1
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Ye L, Cui Z, Sun Y, Zhou H, Rong Q, Wang D, Jin J, Zhang Q, Kang D, Hu L, Wang J. Discovery of a potent Gilteritinib-based FLT3-PROTAC degrader for the treatment of Acute myeloid leukemia. Bioorg Chem 2024; 149:107477. [PMID: 38820938 DOI: 10.1016/j.bioorg.2024.107477] [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: 05/15/2024] [Accepted: 05/18/2024] [Indexed: 06/02/2024]
Abstract
Fms-like tyrosine receptor kinase 3 (FLT3) proteolysis targeting chimeras (PROTACs) emerge as a promising approach to overcome the limitations of FLT3 inhibitors, while the development of orally bioavailable FLT3-PROTACs faces great challenges. Here, we report the rational design and evaluation of a series of Gilteritinib-based FLT3-PROTACs. Among them, B3-2 exhibited the strongest antiproliferative activity against FLT3-ITD mutant AML cells, and significantly induced FLT3-ITD protein degradation. Mechanistic investigations demonstrated that B3-2 induced FLT3-ITD degradation in a ubiquitin-proteasome-dependent manner. More importantly, B3-2 exhibited an oral bioavailability of 5.65%, and oral administration of B3-2 showed good antitumor activity in MV-4-11 xenograft models. Furthermore, B3-2 showed strong antiproliferative activity against FLT3 resistant mutations, highlighting its potential in overcoming drug resistance.
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MESH Headings
- fms-Like Tyrosine Kinase 3/antagonists & inhibitors
- fms-Like Tyrosine Kinase 3/metabolism
- Humans
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/pathology
- Antineoplastic Agents/pharmacology
- Antineoplastic Agents/chemistry
- Antineoplastic Agents/chemical synthesis
- Pyrazines/chemistry
- Pyrazines/pharmacology
- Pyrazines/chemical synthesis
- Cell Proliferation/drug effects
- Animals
- Structure-Activity Relationship
- Molecular Structure
- Protein Kinase Inhibitors/pharmacology
- Protein Kinase Inhibitors/chemistry
- Protein Kinase Inhibitors/chemical synthesis
- Drug Screening Assays, Antitumor
- Mice
- Dose-Response Relationship, Drug
- Drug Discovery
- Thiophenes/chemistry
- Thiophenes/pharmacology
- Thiophenes/chemical synthesis
- Proteolysis/drug effects
- Aniline Compounds/chemistry
- Aniline Compounds/pharmacology
- Aniline Compounds/chemical synthesis
- Cell Line, Tumor
- Neoplasms, Experimental/drug therapy
- Neoplasms, Experimental/pathology
- Neoplasms, Experimental/metabolism
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Affiliation(s)
- Lei Ye
- Jiangsu Key Laboratory for Functional Substance of Chinese Medicine, School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, PR China
| | - Zhenzhen Cui
- Jiangsu Key Laboratory for Functional Substance of Chinese Medicine, School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, PR China
| | - Yu Sun
- Jiangsu Key Laboratory for Functional Substance of Chinese Medicine, School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, PR China
| | - Haikun Zhou
- Jiangsu Key Laboratory for Functional Substance of Chinese Medicine, School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, PR China
| | - Quanjin Rong
- Jiangsu Key Laboratory for Functional Substance of Chinese Medicine, School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, PR China
| | - Dan Wang
- Jiangsu Key Laboratory for Functional Substance of Chinese Medicine, School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, PR China
| | - Jiaming Jin
- Jiangsu Key Laboratory for Functional Substance of Chinese Medicine, School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, PR China
| | - Qijian Zhang
- Jiangsu Key Laboratory for Functional Substance of Chinese Medicine, School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, PR China
| | - Di Kang
- Jiangsu Key Laboratory for Functional Substance of Chinese Medicine, School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, PR China; National Key Laboratory on Technologies for Chinese Medicine Pharmaceutical Process Control and Intelligent Manufacture, Nanjing 210023, PR China.
| | - Lihong Hu
- Jiangsu Key Laboratory for Functional Substance of Chinese Medicine, School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, PR China; National Key Laboratory on Technologies for Chinese Medicine Pharmaceutical Process Control and Intelligent Manufacture, Nanjing 210023, PR China.
| | - Junwei Wang
- Jiangsu Key Laboratory for Functional Substance of Chinese Medicine, School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, PR China; National Key Laboratory on Technologies for Chinese Medicine Pharmaceutical Process Control and Intelligent Manufacture, Nanjing 210023, PR China.
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2
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Xiao X, Wang P, Zhang W, Wang J, Cai M, Jiang H, Wu Y, Shan H. GNF-7, a novel FLT3 inhibitor, overcomes drug resistance for the treatment of FLT3‑ITD acute myeloid leukemia. Cancer Cell Int 2023; 23:302. [PMID: 38037057 PMCID: PMC10691066 DOI: 10.1186/s12935-023-03142-y] [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: 07/21/2023] [Accepted: 11/13/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Acute myeloid leukemia (AML) with FMS-like tyrosine kinase 3 internal tandem duplication (FLT3-ITD) mutation accounts for a large proportion of AML patients and diagnosed with poor prognosis. Although the prognosis of FLT3-ITD AML has been greatly improved, the drug resistance frequently occurred in the treatment of FLT3 targeting drugs. GNF-7, a multitargeted kinase inhibitor, which provided a novel therapeutic strategy for overriding leukemia. In this study, we explored the antitumor activity of GNF-7 against FLT3-ITD and clinically-relevant drug resistance in FLT3 mutant AML. METHODS Growth inhibitory assays were performed in AML cell lines and Ba/F3 cells expressing various FLT3 mutants to evaluate the antitumor activity of GNF-7 in vitro. Western blotting was used to examine the inhibitory effect of GNF-7 on FLT3 and its downstream pathways. Molecular docking and cellular thermal shift assay (CETSA) were performed to demonstrate the binding of FLT3 to GNF-7. The survival benefit of GNF-7 in vivo was assessed in mouse models of transformed Ba/F3 cells harboring FLT3-ITD and FLT3-ITD/F691L mutation. Primary patient samples and a patient-derived xenograft (PDX) model were also used to determine the efficacy of GNF-7. RESULTS GNF-7 inhibited the cell proliferation of Ba/F3 cells expressing FLT3-ITD and exhibited potently anti-leukemia activity on primary FLT3-ITD AML samples. Moreover, GNF-7 could bind to FLT3 protein and inhibit the downstream signaling pathway activated by FLT3 including STAT5, PI3K/AKT and MAPK/ERK. In vitro and in vivo studies showed that GNF-7 exhibited potent inhibitory activity against FLT3-ITD/F691L that confers resistant to quizartinib (AC220) or gilteritinib. Importantly, GNF-7 showed potent cytotoxic effect on leukemic stem cells, significantly extend the survival of PDX model and exhibited similar therapy effect compared with gilteritinib. CONCLUSIONS Our results show that GNF-7 is a potent FLT3-ITD inhibitor and may become a promising lead compound applied for treating some of the clinically drug resistant patients.
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Affiliation(s)
- Xinhua Xiao
- Department of Hematology and Oncology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China.
| | - Peihong Wang
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, 510000, Guangdong, China
| | - Weina Zhang
- Department of Hematology and Oncology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Jiayi Wang
- Department of Hematology and Oncology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Mansi Cai
- Department of Hematology and Oncology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Hua Jiang
- Department of Hematology and Oncology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China.
| | - Yingli Wu
- Hongqiao International Institute of Medicine, Shanghai Tongren Hospital/Faculty of Basic Medicine, Chemical Biology Division of Shanghai Universities E-Institutes, Key Laboratory of Cell Differentiation and Apoptosis of the Chinese Ministry of Education, Research Units of Stress and Tumor (2019RU043), Shanghai Jiao Tong University School of Medicine, Chinese Academy of Medical Sciences, Shanghai, 200025, China.
| | - Huizhuang Shan
- Department of Clinical Laboratory Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510000, Guangdong, China.
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3
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Popescu B, Stahlhut C, Tarver TC, Wishner S, Lee BJ, Peretz CAC, Luck C, Phojanakong P, Camara Serrano JA, Hongo H, Rivera JM, Xirenayi S, Chukinas JA, Steri V, Tasian SK, Stieglitz E, Smith CC. Allosteric SHP2 inhibition increases apoptotic dependency on BCL2 and synergizes with venetoclax in FLT3- and KIT-mutant AML. Cell Rep Med 2023; 4:101290. [PMID: 37992684 PMCID: PMC10694768 DOI: 10.1016/j.xcrm.2023.101290] [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: 01/11/2023] [Revised: 07/31/2023] [Accepted: 10/20/2023] [Indexed: 11/24/2023]
Abstract
Mutations in the receptor tyrosine kinases (RTKs) FLT3 and KIT are frequent and associated with poor outcomes in acute myeloid leukemia (AML). Although selective FLT3 inhibitors (FLT3i) are clinically effective, remissions are short-lived due to secondary resistance characterized by acquired mutations constitutively activating the RAS/MAPK pathway. Hereby, we report the pre-clinical efficacy of co-targeting SHP2, a critical node in MAPK signaling, and BCL2 in RTK-driven AML. The allosteric SHP2 inhibitor RMC-4550 suppresses proliferation of AML cell lines with FLT3 and KIT mutations, including cell lines with acquired resistance to FLT3i. We demonstrate that pharmacologic SHP2 inhibition unveils an Achilles' heel of RTK-driven AML, increasing apoptotic dependency on BCL2 via MAPK-dependent mechanisms, including upregulation of BMF and downregulation of MCL1. Consequently, RMC-4550 and venetoclax are synergistically lethal in AML cell lines and in clinically relevant xenograft models. Our results provide mechanistic rationale and pre-clinical evidence for co-targeting SHP2 and BCL2 in RTK-driven AML.
