General Hospital Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Xin Yu
- Bristol Myers Squibb, Princeton, NJ
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How I treat with maintenance therapy after allogeneic HCT. Blood 2023; 141:39-48. [PMID: 35231083 DOI: 10.1182/blood.2021012412] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/03/2022] [Accepted: 02/03/2022] [Indexed: 01/10/2023] Open
Abstract
Disease relapse is the leading cause of failure for patients receiving allogeneic hematopoietic cell transplantation (allo-HCT). Maintenance therapy administered after allo-HCT is a promising strategy to reduce the incidence of relapse and enhance the curative potential of allo-HCT. Research investigations and clinical applications of this approach have greatly increased in recent years, with an expanding number of available therapeutic agents to introduce in the posttransplant setting. However, many questions and challenges remain regarding the feasibility and clinical impact of maintenance. In this article, we present four common case scenarios addressing select available therapeutic agents as a framework to review published data and ongoing studies and describe our current standard practice in the rapidly evolving field of maintenance therapy after allo-HCT.
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Watts JM, Baer MR, Yang J, Prebet T, Lee S, Schiller GJ, Dinner SN, Pigneux A, Montesinos P, Wang ES, Seiter KP, Wei AH, De Botton S, Arnan M, Donnellan W, Schwarer AP, Récher C, Jonas BA, Ferrell PB, Marzac C, Kelly P, Sweeney J, Forsyth S, Guichard SM, Brevard J, Henrick P, Mohamed H, Cortes JE. Olutasidenib alone or with azacitidine in IDH1-mutated acute myeloid leukaemia and myelodysplastic syndrome: phase 1 results of a phase 1/2 trial. Lancet Haematol 2023; 10:e46-e58. [PMID: 36370742 DOI: 10.1016/s2352-3026(22)00292-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Olutasidenib (FT-2102) is a potent, selective, oral, small-molecule inhibitor of mutant isocitrate dehydrogenase 1 (IDH1). The aims for phase 1 of this phase 1/2 study were to assess the safety, pharmacokinetics, pharmacodynamics, and clinical activity of olutasidenib, as monotherapy or in combination with azacitidine, in patients with acute myeloid leukaemia or myelodysplastic syndrome, harbouring mutant IDH1. METHODS In this phase 1/2, multicentre, open-label clinical trial, we enrolled patients aged 18 years or older with acute myeloid leukaemia or intermediate, high, or very high risk myelodysplastic syndrome harbouring mutant IDH1 at 18 study sites in the USA, Australia, France, and Spain. Other key eligibility criteria included Eastern Cooperative Oncology Group performance status 0-2 with adequate liver and renal function. The primary outcomes were dose-limiting toxicities and the maximum tolerated dose, maximum evaluated dose, and the recommended phase 2 dose of olutasidenib. Olutasidenib was administered orally in doses of 150 mg once daily, 150 mg twice per day, and 300 mg once daily. Azacitidine (75 mg/m2) was administered subcutaneously or intravenously daily for 7 days on, 21 days off. The study was ongoing at the data cutoff (Oct 2, 2019) and is registered with ClinicalTrials.gov, NCT02719574. FINDINGS Patients were enrolled between Aug 8, 2016, and Nov 14, 2018. 78 patients received olutasidenib as monotherapy (n=32) or in combination with azacitidine (n=46). The median follow-up was 8·3 months (IQR 3·1-13·3) for monotherapy and 10·1 months (4·2-15·3) for combination therapy. 16 (50%) of 32 patients in the monotherapy group and 24 (52%) of 46 patients in the combination therapy group were women. Most patients were White (26 [81%] for monotherapy and 31 [67%] for combination therapy). No dose-limiting toxicities were reported in the dose-escalation cohorts and 150 mg twice per day was declared the recommended phase 2 dose on the basis of safety, pharmacokinetics and pharmacodynamics, and clinical activity. The most common (≥20%) grade 3-4 treatment-emergent adverse events with monotherapy were thrombocytopenia (nine [28%] of 32 patients), febrile neutropenia (seven [22%] of 32), and anaemia (seven [22%] of 32); and with combination therapy were thrombocytopenia (19 [41%] of 46), febrile neutropenia (13 [28%] of 46), neutropenia (13 [28%] of 46), and anaemia (nine [20%] of 46). 11 (34%) of 32 patients in the monotherapy group and nine (20%) of 46 patients in the combination therapy group died (most commonly from disease progression [three (9%) of 32 and four (9%) of 46]). No deaths were considered study-drug related. For patients with relapsed or refractory acute myeloid leukaemia, 41% (95% CI 21-64; nine of 22) receiving monotherapy and 46% (27-67; 12 of 26) receiving combination therapy had an overall response. For treatment-naive patients with acute myeloid leukaemia, 25% (1-81; one of four) receiving monotherapy and 77% (46-95; ten of 13) receiving combination therapy had an overall response. INTERPRETATION Olutasidenib, with or without azacitidine, was well tolerated and showed meaningful clinical activity in patients with IDH1-mutated acute myeloid leukaemia. The results of this phase 1 study provide rationale for the continued evaluation of olutasidenib in multiple patient populations with myeloid malignancies. FUNDING Forma Therapeutics.