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Affiliation(s)
- Bogdan Popescu
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Theodore C Tarver
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Sydney Wishner
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Bianca J Lee
- Revolution Medicines, Inc., Redwood City, CA, USA
| | - Cheryl A C Peretz
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA; Helen Diller Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - Cuyler Luck
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Paul Phojanakong
- Preclinical Therapeutics Core, Helen Diller Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA; Helen Diller Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - Juan Antonio Camara Serrano
- Preclinical Therapeutics Core, Helen Diller Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA; Helen Diller Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - Henry Hongo
- Helen Diller Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - Jose M Rivera
- Helen Diller Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - Simayijiang Xirenayi
- Helen Diller Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - John A Chukinas
- Division of Oncology, Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Veronica Steri
- Preclinical Therapeutics Core, Helen Diller Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA; Helen Diller Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - Sarah K Tasian
- Division of Oncology, Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Elliot Stieglitz
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA; Helen Diller Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - Catherine C Smith
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; Helen Diller Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA.
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4
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Abdel-Aziz AK, Dokla EME, Saadeldin MK. FLT3 inhibitors and novel therapeutic strategies to reverse AML resistance: An updated comprehensive review. Crit Rev Oncol Hematol 2023; 191:104139. [PMID: 37717880 DOI: 10.1016/j.critrevonc.2023.104139] [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: 04/01/2023] [Revised: 08/20/2023] [Accepted: 09/12/2023] [Indexed: 09/19/2023] Open
Abstract
FMS-like tyrosine kinase 3 (FLT3) mutations occur in almost 30% of acute myeloid leukemia (AML) patients. Despite the initial clinical efficacy of FLT3 inhibitors, many treated AML patients with mutated FLT3 eventually relapse. This review critically discusses the opportunities and challenges of FLT3-targeted therapies and sheds light on their drug interactions as well as potential biomarkers. Furthermore, we focus on the molecular mechanisms underlying the resistance of FLT3 internal tandem duplication (FLT3-ITD) AMLs to FLT3 inhibitors alongside novel therapeutic strategies to reverse resistance. Notably, dynamic heterogeneous patterns of clonal selection and evolution contribute to the resistance of FLT3-ITD AMLs to FLT3 inhibitors. Ongoing preclinical research and clinical trials are actively directed towards devising rational "personalized" or "patient-tailored" combinatorial therapeutic regimens to effectively treat patients with FLT3 mutated AML.
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Affiliation(s)
- Amal Kamal Abdel-Aziz
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Ain Shams University, Cairo 11566, Egypt; Smart Health Initiative, Biological and Environmental Sciences and Engineering Division, King Abdullah University of Science and Technology (KAUST), Thuwal 23955, Saudi Arabia.
| | - Eman M E Dokla
- Pharmaceutical Chemistry Department, Faculty of Pharmacy, Ain Shams University, Abbassia, Cairo 11566, Egypt
| | - Mona Kamal Saadeldin
- Department of Chemical and Biomolecular Engineering, University of Notre Dame, Leahy Drive, Notre Dame, IN 46556, USA
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5
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Liu Y, Zhang X, Zhang P, He T, Zhang W, Ma D, Li P, Chen J. A high-throughput Gaussia luciferase reporter assay for screening potential gasdermin E activators against pancreatic cancer. Acta Pharm Sin B 2023; 13:4253-4272. [PMID: 37799380 PMCID: PMC10548051 DOI: 10.1016/j.apsb.2023.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 05/20/2023] [Accepted: 06/15/2023] [Indexed: 10/07/2023] Open
Abstract
It is discovered that activated caspase-3 tends to induce apoptosis in gasdermin E (GSDME)-deficient cells, but pyroptosis in GSDME-sufficient cells. The high GSDME expression and apoptosis resistance of pancreatic ductal adenocarcinoma (PDAC) cells shed light on another attractive strategy for PDAC treatment by promoting pyroptosis. Here we report a hGLuc-hGSDME-PCA system for high-throughput screening of potential GSDME activators against PDAC. This screening system neatly quantifies the oligomerization of GSDME-N to characterize whether pyroptosis occurs under the stimulation of chemotherapy drugs. Based on this system, ponatinib and perifosine are screened out from the FDA-approved anti-cancer drug library containing 106 compounds. Concretely, they exhibit the most potent luminescent activity and cause drastic pyroptosis in PDAC cells. Further, we demonstrate that perifosine suppresses pancreatic cancer by promoting pyroptosis via caspase-3/GSDME pathway both in vitro and in vivo. Collectively, this study reveals the great significance of hGLuc-hGSDME-PCA in identifying compounds triggering GSDME-dependent pyroptosis and developing promising therapeutic agents for PDAC.
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Affiliation(s)
- Yang Liu
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing 210009, China
- Department of Pharmacognosy, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Xiaowei Zhang
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing 210009, China
- Department of Pharmacognosy, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Ping Zhang
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing 210009, China
- Department of Pharmacognosy, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Tingting He
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing 210009, China
- Department of Pharmacognosy, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Weitao Zhang
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing 210009, China
- Department of Pharmacognosy, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Dingyuan Ma
- Department of Prenatal Diagnosis, Nanjing Maternity and Child Health Care Hospital, Women's Hospital of Nanjing Medical University, Nanjing 210004, China
| | - Ping Li
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing 210009, China
| | - Jun Chen
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing 210009, China
- Department of Pharmacognosy, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing 211198, China
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6
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Gao Y, Ding Y, Tai XR, Zhang C, Wang D. Ponatinib: An update on its drug targets, therapeutic potential and safety. Biochim Biophys Acta Rev Cancer 2023; 1878:188949. [PMID: 37399979 DOI: 10.1016/j.bbcan.2023.188949] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/27/2023] [Accepted: 06/27/2023] [Indexed: 07/05/2023]
Abstract
Leukemia is a malignancy of the hematopoietic system, and as its pathogenesis has become better understood, three generations of tyrosine kinase inhibitors (TKIs) have been developed. Ponatinib is the third-generation breakpoint cluster region (BCR) and Abelson (ABL) TKI, which has been influential in the leukemia therapy for a decade. Moreover, ponatinib is a potent multi-target kinase inhibitor that acts on various kinases, such as KIT, RET, and Src, making it a promising treatment option for triple-negative breast cancer (TNBC), lung cancer, myeloproliferative syndrome, and other diseases. The drug's significant cardiovascular toxicity poses a significant challenge to its clinical use, requiring the development of strategies to minimize its toxicity and side effects. In this article, the pharmacokinetics, targets, therapeutic potential, toxicity and production mechanism of ponatinib will be reviewed. Furthermore, we will discuss methods to reduce the drug's toxicity, providing new avenues for research to improve its safety in clinical use.
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MESH Headings
- Humans
- Fusion Proteins, bcr-abl/pharmacology
- Fusion Proteins, bcr-abl/therapeutic use
- Drug Resistance, Neoplasm
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/chemically induced
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Antineoplastic Agents/therapeutic use
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Affiliation(s)
- Yue Gao
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Basic Medical Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, PR China
| | - Yue Ding
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Basic Medical Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, PR China
| | - Xin-Ran Tai
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Basic Medical Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, PR China
| | - Chen Zhang
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, PR China.
| | - Dong Wang
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Basic Medical Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, PR China.
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7
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Mecklenbrauck R, Heuser M. Resistance to targeted therapies in acute myeloid leukemia. Clin Exp Metastasis 2023; 40:33-44. [PMID: 36318439 PMCID: PMC9898349 DOI: 10.1007/s10585-022-10189-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 10/12/2022] [Indexed: 02/04/2023]
Abstract
The introduction of new targeted therapies to the treatment algorithm of acute myeloid leukemia (AML) offers new opportunities, but also presents new challenges. Patients diagnosed with AML receiving targeted therapies as part of lower intensity regimens will relapse inevitably due to primary or secondary resistance mechanisms. In this review, we summarize the current knowledge on the main mechanisms of resistance to targeted therapies in AML. Resistance to FLT3 inhibitors is mainly mediated by on target mutations and dysregulation of downstream pathways. Switching the FLT3 inhibitor has a potential therapeutic benefit. During treatment with IDH inhibitors resistance can develop due to aberrant cell metabolism or secondary site IDH mutations. As a unique resistance mechanism the mutated IDH isotype may switch from IDH1 to IDH2 or vice versa. Resistance to gemtuzumab-ozogamicin is determined by the CD33 isotype and the degradation of the cytotoxin. The main mechanisms of resistance to venetoclax are the dysregulation of alternative pathways especially the upregulation of the BCL-2-analogues MCL-1 and BCL-XL or the induction of an aberrant cell metabolism. The introduction of therapies targeting immune processes will lead to new forms of therapy resistance. Knowing those mechanisms will help to develop strategies that can overcome resistance to treatment.