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Affiliation(s)
- Justin M Watts
- University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA.
| | - Maria R Baer
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA
| | - Jay Yang
- Karmanos Cancer Institute, Detroit, MI, USA
| | - Thomas Prebet
- Department of Hematology, Yale University, New Haven, CT, USA
| | - Sangmin Lee
- Department of Hematology and Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Gary J Schiller
- David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - Shira N Dinner
- Department of Hematology and Oncology, Northwestern University, Chicago, IL, USA
| | - Arnaud Pigneux
- Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
| | - Pau Montesinos
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Eunice S Wang
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | | | - Andrew H Wei
- The Alfred Hospital and Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | | | - Montserrat Arnan
- Institut Català d'Oncologia-Hospital Duran i Reynals, IDIBELL, Hospitalet Llobregat, Barcelona, Spain
| | - Will Donnellan
- Sarah Cannon Research Institute at Tennessee Oncology, Nashville, TN, USA
| | - Anthony P Schwarer
- Eastern Health Monash University Clinical School and Austin Hospital, Melbourne, Australia
| | - Christian Récher
- Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer Toulouse-Oncopole, Toulouse, France
| | - Brian A Jonas
- University of California, Davis Comprehensive Cancer Center, Sacramento, CA, USA
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Saultz JN, Tyner JW. Chasing leukemia differentiation through induction therapy, relapse and transplantation. Blood Rev 2023; 57:101000. [PMID: 36041918 DOI: 10.1016/j.blre.2022.101000] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/23/2022] [Accepted: 08/09/2022] [Indexed: 01/28/2023]
Abstract
Despite rapid advances in our understanding of acute myeloid leukemia (AML), the disease remains challenging to treat with 5-year survival for adult patients 20 years or older estimated to be 26% (Cancer 2021). The use of new targeted therapies including BCL2, IDH1/IDH2, and FLT3 inhibitors has revolutionized treatment approaches but also changed the disease trajectory with unique modes of resistance. Recent studies have shown that stem cell maturation state drives expression level and/or dependence on various pathways, critical to determining drug response. Instead of anticipating these changes, we remain behind the curve chasing the next expanded clone. This review will focus on current approaches to treatment in AML, including defining the significance of blast differentiation state on chemotherapeutic response, signaling pathway dependence, metabolism, immune response, and phenotypic changes. We conclude that multimodal treatment approaches are necessary to target both the immature and mature clones, thereby, sustaining drug response.
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Affiliation(s)
- Jennifer N Saultz
- Knight Cancer Institute, Oregon Health and Science University, Portland, OR, United States of America; Division of Hematology and Medical Oncology, Oregon Health and Science University, Portland, OR, United States of America.
| | - Jeffrey W Tyner
- Knight Cancer Institute, Oregon Health and Science University, Portland, OR, United States of America; Division of Hematology and Medical Oncology, Oregon Health and Science University, Portland, OR, United States of America; Department of Cell, Developmental and Cancer Biology, Oregon Health and Science University, Portland, OR, United States of America
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Gandhi A, Andrick B, Darling J, Truong T, Signorelli J. Oral Antineoplastics in Acute Myeloid Leukemia: A Comprehensive Review. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e1033-e1049. [PMID: 36192350 DOI: 10.1016/j.clml.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 01/26/2023]
Abstract
AML is a biologically and clinically heterogeneous disease that is associated with poor overall long-term survival. The expanding knowledge of genomic landscape in AML as well as advancements in molecular and chemical biology over the pathway in AML. After 40 years of stagnancy, the recent approval of numerous novel oral anti-leukemic agents for the treatment of AML has changed both the armamentarium of medications and treatment paradigms. These agents have unique clinical considerations in terms of administration, adverse effects, and monitoring parameters which may differ from clinician's historical expectations. Understanding the data, indication and clinical considerations for such novel oral anti-leukemic agents is paramount for clinicians caring patients with AML.
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Affiliation(s)
- Arpita Gandhi
- Assistant Director, Hematology/Oncology Clinical Pharmacy Specialist, Emory Healthcare, Atlanta, GA.
| | - Benjamin Andrick
- Assistant Professor, Clinical Research, Center for Pharmacy Innovations and Outcomes, Geisinger Health, Hematology/Oncology Pharmacy, Danville, PA
| | - Julianne Darling
- Manger of Education, National Community Oncology Dispensing Association, Inc., Cazenovia, NY
| | - Tuyet Truong
- Northeastern University School of Pharmacy, Boston, MA
| | - Jessie Signorelli
- Clinical Pharmacist Specialist, Hematology, Massachusetts General Hospital, Boston, MA
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35
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In Pursuit of Genetic Prognostic Factors and Treatment Approaches in Secondary Acute Myeloid Leukemia—A Narrative Review of Current Knowledge. J Clin Med 2022; 11:jcm11154283. [PMID: 35893374 PMCID: PMC9332027 DOI: 10.3390/jcm11154283] [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: 05/22/2022] [Revised: 07/01/2022] [Accepted: 07/15/2022] [Indexed: 02/05/2023] Open
Abstract
Secondary acute myeloid leukemia can be divided into two categories: AML evolving from the antecedent hematological condition (AHD-AML) and therapy related AML (t-AML). AHD-AML can evolve from hematological conditions such as myelodysplastic syndromes, myeloproliferative neoplasms, MDS/MPN overlap syndromes, Fanconi anemia, and aplastic anemia. Leukemic transformation occurs as a consequence of the clonal evolution—a process of the acquisition of mutations in clones, while previous mutations are also passed on, leading to somatic mutations accumulation. Compared de novo AML, secondary AML is generally associated with poorer response to chemotherapy and poorer prognosis. The therapeutic options for patients with s-AML have been confirmed to be limited, as s-AML has often been analyzed either both with de novo AML or completely excluded from clinical trials. The treatment of s-AML was not in any way different than de novo AML, until, that is, the introduction of CPX-351—liposomal daunorubicin and cytarabine. CPX-351 significantly improved the overall survival and progression free survival in elderly patients with s-AML. The only definitive treatment in s-AML at this time is allogeneic hematopoietic cell transplantation. A better understanding of the genetics and epigenetics of s-AML would allow us to determine precise biologic drivers leading to leukogenesis and thus help to apply a targeted treatment, improving prognosis.
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36
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Raimondi V, Ciotti G, Gottardi M, Ciccarese F. 2-Hydroxyglutarate in Acute Myeloid Leukemia: A Journey from Pathogenesis to Therapies. Biomedicines 2022; 10:biomedicines10061359. [PMID: 35740380 PMCID: PMC9220225 DOI: 10.3390/biomedicines10061359] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/31/2022] [Accepted: 06/02/2022] [Indexed: 12/19/2022] Open
Abstract
The oncometabolite 2-hydroxyglutarate (2-HG) plays a key role in differentiation blockade and metabolic reprogramming of cancer cells. Approximatively 20–30% of acute myeloid leukemia (AML) cases carry mutations in the isocitrate dehydrogenase (IDH) enzymes, leading to a reduction in the Krebs cycle intermediate α-ketoglutarate (α-KG) to 2-HG. Relapse and chemoresistance of AML blasts following initial good response to standard therapy account for the very poor outcome of this pathology, which represents a great challenge for hematologists. The decrease of 2-HG levels through pharmacological inhibition of mutated IDH enzymes induces the differentiation of AML blasts and sensitizes leukemic cells to several anticancer drugs. In this review, we provide an overview of the main genetic mutations in AML, with a focus on IDH mutants and the role of 2-HG in AML pathogenesis. Moreover, we discuss the impact of high levels of 2-HG on the response of AML cells to antileukemic therapies and recent evidence for highly efficient combinations of mutant IDH inhibitors with other drugs for the management of relapsed/refractory (R/R) AML.
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Affiliation(s)
- Vittoria Raimondi
- Department of Surgery, Oncology and Gastroenterology, University of Padua, 35128 Padova, Italy
- Correspondence:
| | - Giulia Ciotti
- Onco Hematology, Department of Oncology, Veneto Institute of Oncology IOV–IRCCS, 31033 Castelfranco Veneto, Italy; (G.C.); (M.G.)
| | - Michele Gottardi
- Onco Hematology, Department of Oncology, Veneto Institute of Oncology IOV–IRCCS, 31033 Castelfranco Veneto, Italy; (G.C.); (M.G.)
| | - Francesco Ciccarese
- Immunology and Molecular Oncology Unit, Veneto Institute of Oncology IOV–IRCCS, 35128 Padova, Italy;
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37
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New Therapeutic Strategies for Adult Acute Myeloid Leukemia. Cancers (Basel) 2022; 14:cancers14112806. [PMID: 35681786 PMCID: PMC9179253 DOI: 10.3390/cancers14112806] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 05/27/2022] [Accepted: 05/29/2022] [Indexed: 12/19/2022] Open
Abstract
Simple Summary For almost 40 years, the combination of anthracyclines and cytarabine, called 3 + 7, has been the standard of induction chemotherapy for the treatment of acute myeloid leukemia (AML). However, with the advent of new drugs in recent years, it has become possible to improve the prognosis of patients with AML harboring certain genetic mutations. Additionally, immunotherapies and therapies targeting cell-surface antigens, which are highly expressed in AML, are emerging. Herein, we review new therapeutic strategies for AML that are evolving with the introduction of these drugs. Abstract Acute myeloid leukemia (AML) is a genetically heterogeneous hematological malignancy. Chromosomal and genetic analyses are important for the diagnosis and prognosis of AML. Some patients experience relapse or have refractory disease, despite conventional cytotoxic chemotherapies and allogeneic transplantation, and a variety of new agents and treatment strategies have emerged. After over 20 years during which no new drugs became available for the treatment of AML, the CD33-targeting antibody–drug conjugate gemtuzumab ozogamicin was developed. This is currently used in combination with standard chemotherapy or as a single agent. CPX-351, a liposomal formulation containing daunorubicin and cytarabine, has become one of the standard treatments for secondary AML in the elderly. FMS-like tyrosine kinase 3 (FLT3) inhibitors and isocitrate dehydrogenase 1/2 (IDH 1/2) inhibitors are mainly used for AML patients with actionable mutations. In addition to hypomethylating agents and venetoclax, a B-cell lymphoma-2 inhibitor is used in frail patients with newly diagnosed AML. Recently, tumor protein p53 inhibitors, cyclin-dependent kinase inhibitors, and NEDD8 E1-activating enzyme inhibitors have been gaining attention, and a suitable strategy for the use of these drugs is required. Antibody drugs targeting cell-surface markers and immunotherapies, such as antibody–drug conjugates and chimeric antigen receptor T-cell therapy, have also been developed for AML.