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Affiliation(s)
- Rabea Mecklenbrauck
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Michael Heuser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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8
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Knight TE, Edwards H, Meshinchi S, Taub JW, Ge Y. "FLipping" the Story: FLT3-Mutated Acute Myeloid Leukemia and the Evolving Role of FLT3 Inhibitors. Cancers (Basel) 2022; 14:3398. [PMID: 35884458 PMCID: PMC9315611 DOI: 10.3390/cancers14143398] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/07/2022] [Accepted: 07/11/2022] [Indexed: 12/19/2022] Open
Abstract
The treatment of many types of cancers, including acute myeloid leukemia (AML), has been revolutionized by the development of therapeutics targeted at crucial molecular drivers of oncogenesis. In contrast to broad, relatively indiscriminate conventional chemotherapy, these targeted agents precisely disrupt key pathways within cancer cells. FMS-like tyrosine kinase 3 (FLT3)-encoding a critical regulator of hematopoiesis-is the most frequently mutated gene in patients with AML, and these mutations herald reduced survival and increased relapse in these patients. Approximately 30% of newly diagnosed AML carries an FLT3 mutation; of these, approximately three-quarters are internal tandem duplication (ITD) mutations, and the remainder are tyrosine kinase domain (TKD) mutations. In contrast to its usual, tightly controlled expression, FLT3-ITD mutants allow constitutive, "run-away" activation of a large number of key downstream pathways which promote cellular proliferation and survival. Targeted inhibition of FLT3 is, therefore, a promising therapeutic avenue. In April 2017, midostaurin became both the first FLT3 inhibitor and the first targeted therapy of any kind in AML to be approved by the US FDA. The use of FLT3 inhibitors has continued to grow as clinical trials continue to demonstrate the efficacy of this class of agents, with an expanding number available for use as both experimental standard-of-care usage. This review examines the biology of FLT3 and its downstream pathways, the mechanism of FLT3 inhibition, the development of the FLT3 inhibitors as a class and uses of the agents currently available clinically, and the mechanisms by which resistance to FLT3 inhibition may both develop and be overcome.
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Affiliation(s)
- Tristan E. Knight
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, Seattle, WA 98105, USA;
- Division of Hematology and Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98105, USA
| | - Holly Edwards
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI 48202, USA; (H.E.); (Y.G.)
- Molecular Therapeutics Program, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Soheil Meshinchi
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, Seattle, WA 98105, USA;
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Jeffrey W. Taub
- Division of Hematology/Oncology, Children’s Hospital of Michigan, Detroit, MI 48201, USA;
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI 48202, USA
- Department of Pediatrics, Central Michigan University, Mt. Pleasant, MI 48859, USA
| | - Yubin Ge
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI 48202, USA; (H.E.); (Y.G.)
- Molecular Therapeutics Program, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI 48201, USA
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9
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Katayama K, Nishihata A. RSK Inhibition Induces Apoptosis by Downregulating Protein Synthesis in a Variety of Acute Myeloid Leukemia Cell Lines. Biol Pharm Bull 2021; 44:1843-1850. [PMID: 34602526 DOI: 10.1248/bpb.b21-00531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Fms-like tyrosine kinase 3 (FLT3) and isocitrate dehydrogenase 1/2 (IDH1/2) mutations drive malignancy in acute myeloid leukemia (AML), which accounts for approximately 40% of AML cases. Treatment with FLT3 or IDH1/2 inhibitors is used for such patients; however, it is not considered for most patients with AML who lack mutations on the respective genes. In this study, p90 ribosomal S6 kinase (RSK) was found to serve as a new therapeutic target in various AMLs with or without FLT3 mutations. BI-D1870, a potent inhibitor of RSK, significantly suppressed the proliferation of AML cell lines, among which three encoded wild-type FLT3 and three contained FLT3 driver mutations, compared with chronic myeloid leukemia K562 cells or other adherent cancer cells. BI-D1870 inhibited protein synthesis by dephosphorylating the p70 S6 kinase and eukaryotic initiation factor 4E-binding protein 1 in all AML cells except KG-1a cells. Meanwhile, the expression of microtubule-associated protein light chain 3B-I and -II increased in KG-1a cells treated with BI-D1870. BI-D1870 induced caspase-dependent apoptosis in all AML cells, including KG-1a cells. We next investigated the synergistic effect of BI-D1870 with cytarabine, a traditional anticancer drug used in AML. Synergistic effects of BI-D1870 and cytarabine were not observed in any of the cell lines. The findings suggested that BI-D1870 alone exerts an adequate antiproliferative effect on AML with or without FLT3 mutations and serves as a novel AML therapeutic agent.
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Affiliation(s)
- Kazuhiro Katayama
- Laboratory of Molecular Targeted Therapeutics, School of Pharmacy, Nihon University.,Division of Chemotherapy, Faculty of Pharmacy, Keio University
| | - Ayane Nishihata
- Division of Chemotherapy, Faculty of Pharmacy, Keio University
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10
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Dellomo AJ, Abbotts R, Eberly CL, Karbowski M, Baer MR, Kingsbury TJ, Rassool FV. PARP1 PARylates and stabilizes STAT5 in FLT3-ITD acute myeloid leukemia and other STAT5-activated cancers. Transl Oncol 2021; 15:101283. [PMID: 34808460 PMCID: PMC8609071 DOI: 10.1016/j.tranon.2021.101283] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 11/08/2021] [Indexed: 12/11/2022] Open
Abstract
PARP1-dependent PARylation post-translationally modifies and regulates STAT5. Catalytic PARP inhibition reduces STAT5 stability. PARP1 loss results in reduced STAT5 signaling and activation of downstream targets. STAT5-activated cancers are sensitive to PARP inhibition. PARP inhibition overcomes TKI-resistance in FLT3-ITD AML.
Signal transducer and activator of transcription 5 (STAT5) signaling plays a pathogenic role in both hematologic malignancies and solid tumors. In acute myeloid leukemia (AML), internal tandem duplications of fms-like tyrosine kinase 3 (FLT3-ITD) constitutively activate the FLT3 receptor, producing aberrant STAT5 signaling, driving cell survival and proliferation. Understanding STAT5 regulation may aid development of new treatment strategies in STAT5-activated cancers including FLT3-ITD AML. Poly ADP-ribose polymerase (PARP1), upregulated in FLT3-ITD AML, is primarily known as a DNA repair factor, but also regulates a diverse range of proteins through PARylation. Analysis of STAT5 protein sequence revealed putative PARylation sites and we demonstrate a novel PARP1 interaction and direct PARylation of STAT5 in FLT3-ITD AML. Moreover, PARP1 depletion and PARylation inhibition decreased STAT5 protein expression and activity via increased degradation, suggesting that PARP1 PARylation of STAT5 at least in part potentiates aberrant signaling by stabilizing STAT5 protein in FLT3-ITD AML. Importantly for translational significance, PARPis are cytotoxic in numerous STAT5-activated cancer cells and are synergistic with tyrosine kinase inhibitors (TKI) in both TKI-sensitive and TKI-resistant FLT3-ITD AML. Therefore, PARPi may have therapeutic benefit in STAT5-activated and therapy-resistant leukemias and solid tumors.
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Affiliation(s)
- Anna J Dellomo
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD 21201, USA
| | - Rachel Abbotts
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD 21201, USA
| | - Christian L Eberly
- Center for Stem Cell Biology & Regenerative Medicine, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Mariusz Karbowski
- Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Maria R Baer
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA; University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD 21201, USA
| | - Tami J Kingsbury
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD 21201, USA
| | - Feyruz V Rassool
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD 21201, USA.