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38
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Dunn-Valadez S, Bathini S, Elston C, Rangaraju S, Stasi AD, Worth S, Morlote D, Harada S, Vachhani P. IDH1 inhibitor-induced neutrophilic dermatosis in a patient with acute myeloid leukemia. Cancer Treat Res Commun 2022; 31:100560. [PMID: 35460975 DOI: 10.1016/j.ctarc.2022.100560] [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: 11/17/2021] [Revised: 02/13/2022] [Accepted: 04/10/2022] [Indexed: 06/14/2023]
Abstract
Ivosidenib is an oral inhibitor of mutant Isocitrate dehydrogenase 1 (IDH1). It is approved for treatment of patients with relapsed or refractory IDH1-mutated acute myeloid leukemia (AML) and patients with newly diagnosed IDH1-mutated AML who are 75 years or older or those who are ineligible to receive intensive chemotherapy. While generally well tolerated, differentiation syndrome has been reported in 15-20% of patients. Here, we report a case of acute febrile neutrophilic dermatosis or Sweet's syndrome in conjunction with the use of ivosidenib for the treatment of relapsed AML. We discuss the clinical presentation of this rare entity, review relevant literature, and comment on its association with differentiation syndrome.
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Affiliation(s)
- Sydney Dunn-Valadez
- Dept of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Srilakshmi Bathini
- Dept of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Carly Elston
- Dept of Dermatology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Sravanti Rangaraju
- Div of Hematology/Oncology, Dept of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Antonio Di Stasi
- Div of Hematology/Oncology, Dept of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Sarah Worth
- Dept of Pharmacy, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Diana Morlote
- Div of Anatomic Pathology and Neuropathology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Shuko Harada
- Div of Anatomic Pathology and Neuropathology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Pankit Vachhani
- Div of Hematology/Oncology, Dept of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States.
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de Leeuw DC, Ossenkoppele GJ, Janssen JJWM. Older Patients with Acute Myeloid Leukemia Deserve Individualized Treatment. Curr Oncol Rep 2022; 24:1387-1400. [PMID: 35653050 PMCID: PMC9606099 DOI: 10.1007/s11912-022-01299-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Treatment of elderly patients with acute myeloid leukemia is a known challenge for hematologists due to patient diversity, heterogeneous disease biology, and a rapidly evolving treatment landscape. Here, we highlight the importance of determining fitness, review the latest therapeutic developments, and discuss clinical scenarios to provide guidance on individualized treatment for older AML patients. RECENT FINDINGS Several factors, like age, performance status, and comorbidities, play a role in fitness and are associated with outcome. Comorbidity scoring systems and geriatric assessments are tools to help physicians select the most appropriate treatment for each patient. The addition of venetoclax, targeted therapy with IDH1/2 and FLT3 inhibitors, and enhanced formulas of existing drugs like CPX-351 and oral azacitidine have improved responses and outcomes. New drugs and combination therapies have increased the therapeutic options for elderly AML patients but determination of fitness and disease biology is essential to select patient-tailored treatments.
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Affiliation(s)
- David C. de Leeuw
- grid.509540.d0000 0004 6880 3010Department of Hematology, Amsterdam University Medical Centers, Location VUmc, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Gert J. Ossenkoppele
- grid.509540.d0000 0004 6880 3010Department of Hematology, Amsterdam University Medical Centers, Location VUmc, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Jeroen J. W. M. Janssen
- grid.509540.d0000 0004 6880 3010Department of Hematology, Amsterdam University Medical Centers, Location VUmc, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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40
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Molenaar RJ, Wilmink JW. IDH1/2 Mutations in Cancer Stem Cells and Their Implications for Differentiation Therapy. J Histochem Cytochem 2021; 70:83-97. [PMID: 34967233 PMCID: PMC8721574 DOI: 10.1369/00221554211062499] [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] [Indexed: 11/22/2022] Open
Abstract
Isocitrate dehydrogenase 1 and 2 (IDH1/2) are enzymes recurrently mutated in various types of cancer, including glioma, cholangiocarcinoma, chondrosarcoma, and acute myeloid leukemia. Mutant IDH1/2 induce a block in differentiation and thereby contribute to the stemness and oncogenesis of their cells of origin. Recently, small-molecule inhibitors of mutant IDH1/2 have been Food and Drug Administration-approved for the treatment of IDH1/2-mutated acute myeloid leukemia. These inhibitors decrease the stemness of the targeted IDH1/2-mutated cancer cells and induce their differentiation to more mature cells. In this review, we elucidate the mechanisms by which mutant IDH1/2 induce a block in differentiation and the biological and clinical effects of the release into differentiation by mutant-IDH1/2 inhibitors. (J Histochem Cytochem 70:83-97, 2022).
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Affiliation(s)
- Remco J Molenaar
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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41
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Austin AE, Byrne M. Detecting and preventing post-hematopoietic cell transplant relapse in AML. Curr Opin Hematol 2021; 28:380-388. [PMID: 34534984 DOI: 10.1097/moh.0000000000000686] [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: 11/25/2022]
Abstract
PURPOSE OF REVIEW Relapsed disease is the primary cause of mortality for acute myeloid leukemia (AML) patients after allogeneic hematopoietic cell transplantation (HCT). This review outlines the most recent advances in the detection and prevention of AML relapse following allogeneic HCT. RECENT FINDINGS Conventional methods for predicting post-HCT relapse rely on the molecular and cytogenetics features present at diagnosis. These methods are slow to reflect a growing understanding of the molecular heterogeneity of AML and impact of new therapies on post-HCT outcomes. The use of measurable residual disease (MRD) techniques, including multiparameter flow cytometry and molecular testing, may improve the prognostic ability of these models and should be incorporated into post-HCT surveillance whenever possible.In the post-HCT setting, FLT3 inhibitor maintenance data indicate that effective therapies can improve post-HCT outcomes. Maintenance data with DNA methyltransferase inhibitor monotherapy is less compelling and outcomes may improve with combinations. Early interventions directed at preemptive management of MRD may further improve post-HCT outcomes. SUMMARY Post-HCT AML relapse prevention has evolved to include more sensitive measures of disease detection and novel therapies that may improve outcomes of poor-risk AML patients. Additional work is needed to maintain this progress.
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Affiliation(s)
| | - Michael Byrne
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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42
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DiNardo CD, Schuh AC, Stein EM, Montesinos P, Wei AH, de Botton S, Zeidan AM, Fathi AT, Kantarjian HM, Bennett JM, Frattini MG, Martin-Regueira P, Lersch F, Gong J, Hasan M, Vyas P, Döhner H. Enasidenib plus azacitidine versus azacitidine alone in patients with newly diagnosed, mutant-IDH2 acute myeloid leukaemia (AG221-AML-005): a single-arm, phase 1b and randomised, phase 2 trial. Lancet Oncol 2021; 22:1597-1608. [PMID: 34672961 DOI: 10.1016/s1470-2045(21)00494-0] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/13/2021] [Accepted: 08/17/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Enasidenib is an oral inhibitor of mutant isocitrate dehydrogenase-2 (IDH2) proteins. We evaluated the safety and activity of enasidenib plus azacitidine versus azacitidine alone in patients with newly diagnosed, mutant-IDH2 acute myeloid leukaemia ineligible for intensive chemotherapy. METHODS This open-label, phase 1b/2 trial was done at 43 clinical sites in 12 countries (the USA, Germany, Canada, the UK, France, Spain, Australia, Italy, the Netherlands, Portugal, Switzerland, and South Korea). Eligible patients were aged 18 years or older and had newly diagnosed, mutant-IDH2 acute myeloid leukaemia, and an Eastern Cooperative Oncology Group performance status of 0-2. In the phase 1b dose-finding portion, patients received oral enasidenib 100 mg/day or 200 mg/day in continuous 28-day cycles, plus subcutaneous azacitidine 75 mg/m2 per day for 7 days of each cycle. In phase 2, patients were randomly assigned (2:1) via an interactive web response system to enasidenib plus azacitidine or azacitidine-only, stratified by acute myeloid leukaemia subtype (de novo or secondary). The primary endpoint in the phase 2 portion was the overall response rate in the intention-to-treat population at a prespecified interim analysis (Aug 20, 2019) when all patients had at least 1 year of follow-up. Safety was assessed in all patients who received at least one dose of study drug. The trial is registered with ClinicalTrials.gov, NCT02677922, and is ongoing. FINDINGS Between June 3, 2016, and Aug 2, 2018, 322 patients were screened and 107 patients with mutant-IDH2 acute myeloid leukaemia were enrolled. At data cutoff for the interim analysis, 24 patients (including two from the phase 1 portion) were still receiving their assigned treatment. Six patients were enrolled in the phase 1b dose-finding portion of the trial and received enasidenib 100 mg (n=3) or 200 mg (n=3) in combination with azacitidine. No dose-limiting toxicities occurred and the enasidenib 100 mg dose was selected for phase 2. In phase 2, 101 patients were randomly assigned to enasidenib plus azacitidine (n=68) or azacitidine only (n=33). Median age was 75 years (IQR 71-78). 50 (74%; 95% CI 61-84) patients in the enasidenib plus azacitidine combination group and 12 (36%; 20-55) patients in the azacitidine monotherapy group achieved an overall response (odds ratio 4·9 [95% CI 2·0-11·9]; p=0·0003). Common treatment-related grade 3 or 4 adverse events with enasidenib plus azacitidine were thrombocytopenia (25 [37%] of 68 vs six [19%] of 32 in the azacitidine-only group), neutropenia (25 [37%] vs eight [25%]), anaemia (13 [19%] vs seven [22%]), and febrile neutropenia (11 [16%] vs five [16%]). Serious treatment-related adverse events were reported in 29 (43%) patients in the combination group and 14 (44%) patients in the azacitidine-only group; serious treatment-related adverse events occurring in more than 5% of patients in either group were febrile neutropenia (nine [13%] in the combination group vs five [16%] in the azacitidine-only group), differentiation syndrome (seven [10%] vs none), and pneumonia (three [4%] vs two [6%]). No treatment-related deaths were reported. INTERPRETATION Combination enasidenib plus azacitidine was well tolerated and significantly improved overall response rates compared with azacitidine monotherapy, suggesting that this regimen can improve outcomes for patients with newly diagnosed, mutant-IDH2 acute myeloid leukaemia. FUNDING Bristol Myers Squibb.