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11
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Smith CC, Viny AD, Massi E, Kandoth C, Socci ND, Rapaport F, Najm M, Medina-Martinez JS, Papaemmanuil E, Tarver TC, Hsu HH, Le MH, West B, Bollag G, Taylor BS, Levine RL, Shah NP. Recurrent Mutations in Cyclin D3 Confer Clinical Resistance to FLT3 Inhibitors in Acute Myeloid Leukemia. Clin Cancer Res 2021; 27:4003-4011. [PMID: 34103301 DOI: 10.1158/1078-0432.ccr-20-3458] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 03/25/2021] [Accepted: 05/14/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE Biomarkers of response and resistance to FLT3 tyrosine kinase inhibitors (TKI) are still emerging, and optimal clinical combinations remain unclear. The purpose of this study is to identify co-occurring mutations that influence clinical response to the novel FLT3 inhibitor pexidartinib (PLX3397). EXPERIMENTAL DESIGN We performed targeted sequencing of pretreatment blasts from 29 patients with FLT3 internal tandem duplication (ITD) mutations treated on the phase I/II trial of pexidartinib in relapsed/refractory FLT3-ITD+ acute myeloid leukemia (AML). We sequenced 37 samples from 29 patients with available material, including 8 responders and 21 non-responders treated at or above the recommended phase II dose of 3,000 mg. RESULTS Consistent with other studies, we identified mutations in NRAS, TP53, IDH2, and a variety of epigenetic and transcriptional regulators only in non-responders. Among the most frequently mutated genes in non-responders was Cyclin D3 (CCND3). A total of 3 individual mutations in CCND3 (Q276*, S264R, and T283A) were identified in 2 of 21 non-responders (one patient had both Q276* and S264R). No CCND3 mutations were found in pexidartinib responders. Expression of the Q276* and T283A mutations in FLT3-ITD MV4;11 cells conferred resistance to apoptosis, decreased cell-cycle arrest, and increased proliferation in the presence of pexidartinib and other FLT3 inhibitors. Inhibition of CDK4/6 activity in CCND3 mutant MV4;11 cells restored pexidartinib-induced cell-cycle arrest but not apoptosis. CONCLUSIONS Mutations in CCND3, a gene not commonly mutated in AML, are a novel cause of clinical primary resistance to FLT3 inhibitors in AML and may have sensitivity to CDK4/6 inhibition.
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Affiliation(s)
- Catherine C Smith
- Division of Hematology/Oncology, University of California, San Francisco, California. .,Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California
| | - Aaron D Viny
- Human Oncology & Pathogenesis Program and Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Evan Massi
- Division of Hematology/Oncology, University of California, San Francisco, California
| | - Cyriac Kandoth
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nicholas D Socci
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Franck Rapaport
- Center for Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Matthieu Najm
- Center for Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Juan S Medina-Martinez
- Center for Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Elli Papaemmanuil
- Center for Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Theodore C Tarver
- Division of Hematology/Oncology, University of California, San Francisco, California
| | | | - Mai H Le
- Plexxikon Inc, Berkeley, California
| | | | | | - Barry S Taylor
- Human Oncology & Pathogenesis Program and Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ross L Levine
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California.,Human Oncology & Pathogenesis Program and Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Neil P Shah
- Division of Hematology/Oncology, University of California, San Francisco, California. .,Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California
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12
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A phase 1/2 study of the oral FLT3 inhibitor pexidartinib in relapsed/refractory FLT3-ITD-mutant acute myeloid leukemia. Blood Adv 2021; 4:1711-1721. [PMID: 32330242 DOI: 10.1182/bloodadvances.2020001449] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/25/2020] [Indexed: 01/10/2023] Open
Abstract
FMS-like tyrosine kinase 3 (FLT3) tyrosine kinase inhibitors (TKIs) have activity in acute myeloid leukemia (AML) patients with FLT3 internal tandem duplication (ITD) mutations, but efficacy is limited by resistance-conferring kinase domain mutations. This phase 1/2 study evaluated the safety, tolerability, and efficacy of the oral FLT3 inhibitor PLX3397 (pexidartinib), which has activity against the FLT3 TKI-resistant F691L gatekeeper mutation in relapsed/refractory FLT3-ITD-mutant AML. Ninety patients were treated: 34 in dose escalation (part 1) and 56 in dose expansion (part 2). Doses of 800 to 5000 mg per day in divided doses were tested. No maximally tolerated dose was reached. Plasma inhibitory assay demonstrated that patients dosed with ≥3000 mg had sufficient levels of active drug in their trough plasma samples to achieve 95% inhibition of FLT3 phosphorylation in an FLT3-ITD AML cell line. Based on a plateau in drug exposure, the 3000-mg dose was chosen as the recommended phase 2 dose. The most frequently reported treatment-emergent adverse events were diarrhea (50%), fatigue (47%), and nausea (46%). Based on modified response criteria, the overall response rate to pexidartinib among all patients was 21%. Twenty-three percent of patients treated at ≥2000 mg responded. The overall composite complete response rate for the study was 11%. Six patients were successfully bridged to transplantation. Median overall survival (OS) of patients treated in dose expansion was 112 days (90% confidence interval [CI], 77-150 days), and median OS of responders with complete remission with or without recovery of blood counts was 265 days (90% CI, 170-422 days). This trial was registered at www.clinicaltrials.gov as #NCT01349049.
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13
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Gilteritinib is a clinically active FLT3 inhibitor with broad activity against FLT3 kinase domain mutations. Blood Adv 2021; 4:514-524. [PMID: 32040554 DOI: 10.1182/bloodadvances.2019000919] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 01/06/2020] [Indexed: 11/20/2022] Open
Abstract
Gilteritinib is the first FMS-like tyrosine kinase 3 (FLT3) tyrosine kinase inhibitor (TKI) approved as monotherapy in acute myeloid leukemia with FLT3 internal tandem duplication and D835/I836 tyrosine kinase domain (TKD) mutations. Sequencing studies in patients have uncovered less common, noncanonical (NC) mutations in FLT3 and have implicated secondary TKD mutations in FLT3 TKI resistance. We report that gilteritinib is active against FLT3 NC and TKI resistance-causing mutations in vitro. A mutagenesis screen identified FLT3 F691L, Y693C/N, and G697S as mutations that confer moderate resistance to gilteritinib in vitro. Analysis of patients treated with gilteritinib revealed that 2/9 patients with preexisting NC FLT3 mutations responded and that secondary TKD mutations are acquired in a minority (5/31) of patients treated with gilteritinib. Four of 5 patients developed F691L mutations (all treated at <200 mg). These studies suggest that gilteritinib has broad activity against FLT3 mutations and limited vulnerability to resistance-causing FLT3 TKD mutations, particularly when used at higher doses.
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14
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Yang J, Lindström HJG, Friedman R. Combating drug resistance in acute myeloid leukaemia by drug rotations: the effects of quizartinib and pexidartinib. Cancer Cell Int 2021; 21:198. [PMID: 33832508 PMCID: PMC8033742 DOI: 10.1186/s12935-021-01856-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 02/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute myeloid leukaemia (AML) is an aggressive blood cancer. In approximately 30% of the cases, driver mutations in the FLT3 gene are identified. FLT3 inhibitors are used in treatment of such patients together with cytotoxic drugs or (in refractory AML) as single agents. Unfortunately, resistance to FLT3 inhibitors limits their efficacy. Resistance is often due to secondary mutations in the gene encoding the molecular target. The gatekeeper mutation F691L confers resistance to specific FLT3 inhibitors such as quizartinib, but pexidartinib is much less resistance to this mutation. Pexidartinib alone is however sensitive to many other resistance mutations. In chronic myeloid leukaemia (CML), it has been suggested that rotation between drugs with a different landscape of resistance mutations might postpone the emergence of resistance. METHODS We studied the effect of quizartinib and pexidartinib in AML cell lines that express FLT3 (MOLM-14 and MV4-11). Using a rotation protocol, we further examined whether the emergence of resistance could be postponed. Computational modelling was used to analyse the onset of resistance and suggest which mutations are most likely to occur in a quantitative fashion. RESULTS The cells were sensitive to both inhibitors but quickly developed resistance that could be inherited, suggesting a genetic origin. Rotation protocols were not useful to postpone the emergence of resistance, which implies that such protocols, or changing from pexidartinib to quizartinib (or vice-versa) should not be used in patients. The computational modelling led to similar conclusions and suggested that F691L is the most common mutation to occur with quizartinib, and also when both drugs are used in rotation. CONCLUSIONS AML patients are not likely to benefit from a quizartinib/pexidartinib rotation protocol. A combination of tyrosine kinase inhibitors (with different molecular targets) might be more useful in the future. Development of specific FLT3 inhibitors that are less sensitive to resistance mutations might also lead to a better outcome.
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Affiliation(s)
- Jingmei Yang
- Department of Chemistry and Biomedical Science, Linnaeus University, Kalmar Campus, Kalmar, 391 82, Sweden
| | - H Jonathan G Lindström
- Department of Chemistry and Biomedical Science, Linnaeus University, Kalmar Campus, Kalmar, 391 82, Sweden
- Faeth Therapeutics Inc., 237 Kearny Street, #9245, San Francisco, CA, 94108, US
| | - Ran Friedman
- Department of Chemistry and Biomedical Science, Linnaeus University, Kalmar Campus, Kalmar, 391 82, Sweden.
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15
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Kennedy VE, Smith CC. FLT3 Mutations in Acute Myeloid Leukemia: Key Concepts and Emerging Controversies. Front Oncol 2021; 10:612880. [PMID: 33425766 PMCID: PMC7787101 DOI: 10.3389/fonc.2020.612880] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/19/2020] [Indexed: 12/27/2022] Open
Abstract
The FLT3 receptor is overexpressed on the majority of acute myeloid leukemia (AML) blasts. Mutations in FLT3 are the most common genetic alteration in AML, identified in approximately one third of newly diagnosed patients. FLT3 internal tandem duplication mutations (FLT3-ITD) are associated with increased relapse and inferior overall survival. Multiple small molecule inhibitors of FLT3 signaling have been identified, two of which (midostaurin and gilteritinib) are currently approved in the United States, and many more of which are in clinical trials. Despite significant advances, resistance to FLT3 inhibitors through secondary FLT3 mutations, upregulation of parallel pathways, and extracellular signaling remains an ongoing challenge. Novel therapeutic strategies to overcome resistance, including combining FLT3 inhibitors with other antileukemic agents, development of new FLT3 inhibitors, and FLT3-directed immunotherapy are in active clinical development. Multiple questions regarding FLT3-mutated AML remain. In this review, we highlight several of the current most intriguing controversies in the field including the role of FLT3 inhibitors in maintenance therapy, the role of hematopoietic cell transplantation in FLT3-mutated AML, use of FLT3 inhibitors in FLT3 wild-type disease, significance of non-canonical FLT3 mutations, and finally, emerging concerns regarding clonal evolution.
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Affiliation(s)
- Vanessa E Kennedy
- Division of Hematology and Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Catherine C Smith
- Division of Hematology and Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
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16
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Marconi G, De Polo S, Martinelli G, Nanni J, Bertamini L, Talami A, Olivi M, Ragaini S, Abbenante MC, Sartor C, Ottaviani E, Bochicchio MT, Parisi S, Fontana MC, Cristiano G, Raffini M, Baldazzi C, Testoni N, Bonifazi F, Paolini S, Curti A, Cavo M, Papayannidis C. Safety profile and impact on survival of tyrosine kinase inhibitors versus conventional therapy in relapse or refractory FLT3 positive acute myeloid leukemia patients. Leuk Res 2020; 101:106497. [PMID: 33385697 DOI: 10.1016/j.leukres.2020.106497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 12/14/2020] [Accepted: 12/22/2020] [Indexed: 11/18/2022]
Abstract
Relapsed or refractory (R/R) acute myeloid leukemia (AML) has a poor prognosis, and new therapies are a major clinical need. When mutated, FLT3 drives neoplastic cell proliferation. New drugs (i.e., tyrosine kinase inhibitors, TKIs) showed effectiveness in FLT3-AML and promise to change disease history and outcome. We evaluated the benefit conferred by TKIs in terms of survival, burden of complications and surrogate endpoint of quality of life in a retrospective cohort of 49 FLT3 positive, R/R AML patients. Patients who received TKIs were compared to those treated with conventional chemotherapy. Treatment with TKIs conferred a better OS and wea associated with a lower burden and severity of adverse events. Importantly, patients who received TKIs showed reduced time of hospitalization. In conclusion, treatment with TKI in R/R FLT3-AML was related to a better survival, less and milder AEs, and shorter hospitalization.
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Affiliation(s)
- Giovanni Marconi
- Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi, Bologna, Italy.
| | - Stefano De Polo
- Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi, Bologna, Italy
| | - Giovanni Martinelli
- Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi, Bologna, Italy; Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Jacopo Nanni
- Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi, Bologna, Italy
| | - Luca Bertamini
- Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi, Bologna, Italy; Division of Hematology, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Annalisa Talami
- Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi, Bologna, Italy
| | - Matteo Olivi
- Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi, Bologna, Italy; Division of Hematology, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Simone Ragaini
- Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi, Bologna, Italy; Division of Hematology, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Maria Chiara Abbenante
- Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi, Bologna, Italy; Department of Haematology and Stem Cell Transplantation Unit, IRCCS "Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Italy
| | - Chiara Sartor
- Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi, Bologna, Italy
| | - Emanuela Ottaviani
- Azienda Ospedaliero-Universitaria di Bologna, via Albertoni 15, Bologna, Italy
| | - Maria Teresa Bochicchio
- Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi, Bologna, Italy; Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Sarah Parisi
- Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi, Bologna, Italy; Azienda Ospedaliero-Universitaria di Bologna, via Albertoni 15, Bologna, Italy
| | - Maria Chiara Fontana
- Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi, Bologna, Italy; Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Gianluca Cristiano
- Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi, Bologna, Italy
| | - Maddalena Raffini
- Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi, Bologna, Italy
| | - Carmen Baldazzi
- Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi, Bologna, Italy
| | - Nicoletta Testoni
- Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi, Bologna, Italy
| | - Francesca Bonifazi
- Azienda Ospedaliero-Universitaria di Bologna, via Albertoni 15, Bologna, Italy
| | - Stefania Paolini
- Azienda Ospedaliero-Universitaria di Bologna, via Albertoni 15, Bologna, Italy
| | - Antonio Curti
- Azienda Ospedaliero-Universitaria di Bologna, via Albertoni 15, Bologna, Italy
| | - Michele Cavo
- Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi, Bologna, Italy; Azienda Ospedaliero-Universitaria di Bologna, via Albertoni 15, Bologna, Italy
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17
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Jeon JY, Buelow DR, Garrison DA, Niu M, Eisenmann ED, Huang KM, Zavorka Thomas ME, Weber RH, Whatcott CJ, Warner SL, Orwick SJ, Carmichael B, Stahl E, Brinton LT, Lapalombella R, Blachly JS, Hertlein E, Byrd JC, Bhatnagar B, Baker SD. TP-0903 is active in models of drug-resistant acute myeloid leukemia. JCI Insight 2020; 5:140169. [PMID: 33268594 PMCID: PMC7714403 DOI: 10.1172/jci.insight.140169] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/16/2020] [Indexed: 12/17/2022] Open
Abstract
Effective treatment for AML is challenging due to the presence of clonal heterogeneity and the evolution of polyclonal drug resistance. Here, we report that TP-0903 has potent activity against protein kinases related to STAT, AKT, and ERK signaling, as well as cell cycle regulators in biochemical and cellular assays. In vitro and in vivo, TP-0903 was active in multiple models of drug-resistant FLT3 mutant AML, including those involving the F691L gatekeeper mutation and bone marrow microenvironment–mediated factors. Furthermore, TP-0903 demonstrated preclinical activity in AML models with FLT3-ITD and common co-occurring mutations in IDH2 and NRAS genes. We also showed that TP-0903 had ex vivo activity in primary AML cells with recurrent mutations including MLL-PTD, ASXL1, SRSF2, and WT1, which are associated with poor prognosis or promote clinical resistance to AML-directed therapies. Our preclinical studies demonstrate that TP-0903 is a multikinase inhibitor with potent activity against multiple drug-resistant models of AML that will have an immediate clinical impact in a heterogeneous disease like AML. TP-0903, a multikinase inhibitor, demonstrates preclinical activity in models of drug-resistant AML, including those involving FLT3 mutations, bone marrow microenvironment-mediated factors and recurrent mutations.
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Affiliation(s)
- Jae Yoon Jeon
- Division of Pharmaceutics and Pharmacology, College of Pharmacy
| | | | | | - Mingshan Niu
- Division of Pharmaceutics and Pharmacology, College of Pharmacy
| | | | - Kevin M Huang
- Division of Pharmaceutics and Pharmacology, College of Pharmacy
| | | | - Robert H Weber
- Division of Pharmaceutics and Pharmacology, College of Pharmacy
| | | | | | | | | | - Emily Stahl
- Division of Hematology, Department of Internal Medicine, and
| | | | - Rosa Lapalombella
- Division of Hematology, Department of Internal Medicine, and.,Comprehensive Cancer Center, The Ohio State University (OSU), Columbus, Ohio, USA
| | - James S Blachly
- Division of Hematology, Department of Internal Medicine, and.,Comprehensive Cancer Center, The Ohio State University (OSU), Columbus, Ohio, USA
| | - Erin Hertlein
- Division of Hematology, Department of Internal Medicine, and.,Comprehensive Cancer Center, The Ohio State University (OSU), Columbus, Ohio, USA
| | - John C Byrd
- Division of Pharmaceutics and Pharmacology, College of Pharmacy.,Division of Hematology, Department of Internal Medicine, and.,Comprehensive Cancer Center, The Ohio State University (OSU), Columbus, Ohio, USA
| | - Bhavana Bhatnagar
- Division of Hematology, Department of Internal Medicine, and.,Comprehensive Cancer Center, The Ohio State University (OSU), Columbus, Ohio, USA
| | - Sharyn D Baker
- Division of Pharmaceutics and Pharmacology, College of Pharmacy.,Division of Hematology, Department of Internal Medicine, and.,Comprehensive Cancer Center, The Ohio State University (OSU), Columbus, Ohio, USA
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18
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Gebru MT, Wang HG. Therapeutic targeting of FLT3 and associated drug resistance in acute myeloid leukemia. J Hematol Oncol 2020; 13:155. [PMID: 33213500 PMCID: PMC7678146 DOI: 10.1186/s13045-020-00992-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 11/03/2020] [Indexed: 02/07/2023] Open
Abstract
Acute myeloid leukemia (AML) is a heterogeneous disease caused by several gene mutations and cytogenetic abnormalities affecting differentiation and proliferation of myeloid lineage cells. FLT3 is a receptor tyrosine kinase commonly overexpressed or mutated, and its mutations are associated with poor prognosis in AML. Although aggressive chemotherapy often followed by hematopoietic stem cell transplant is the current standard of care, the recent approval of FLT3-targeted drugs is revolutionizing AML treatment that had remained unchanged since the 1970s. However, despite the dramatic clinical response to targeted agents, such as FLT3 inhibitors, remission is almost invariably short-lived and ensued by relapse and drug resistance. Hence, there is an urgent need to understand the molecular mechanisms driving drug resistance in order to prevent relapse. In this review, we discuss FLT3 as a target and highlight current understanding of FLT3 inhibitor resistance.