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Affiliation(s)
- Courtney D DiNardo
- Department of Leukemia, MD Anderson Cancer Center, University of Texas, Houston, TX, USA.
| | - Andre C Schuh
- Cancer Clinical Research Unit, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Eytan M Stein
- Division of Hematologic Malignancies, Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY, USA
| | - Pau Montesinos
- Department of Haematology, Hospital Universitari i Politecnic La Fe, Valencia, Spain
| | - Andrew H Wei
- The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | | | | | - Amir T Fathi
- Hematology and Oncology, Harvard Medical School and Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Hagop M Kantarjian
- Department of Leukemia, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - John M Bennett
- Department of Pathology, Hematopathology Division, University of Rochester Medical Center, Rochester, NY, USA
| | | | | | - Frederik Lersch
- Celgene, a Bristol Myers Squibb Company, Boudry, Switzerland
| | - Jing Gong
- Bristol Myers Squibb, Princeton, NJ, USA
| | | | - Paresh Vyas
- MRC Molecular Haematology Unit and Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals, Oxford, UK
| | - Hartmut Döhner
- Department of Internal Medicine III, Universitätsklinikum Ulm, Ulm, Germany
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Brown NJ, Ye Z, Stutterd C, Jayasinghe SI, Schneider A, Mullen SA, Mandelstam SA, Hildebrand MS. Somatic IDH1 variant (p.R132C) in an adult male with Maffucci syndrome. Cold Spring Harb Mol Case Stud 2021; 7:mcs.a006127. [PMID: 34588213 PMCID: PMC8751415 DOI: 10.1101/mcs.a006127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/23/2021] [Indexed: 12/02/2022] Open
Abstract
Maffucci syndrome is a rare, highly variable somatic mosaic condition, and well-known cancer-related gain-of-function variants in either the IDH1 or IDH2 genes have been found in the affected tissues of most reported individuals. Features include benign enchondroma and spindle-cell hemangioma, with a recognized increased risk of various malignancies. Fewer than 200 affected individuals have been reported; therefore, accurate estimates of malignancy risk are difficult to quantify and recommended surveillance guidelines are not available. The same gain-of-function IDH1 and IDH2 variants are also implicated in a variety of other benign and malignant tumors. An adult male presented with several soft palpable lesions on the right upper limb. Imaging and histopathology raised the possibility of Maffucci syndrome. DNA was extracted from peripheral blood lymphocytes and tissue surgically resected from a spindle-cell hemangioma. Sanger sequencing and droplet digital polymerase chain reaction (PCR) analysis of the IDH1 gene were performed. We identified a somatic mosaic c.394C > T (p.R132C) variant in exon 5 of IDH1, in DNA derived from hemangioma tissue at ∼17% variant allele fraction. This variant was absent in DNA derived from blood. This variant has been identified in the affected tissue of most reported individuals with Maffucci syndrome. Although this individual has a potentially targetable variant, and there is a recognized risk of malignant transformation in this condition, a decision was made not to intervene with an IDH1 inhibitor. The reasons and prospects for therapy in this condition are discussed.
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Affiliation(s)
| | - Zimeng Ye
- Department of Medicine, Austin Hospital, University of Melbourne, Heidelberg, Victoria, Australia
| | - Chloe Stutterd
- Victorian Clinical Genetics Services, Melbourne, Parkville, Australia
| | - Sureshni I Jayasinghe
- Department of Clinical Pathology, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Amy Schneider
- Department of Medicine, Austin Hospital, University of Melbourne, Heidelberg, Victoria, Australia
| | - Saul A Mullen
- Department of Medicine, Austin Hospital, University of Melbourne, Heidelberg, Victoria, Australia
| | - Simone A Mandelstam
- Royal Children's Hospital Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - Michael S Hildebrand
- Epilepsy Research Centre, Department of Medicine (Austin Hospital), University of Melbourne, Heidelberg, Victoria, Australia
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Targeted Therapies for the Evolving Molecular Landscape of Acute Myeloid Leukemia. Cancers (Basel) 2021; 13:cancers13184646. [PMID: 34572873 PMCID: PMC8471378 DOI: 10.3390/cancers13184646] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/13/2021] [Indexed: 01/09/2023] Open
Abstract
Despite considerable growth in our understanding of the heterogeneous biology and pathogenesis of acute myeloid leukemia (AML) in recent decades, for nearly forty years, little progress was gained in the realm of novel therapeutics. Since 2017, however, nine agents have been FDA-approved for patients with AML in both the upfront and relapsed/refractory (R/R) settings. Most of these compounds function as inhibitors of key cell cycle enzymatic pathways or mediators of leukemic proliferation and survival. They have been approved both as single agents and in combination with conventional or reduced-intensity conventional chemotherapeutics. In this article, we review the molecular landscape of de novo vs. R/R AML and highlight the potential translational impact of defined molecular disease subsets. We also highlight several recent agents that have entered the therapeutic armamentarium and where they fit in the AML treatment landscape, with a focus on FLT3 inhibitors, IDH1 and IDH2 inhibitors, and venetoclax. Finally, we close with a survey of two promising novel agents under investigation that are poised to enter the mainstream clinical arena in the near future.