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Affiliation(s)
- Melat T Gebru
- Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Hong-Gang Wang
- Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, PA, USA. .,Department of Pharmacology, Pennsylvania State University College of Medicine, Hershey, PA, USA. .,Penn State College of Medicine, 500 University Drive, Hershey, PA, 17033, USA.
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19
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Zhang G, Zhang W, Shen C, Nan J, Chen M, Lai S, Zhong J, Li B, Wang T, Wang Y, Yang S, Li L. Discovery of small molecule FLT3 inhibitors that are able to overcome drug-resistant mutations. Bioorg Med Chem Lett 2020; 30:127532. [PMID: 32891702 DOI: 10.1016/j.bmcl.2020.127532] [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: 04/23/2020] [Revised: 08/24/2020] [Accepted: 08/29/2020] [Indexed: 02/05/2023]
Abstract
Herein we report the discovery of 1-(5-(tert-butyl)isoxazol-3-yl)-3- (3-fluorophenyl)urea derivatives as new FLT3 inhibitors that are able to overcome the drug resistance mutations: the secondary D835Y and F691L mutations on the basis of the internal tandem duplications (ITD) mutation of FLT3 (FLT3-ITD/D835Y and FLT3-ITD/F691L, respectively). The most potent compound corresponds to 1-(5-(tert-butyl)isoxazol-3-yl)-3-(4-((6,7-dimethoxyquinolin-4-yl)oxy)-3- fluorophenyl)urea (4d), which showed IC50s (half maximal inhibitory concentrations) of 0.072 nM, 5.86 nM and 3.48 nM against FLT3-ITD, FLT3-ITD/F691L and FLT3-ITD/D835Y, respectively. Compound 4d also showed good selectivity for FLT3 in a kinase profiling assay. Collectively, 4d could be a good lead compound and deserves further in-depth studies.
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Affiliation(s)
- Guo Zhang
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Sichuan 610041, China
| | - Wenqing Zhang
- Key Laboratory of Drug Targeting and Drug Delivery System of Ministry of Education, West China School of Pharmacy, Sichuan University, Sichuan 610041, China
| | - Chenjian Shen
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Sichuan 610041, China
| | - Jinshan Nan
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Sichuan 610041, China
| | - Ming Chen
- Guangxi Wuzhou Pharmaceutical Co. Ltd, Wuzhou, Guangxi 543000, China
| | - Shusheng Lai
- Guangxi Wuzhou Pharmaceutical Co. Ltd, Wuzhou, Guangxi 543000, China
| | - Jiemin Zhong
- Guangxi Wuzhou Pharmaceutical Co. Ltd, Wuzhou, Guangxi 543000, China
| | - Bolin Li
- Guangxi Wuzhou Pharmaceutical Co. Ltd, Wuzhou, Guangxi 543000, China
| | - Tianqi Wang
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Sichuan 610041, China
| | - Yifei Wang
- Key Laboratory of Drug Targeting and Drug Delivery System of Ministry of Education, West China School of Pharmacy, Sichuan University, Sichuan 610041, China
| | - Shengyong Yang
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Sichuan 610041, China
| | - Linli Li
- Key Laboratory of Drug Targeting and Drug Delivery System of Ministry of Education, West China School of Pharmacy, Sichuan University, Sichuan 610041, China.
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20
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Alotaibi AS, Yilmaz M, Loghavi S, DiNardo C, Borthakur G, Kadia TM, Thakral B, Pemmaraju N, Issa GC, Konopleva M, Short NJ, Patel K, Tang G, Ravandi F, Daver N. Emergence of BCR- ABL1 Fusion in AML Post-FLT3 Inhibitor-Based Therapy: A Potentially Targetable Mechanism of Resistance - A Case Series. Front Oncol 2020; 10:588876. [PMID: 33194747 PMCID: PMC7606916 DOI: 10.3389/fonc.2020.588876] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/11/2020] [Indexed: 12/28/2022] Open
Abstract
Despite the promising result with FLT3 inhibitors in AML, the emergence of resistance poses a significant challenge, leading to a shorter response duration and inferior survival. This is frequently driven by on-target or parallel prosurvival mutations. The emergence of BCR–ABL1 as a mechanism of possible clonal evolution in relapsed AML has rarely been reported. Here we report our experience with three patients who had emergent BCR–ABL1 fusion at relapse after FLT3 inhibitors–based therapies. The first patient was refractory to multiple lines of therapies, including FLT3 inhibitors–based therapy. Patients 2 and 3 showed some response to combined FLT3-inhibitor and BCR–ABL targeted therapy (gilteritinib and ponatinib). The availability of effective targeted therapies for BCR–ABL1 makes this an important aberration to proactively identify and possibly target at relapse post–FLT3-inhibitor therapies.
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Affiliation(s)
- Ahmad S Alotaibi
- The Department of Leukemia, MD Anderson Cancer Center, Houston, TX, United States
| | - Musa Yilmaz
- The Department of Leukemia, MD Anderson Cancer Center, Houston, TX, United States
| | - Sanam Loghavi
- The Department of Hematopathology, MD Anderson Cancer Center, Houston, TX, United States
| | - Courtney DiNardo
- The Department of Leukemia, MD Anderson Cancer Center, Houston, TX, United States
| | - Gautam Borthakur
- The Department of Leukemia, MD Anderson Cancer Center, Houston, TX, United States
| | - Tapan M Kadia
- The Department of Leukemia, MD Anderson Cancer Center, Houston, TX, United States
| | - Beenu Thakral
- The Department of Hematopathology, MD Anderson Cancer Center, Houston, TX, United States
| | - Naveen Pemmaraju
- The Department of Leukemia, MD Anderson Cancer Center, Houston, TX, United States
| | - Ghayas C Issa
- The Department of Leukemia, MD Anderson Cancer Center, Houston, TX, United States
| | - Marina Konopleva
- The Department of Leukemia, MD Anderson Cancer Center, Houston, TX, United States
| | - Nicholas J Short
- The Department of Leukemia, MD Anderson Cancer Center, Houston, TX, United States
| | - Keyur Patel
- The Department of Hematopathology, MD Anderson Cancer Center, Houston, TX, United States
| | - Guilin Tang
- The Department of Hematopathology, MD Anderson Cancer Center, Houston, TX, United States
| | - Farhad Ravandi
- The Department of Leukemia, MD Anderson Cancer Center, Houston, TX, United States
| | - Naval Daver
- The Department of Leukemia, MD Anderson Cancer Center, Houston, TX, United States
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21
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Mosquera Orgueira A, Bao Pérez L, Mosquera Torre A, Peleteiro Raíndo A, Cid López M, Díaz Arias JÁ, Ferreiro Ferro R, Antelo Rodríguez B, González Pérez MS, Albors Ferreiro M, Alonso Vence N, Pérez Encinas MM, Bello López JL, Martinelli G, Cerchione C. FLT3 inhibitors in the treatment of acute myeloid leukemia: current status and future perspectives. Minerva Med 2020; 111:427-442. [PMID: 32955823 DOI: 10.23736/s0026-4806.20.06989-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Mutations in the FMS-like tyrosine kinase 3 (FLT3) gene arise in 25-30% of all acute myeloid leukemia (AML) patients. These mutations lead to constitutive activation of the protein product and are divided in two broad types: internal tandem duplication (ITD) of the juxtamembrane domain (25% of cases) and point mutations in the tyrosine kinase domain (TKD). Patients with FLT3 ITD mutations have a high relapse risk and inferior cure rates, whereas the role of FLT3 TKD mutations still remains to be clarified. Additionally, growing research indicates that FLT3 status evolves through a disease continuum (clonal evolution), where AML cases can acquire FLT3 mutations at relapse - not present in the moment of diagnosis. Several FLT3 inhibitors have been tested in patients with FLT3-mutated AML. These drugs exhibit different kinase inhibitory profiles, pharmacokinetics and adverse events. First-generation multi-kinase inhibitors (sorafenib, midostaurin, lestaurtinib) are characterized by a broad-spectrum of drug targets, whereas second-generation inhibitors (quizartinib, crenolanib, gilteritinib) show more potent and specific FLT3 inhibition, and are thereby accompanied by less toxic effects. Notwithstanding, all FLT3 inhibitors face primary and acquired mechanisms of resistance, and therefore the combinations with other drugs (standard chemotherapy, hypomethylating agents, checkpoint inhibitors) and its application in different clinical settings (upfront therapy, maintenance, relapsed or refractory disease) are under study in a myriad of clinical trials. This review focuses on the role of FLT3 mutations in AML, pharmacological features of FLT3 inhibitors, known mechanisms of drug resistance and accumulated evidence for the use of FLT3 inhibitors in different clinical settings.
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Affiliation(s)
- Adrián Mosquera Orgueira
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain - .,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain - .,University of Santiago de Compostela, Santiago de Compostela, Spain -
| | - Laura Bao Pérez
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain
| | - Alicia Mosquera Torre
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain
| | - Andrés Peleteiro Raíndo
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain.,University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Miguel Cid López
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain.,University of Santiago de Compostela, Santiago de Compostela, Spain
| | - José Á Díaz Arias
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain
| | - Roi Ferreiro Ferro
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Beatriz Antelo Rodríguez
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain.,University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Marta S González Pérez
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain
| | - Manuel Albors Ferreiro
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain
| | - Natalia Alonso Vence
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain
| | - Manuel M Pérez Encinas
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain.,University of Santiago de Compostela, Santiago de Compostela, Spain
| | - José L Bello López
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain.,University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Giovanni Martinelli
- Unit of Hematology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy
| | - Claudio Cerchione
- Unit of Hematology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy
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22
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Melgar K, Walker MM, Jones LM, Bolanos LC, Hueneman K, Wunderlich M, Jiang JK, Wilson KM, Zhang X, Sutter P, Wang A, Xu X, Choi K, Tawa G, Lorimer D, Abendroth J, O'Brien E, Hoyt SB, Berman E, Famulare CA, Mulloy JC, Levine RL, Perentesis JP, Thomas CJ, Starczynowski DT. Overcoming adaptive therapy resistance in AML by targeting immune response pathways. Sci Transl Med 2020; 11:11/508/eaaw8828. [PMID: 31484791 DOI: 10.1126/scitranslmed.aaw8828] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 07/24/2019] [Indexed: 12/17/2022]
Abstract
Targeted inhibitors to oncogenic kinases demonstrate encouraging clinical responses early in the treatment course; however, most patients will relapse because of target-dependent mechanisms that mitigate enzyme-inhibitor binding or through target-independent mechanisms, such as alternate activation of survival and proliferation pathways, known as adaptive resistance. Here, we describe mechanisms of adaptive resistance in FMS-like receptor tyrosine kinase (FLT3)-mutant acute myeloid leukemia (AML) by examining integrative in-cell kinase and gene regulatory network responses after oncogenic signaling blockade by FLT3 inhibitors (FLT3i). We identified activation of innate immune stress response pathways after treatment of FLT3-mutant AML cells with FLT3i and showed that innate immune pathway activation via the interleukin-1 receptor-associated kinase 1 and 4 (IRAK1/4) complex contributes to adaptive resistance in FLT3-mutant AML cells. To overcome this adaptive resistance mechanism, we developed a small molecule that simultaneously inhibits FLT3 and IRAK1/4 kinases. The multikinase FLT3-IRAK1/4 inhibitor eliminated adaptively resistant FLT3-mutant AML cells in vitro and in vivo and displayed superior efficacy as compared to current targeted FLT3 therapies. These findings uncover a polypharmacologic strategy for overcoming adaptive resistance to therapy in AML by targeting immune stress response pathways.
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Affiliation(s)
- Katelyn Melgar
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Immunology Graduate Program, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| | - Morgan M Walker
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20892, USA
| | | | - Lyndsey C Bolanos
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Kathleen Hueneman
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Mark Wunderlich
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Jian-Kang Jiang
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20892, USA
| | - Kelli M Wilson
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20892, USA
| | - Xiaohu Zhang
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20892, USA
| | - Patrick Sutter
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20892, USA
| | - Amy Wang
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20892, USA
| | - Xin Xu
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20892, USA
| | - Kwangmin Choi
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Gregory Tawa
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20892, USA
| | | | | | - Eric O'Brien
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Scott B Hoyt
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20892, USA
| | - Ellin Berman
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Christopher A Famulare
- Center for Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - James C Mulloy
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Ross L Levine
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.,Center for Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.,Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - John P Perentesis
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Craig J Thomas
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20892, USA. .,Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20829, USA
| | - Daniel T Starczynowski
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA. .,Department of Cancer Biology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
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23
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Thakral B, Daver N, Tang Z, Patel KP, Ok CY, Loghavi S, Khoury JD, Alotaibi AS, Konopleva M, Yilmaz M, Medeiros LJ. Clonal evolution with acquisition of BCR-ABL1 in refractory acute myeloid leukemia post therapy with FLT3-inhibitor. Leuk Lymphoma 2020; 61:3243-3246. [DOI: 10.1080/10428194.2020.1797008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Beenu Thakral
- Department of Hematopathology, MD Anderson Cancer Center, Houston, TX, USA
| | - Naval Daver
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Zhenya Tang
- Department of Hematopathology, MD Anderson Cancer Center, Houston, TX, USA
| | - Keyur P. Patel
- Department of Hematopathology, MD Anderson Cancer Center, Houston, TX, USA
| | - Chi Young Ok
- Department of Hematopathology, MD Anderson Cancer Center, Houston, TX, USA
| | - Sanam Loghavi
- Department of Hematopathology, MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph D. Khoury
- Department of Hematopathology, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Marina Konopleva
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Musa Yilmaz
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
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24
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Thomas X, Elhamri M, Heiblig M. Emerging pharmacotherapies for elderly acute myeloid leukemia patients. Expert Rev Hematol 2020; 13:619-643. [PMID: 32311298 DOI: 10.1080/17474086.2020.1758058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Acute myeloid leukemia (AML) is a disease mainly seen in the elderly, for which treatment is undergoing rapid changes. Although recent studies have supported the survival benefit of induction chemotherapy in fit patients and that of hypomethylating agents (HMAs) in non-induction candidates, treatment of this patient age population remains a significant challenge for the treating oncologist. AREAS COVERED In this review, we will examine effectiveness and safety outcomes of upcoming novel treatment strategies in elderly (≥60 years old) patients with AML, highlight the current literature and ongoing trials able to maximize therapeutic options in this heterogeneous patient population. EXPERT OPINION Current developments including new chemotherapeutic strategies and combinations of HMAs with novel drugs targeting epigenetic or immunomodulatory pathways are underway to improve patient survival and quality of life.
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Affiliation(s)
- Xavier Thomas
- Hospices Civils de Lyon, Hematology Department, Lyon-Sud University Hospital , Pierre Bénite, France
| | - Mohamed Elhamri
- Hospices Civils de Lyon, Hematology Department, Lyon-Sud University Hospital , Pierre Bénite, France
| | - Maël Heiblig
- Hospices Civils de Lyon, Hematology Department, Lyon-Sud University Hospital , Pierre Bénite, France
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25
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Wang Y, Zhang L, Tang X, Luo J, Tu Z, Jiang K, Ren X, Xu F, Chan S, Li Y, Zhang Z, Ding K. GZD824 as a FLT3, FGFR1 and PDGFRα Inhibitor Against Leukemia In Vitro and In Vivo. Transl Oncol 2020; 13:100766. [PMID: 32247263 PMCID: PMC7125355 DOI: 10.1016/j.tranon.2020.100766] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/16/2020] [Indexed: 11/28/2022] Open
Abstract
GZD824 is a novel third-generation BCR-ABL inhibitor. It entered Phase II clinical trials in China and Phase Ib clinical trials in USA in 2019 for treatment of patients with resistant chronic myeloid leukemia (CML). We found that at concentrations below 10 nM, GZD824 significantly suppresses FLT3, FGFR1 and PDGFRα kinase activities and inhibits their signal pathways in MV4-11Flt3-ITD, KG-1FGFR1OP2-FGFR1 and EOL-1FIP1L1-PDGFRa leukemia cells. It selectively inhibits the growth of MV4-11Flt3-ITD, KG-1FGFR1OP2-FGFR1 and EOL-1FIP1L1-PDGFRa cells, and also effectively suppresses the growth of Ba/F3-FLT3-ITD cells harboring F691I and other mutations with IC50 values <10 nM. GZD824 induces G0/G1 phase arrest and apoptosis in MV4-11, KG-1 and EOL-1 cells and activates cleavage of caspase-3 and PARP. In MV4-11, Ba/F3-ITD-F691I and KG-1 mouse xenograft models, GZD824 at 10 or 20 mg/kg, q2d, p.o. almost completely eradicates tumors. It also inhibits the viability of primary leukemic blasts from a FLT3-ITD positive AML patient but not those expressing native FLT3. Thus GZD824 suppresses leukemia cells of FLT3-ITD-driven AML and other hematologic malignancies driven by FGFR1 or PDGFRa, and it may be considered to be a novel agent for the treatment of leukemia.