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Dragani M, de Botton S. SOHO State of the Art Updates and Next Questions: IDH Inhibition. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2021; 21:567-572. [PMID: 34193376 DOI: 10.1016/j.clml.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/23/2021] [Accepted: 05/03/2021] [Indexed: 06/13/2023]
Abstract
There has been extraordinary progress in the field of targeted therapy for myeloid malignancies in the last few years, especially due to the approval of various agents that can be used as monotherapy or in combination as first-line treatment or when facing a refractory or relapsed disease. Many successful trials have been conducted recently, and a consistent body of work about the efficacy of novel molecules is now available. In this review, we sought to explain how enasidenib and ivosidenib have changed the face of myeloid neoplasm treatment through isocitrate dehydrogenase inhibition and to summarize the trials results that have led to the current commercial indications for the two molecules.
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Affiliation(s)
- Matteo Dragani
- Hematology Department, Gustave Roussy Cancer Centre, Villejuif, France
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46
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Yao K, Liu H, Yin J, Yuan J, Tao H. Synthetic lethality and synergetic effect: the effective strategies for therapy of IDH-mutated cancers. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2021; 40:263. [PMID: 34425876 PMCID: PMC8383362 DOI: 10.1186/s13046-021-02054-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/28/2021] [Indexed: 12/23/2022]
Abstract
Mutant isocitrate dehydrogenase 1/2 (mIDH1/2) gain a novel function for the conversion of α-ketoglutarate (α-KG) to oncometabolite R-2-hydroxyglutarate (R-2-HG). Two molecular entities namely enasidenib (AG-221) and ivosidenib (AG-120) targeting mIDH2 and mIDH1 respectively, have already been approved by FDA for the treatment of relapsed/refractory acute myeloid leukemia (R/R AML). However, the low responses, drug-related adverse effects, and most significantly, the clinically-acquired resistance of AG-221 and AG-120 has shown great influence on their clinical application. Therefore, searching for novel therapeutic strategies to enhance tumor sensitivity, reduce drug-related side effects, and overcome drug resistance have opened a new research field for defeating IDH-mutated cancers. As the effective methods, synthetic lethal interactions and synergetic therapies are extensively investigated in recent years for the cure of different cancers. In this review, the molecules displaying synergetic effects with mIDH1/2 inhibitors, as well as the targets showing relevant synthetic lethal interactions with mIDH1/2 are described emphatically. On these foundations, we discuss the opportunities and challenges for translating these strategies into clinic to combat the defects of existing IDH inhibitors.
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Affiliation(s)
- Kun Yao
- Brain Science Basic Laboratory, The Affiliated Wuxi Mental Health Center with Nanjing Medical University, Wuxi, 214151, Jiangsu, China.,Department of Clinical Psychology, The Affiliated Wuxi Mental Health Center with Nanjing Medical University, Wuxi, 214151, Jiangsu, China
| | - Hua Liu
- Department of Pharmacy, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, Jiangsu, China
| | - Jiajun Yin
- Brain Science Basic Laboratory, The Affiliated Wuxi Mental Health Center with Nanjing Medical University, Wuxi, 214151, Jiangsu, China
| | - Jianmin Yuan
- Brain Science Basic Laboratory, The Affiliated Wuxi Mental Health Center with Nanjing Medical University, Wuxi, 214151, Jiangsu, China.
| | - Hong Tao
- Department of Pharmacy, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, Jiangsu, China.
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Megherea O, Janes C, Kowalski A, Baron J, Ahn E, Soule A, Newman M. Real-world assessment of isocitrate dehydrogenase inhibitor-associated differentiation syndrome. Leuk Lymphoma 2021; 62:3219-3225. [PMID: 34313176 DOI: 10.1080/10428194.2021.1957868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Ivosidenib and enasidenib are targeted agents that inhibit mutant isocitrate dehydrogenase (IDH) enzymes, restoring normal cellular differentiation in affected acute myeloid leukemia patients. Both agents carry a risk of differentiation syndrome (DS), a potentially life-threatening complication. In this multicenter, retrospective study we sought to determine the real-world incidence and characterize DS in patients with a myeloid malignancy treated with an IDH inhibitor. Of 49 total patients, 15 patients (31%) had a documented diagnosis of DS and 8 patients (16%) met the criteria of DS by Montesinos, et al. The most common signs and symptoms of DS were dyspnea/hypoxia (56%), unexplained fever (56%), bone pain/arthralgia (44%), edema/weight gain (39%), and pleural/pericardial effusions (33%). Our study reports a higher real-world incidence of DS in patients treated with IDH inhibitors for myeloid malignancies than previously reported.
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Affiliation(s)
- Oxana Megherea
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Carmen Janes
- Department of Pharmacy/Oncology Division, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Andrew Kowalski
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Jessica Baron
- NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Esther Ahn
- Sibley Memorial Hospital, Washington, DC, USA
| | - Ashley Soule
- University of Kentucky HealthCare, Lexington, KY, USA
| | - Matthew Newman
- Department of Pharmacy/Oncology Division, The Johns Hopkins Hospital, Baltimore, MD, USA
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48
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Pulte ED, Norsworthy KJ, Wang Y, Xu Q, Qosa H, Gudi R, Przepiorka D, Fu W, Okusanya OO, Goldberg KB, De Claro RA, Farrell AT, Pazdur R. FDA Approval Summary: Gilteritinib for Relapsed or Refractory Acute Myeloid Leukemia with a FLT3 Mutation. Clin Cancer Res 2021; 27:3515-3521. [PMID: 33632926 PMCID: PMC8506653 DOI: 10.1158/1078-0432.ccr-20-4271] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/19/2021] [Accepted: 02/09/2021] [Indexed: 11/16/2022]
Abstract
On November 28, 2018, the FDA approved gilteritinib (Xospata; Astellas), a small-molecule FMS-like tyrosine kinase 3 (FLT3) inhibitor, for treatment of relapsed or refractory acute myeloid leukemia with a FLT3 mutation as detected by an FDA-approved test. In the ADMIRAL study, patients were randomized 2:1 to receive gilteritinib or standard chemotherapy and stratified by response to first-line treatment and intensity of prespecified chemotherapy. Efficacy was established on interim analysis on the basis of complete remission (CR) + CR with partial hematologic recovery (CRh) rate, duration of CR + CRh, and conversion from transfusion dependence to transfusion independence in 138 patients in the gilteritinib arm. With median follow-up of 4.6 months [95% confidence interval (CI), 2.8-15.8 months] at interim analysis, the CR + CRh rate was 21% (95% CI, 15%-29%), median duration of CR + CRh was 4.6 months (range, 0.1-15.8+), and conversion from transfusion dependence to transfusion independence was 31%. Revised labeling approved on May 29, 2019 included the results of the final analysis, showing an improvement in overall survival (OS) with gilteritinib compared with chemotherapy (HR, 0.64; 95% CI, 0.49-0.83; one-sided P = 0.0004; median OS, 9.3 vs. 5.6 months). The OS benefit was observed in both high and low chemotherapy intensity subgroups. Labeling includes a boxed warning for differentiation syndrome and warnings for posterior reversible encephalopathy syndrome, QT prolongation, pancreatitis, and embryo-fetal toxicity. Safe use requires frequent monitoring of electrocardiograms and blood chemistries. Assessments of long-term safety are pending.
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Affiliation(s)
- E Dianne Pulte
- Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland.
| | | | - Yaping Wang
- Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland
| | - Qing Xu
- Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland
| | - Hisham Qosa
- Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland
| | - Ramadevi Gudi
- Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland
| | - Donna Przepiorka
- Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland
| | - Wentao Fu
- Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland
| | | | | | - R Angelo De Claro
- Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland
| | - Ann T Farrell
- Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland
| | - Richard Pazdur
- Oncology Center of Excellence, FDA, Silver Spring, Maryland
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Stemer G, Rowe JM, Ofran Y. Efficacy and Safety Profile of Ivosidenib in the Management of Patients with Acute Myeloid Leukemia (AML): An Update on the Emerging Evidence. BLOOD AND LYMPHATIC CANCER-TARGETS AND THERAPY 2021; 11:41-54. [PMID: 34188585 PMCID: PMC8235936 DOI: 10.2147/blctt.s236446] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 05/23/2021] [Indexed: 12/13/2022]
Abstract
The isocitrate dehydrogenase enzyme, catalyzing isocitrate conversion to α-ketoglutarate (αKG) in both the cell cytoplasm and mitochondria, contributes to the production of dihydronicotinamide-adenine dinucleotide phosphate (NADPH) as a reductive potential in various cellular processes. IDH1 gene mutations are revealed in up to 20% of the patients with acute myeloid leukemia (AML). A mutant IDH enzyme, existing in the cell cytoplasm and possessing neomorphic activity, converts αKG into oncometabolite R-2-hydroxyglutarate (R-2-HG) that accumulates in high amounts in the cell and inhibits αKG-dependent enzymes, including epigenetic regulators. The resultant alteration in gene expression and blockade of differentiation ultimately lead to leukemia development. Myeloid differentiation capacity can be restored by obstruction of the mutant enzyme, inducing substantial reduction in R-2-HG levels. Ivosidenib, a potent selective inhibitor of mutant IDH1, is a differentiating agent shown to be clinically effective in newly diagnosed AML (ND-AML) and relapsed/refractory (R/R) AML harboring this mutation. The drug is approved by the Food and Drug Administration (FDA) as a single-agent treatment for R/R AML. Significance of mutated IDH1 targeting and a potential role of ivosidenib in AML management, when used either as a single agent or as part of combination therapies, will be reviewed herein.
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Affiliation(s)
- Galia Stemer
- Institute of Hematology, Ha'Emek Medical Center, Afula, Israel
| | - Jacob M Rowe
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel.,Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Yishai Ofran
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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50
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Targeting IDH1 and IDH2 Mutations in Acute Myeloid Leukemia: Emerging Options and Pending Questions. Hemasphere 2021; 5:e583. [PMID: 34095766 PMCID: PMC8171378 DOI: 10.1097/hs9.0000000000000583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 04/17/2021] [Indexed: 11/26/2022] Open
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