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Affiliation(s)
- Yuting Wang
- International Cooperative Laboratory of Traditional Chinese Medicine Modernization and Innovative Drug Development of Chinese Ministry of Education (MOE), Guangzhou City Key Laboratory of Precision Chemical Drug Development, School of Pharmacy, Jinan University, 601 Huangpu Avenue West, Guangzhou 510632, China
| | - Lenghe Zhang
- Department of Hematology, Zhujiang Hospital, Southern Medical University, No. 253 GongYeDaDaoZhong, Guangzhou, Guangdong, 510280, China
| | - Xia Tang
- International Cooperative Laboratory of Traditional Chinese Medicine Modernization and Innovative Drug Development of Chinese Ministry of Education (MOE), Guangzhou City Key Laboratory of Precision Chemical Drug Development, School of Pharmacy, Jinan University, 601 Huangpu Avenue West, Guangzhou 510632, China
| | - Jinfeng Luo
- Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, 190 Kaiyuan Avenue, Guangzhou Science Park, Guangzhou 510530, China
| | - Zhengchao Tu
- Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, 190 Kaiyuan Avenue, Guangzhou Science Park, Guangzhou 510530, China
| | - Kaili Jiang
- International Cooperative Laboratory of Traditional Chinese Medicine Modernization and Innovative Drug Development of Chinese Ministry of Education (MOE), Guangzhou City Key Laboratory of Precision Chemical Drug Development, School of Pharmacy, Jinan University, 601 Huangpu Avenue West, Guangzhou 510632, China
| | - Xiaomei Ren
- International Cooperative Laboratory of Traditional Chinese Medicine Modernization and Innovative Drug Development of Chinese Ministry of Education (MOE), Guangzhou City Key Laboratory of Precision Chemical Drug Development, School of Pharmacy, Jinan University, 601 Huangpu Avenue West, Guangzhou 510632, China
| | - Fang Xu
- International Cooperative Laboratory of Traditional Chinese Medicine Modernization and Innovative Drug Development of Chinese Ministry of Education (MOE), Guangzhou City Key Laboratory of Precision Chemical Drug Development, School of Pharmacy, Jinan University, 601 Huangpu Avenue West, Guangzhou 510632, China
| | - Shingpan Chan
- International Cooperative Laboratory of Traditional Chinese Medicine Modernization and Innovative Drug Development of Chinese Ministry of Education (MOE), Guangzhou City Key Laboratory of Precision Chemical Drug Development, School of Pharmacy, Jinan University, 601 Huangpu Avenue West, Guangzhou 510632, China
| | - Yuhua Li
- Department of Hematology, Zhujiang Hospital, Southern Medical University, No. 253 GongYeDaDaoZhong, Guangzhou, Guangdong, 510280, China.
| | - Zhang Zhang
- International Cooperative Laboratory of Traditional Chinese Medicine Modernization and Innovative Drug Development of Chinese Ministry of Education (MOE), Guangzhou City Key Laboratory of Precision Chemical Drug Development, School of Pharmacy, Jinan University, 601 Huangpu Avenue West, Guangzhou 510632, China.
| | - Ke Ding
- International Cooperative Laboratory of Traditional Chinese Medicine Modernization and Innovative Drug Development of Chinese Ministry of Education (MOE), Guangzhou City Key Laboratory of Precision Chemical Drug Development, School of Pharmacy, Jinan University, 601 Huangpu Avenue West, Guangzhou 510632, China.
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26
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Sellmer A, Pilsl B, Beyer M, Pongratz H, Wirth L, Elz S, Dove S, Henninger SJ, Spiekermann K, Polzer H, Klaeger S, Kuster B, Böhmer FD, Fiebig HH, Krämer OH, Mahboobi S. A series of novel aryl-methanone derivatives as inhibitors of FMS-like tyrosine kinase 3 (FLT3) in FLT3-ITD-positive acute myeloid leukemia. Eur J Med Chem 2020; 193:112232. [PMID: 32199135 DOI: 10.1016/j.ejmech.2020.112232] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 02/06/2023]
Abstract
Mutants of the FLT3 receptor tyrosine kinase (RTK) with duplications in the juxtamembrane domain (FLT3-ITD) act as drivers of acute myeloid leukemia (AML). Potent tyrosine kinase inhibitors (TKi) of FLT3-ITD entered clinical trials and showed a promising, but transient success due to the occurrence of secondary drug-resistant AML clones. A further caveat of drugs targeting FLT3-ITD is the co-targeting of other RTKs which are required for normal hematopoiesis. This is observed quite frequently. Therefore, novel drugs are necessary to treat AML effectively and safely. Recently bis(1H-indol-2-yl)methanones were found to inhibit FLT3 and PDGFR kinases. In order to optimize these agents we synthesized novel derivatives of these methanones with various substituents. Methanone 16 and its carbamate derivative 17b inhibit FLT3-ITD at least as potently as the TKi AC220 (quizartinib). Models indicate corresponding interactions of 16 and quizartinib with FLT3. The activity of 16 is accompanied by a high selectivity for FLT3-ITD.
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Affiliation(s)
- Andreas Sellmer
- Institute of Pharmacy, Faculty of Chemistry and Pharmacy, University of Regensburg, 93040, Regensburg, Germany
| | - Bernadette Pilsl
- Institute of Pharmacy, Faculty of Chemistry and Pharmacy, University of Regensburg, 93040, Regensburg, Germany
| | - Mandy Beyer
- Department of Toxicology, University Medical Center, Mainz, Germany
| | - Herwig Pongratz
- Institute of Pharmacy, Faculty of Chemistry and Pharmacy, University of Regensburg, 93040, Regensburg, Germany
| | - Lukas Wirth
- Institute of Pharmacy, Faculty of Chemistry and Pharmacy, University of Regensburg, 93040, Regensburg, Germany
| | - Sigurd Elz
- Institute of Pharmacy, Faculty of Chemistry and Pharmacy, University of Regensburg, 93040, Regensburg, Germany
| | - Stefan Dove
- Institute of Pharmacy, Faculty of Chemistry and Pharmacy, University of Regensburg, 93040, Regensburg, Germany
| | | | | | - Harald Polzer
- Department of Medicine III, University Hospital, LMU Munich, Germany
| | - Susan Klaeger
- Technische Universität München, Wissenschaftszentrum Weihenstephan für Ernährung, Landnutzung und Umwelt, Germany
| | - Bernhard Kuster
- Technische Universität München, Wissenschaftszentrum Weihenstephan für Ernährung, Landnutzung und Umwelt, Germany
| | - Frank D Böhmer
- Universitätsklinikum Jena - Bachstrasse 18 - D-07743 Jena, Germany
| | | | - Oliver H Krämer
- Department of Toxicology, University Medical Center, Mainz, Germany
| | - Siavosh Mahboobi
- Institute of Pharmacy, Faculty of Chemistry and Pharmacy, University of Regensburg, 93040, Regensburg, Germany.
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27
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Lam SS, Leung AY. Overcoming Resistance to FLT3 Inhibitors in the Treatment of FLT3-Mutated AML. Int J Mol Sci 2020; 21:E1537. [PMID: 32102366 PMCID: PMC7073218 DOI: 10.3390/ijms21041537] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 02/21/2020] [Accepted: 02/21/2020] [Indexed: 01/13/2023] Open
Abstract
Acute myeloid leukaemia (AML) carrying internal tandem duplication (ITD) of Fms-Like Tyrosine kinase 3 (FLT3) gene is associated with high risk of relapse and poor clinical outcome upon treatment with conventional chemotherapy. FLT3 inhibitors have been approved for the treatment of this AML subtype but leukaemia relapse remains to be a major cause of treatment failure. Mechanisms of drug resistance have been proposed, including evolution of resistant leukaemic clones; adaptive cellular mechanisms and a protective leukaemic microenvironment. These models have provided important leads that may inform design of clinical trials. Clinically, FLT3 inhibitors in combination with conventional chemotherapy as induction treatment for fit patients; with low-intensity treatment as salvage treatment or induction for unfit patients as well as maintenance treatment with FLT3 inhibitors post HSCT hold promise to improve survival in this AML subtype.
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Affiliation(s)
| | - Anskar Y.H. Leung
- Division of Haematology, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China;
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28
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Palve V, Liao Y, Remsing Rix LL, Rix U. Turning liabilities into opportunities: Off-target based drug repurposing in cancer. Semin Cancer Biol 2020; 68:209-229. [PMID: 32044472 DOI: 10.1016/j.semcancer.2020.02.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/29/2020] [Accepted: 02/03/2020] [Indexed: 12/12/2022]
Abstract
Targeted drugs and precision medicine have transformed the landscape of cancer therapy and significantly improved patient outcomes in many cases. However, as therapies are becoming more and more tailored to smaller patient populations and acquired resistance is limiting the duration of clinical responses, there is an ever increasing demand for new drugs, which is not easily met considering steadily rising drug attrition rates and development costs. Considering these challenges drug repurposing is an attractive complementary approach to traditional drug discovery that can satisfy some of these needs. This is facilitated by the fact that most targeted drugs, despite their implicit connotation, are not singularly specific, but rather display a wide spectrum of target selectivity. Importantly, some of the unintended drug "off-targets" are known anticancer targets in their own right. Others are becoming recognized as such in the process of elucidating off-target mechanisms that in fact are responsible for a drug's anticancer activity, thereby revealing potentially new cancer vulnerabilities. Harnessing such beneficial off-target effects can therefore lead to novel and promising precision medicine approaches. Here, we will discuss experimental and computational methods that are employed to specifically develop single target and network-based off-target repurposing strategies, for instance with drug combinations or polypharmacology drugs. By illustrating concrete examples that have led to clinical translation we will furthermore examine the various scientific and non-scientific factors that cumulatively determine the success of these efforts and thus can inform the future development of new and potentially lifesaving off-target based drug repurposing strategies for cancers that constitute important unmet medical needs.
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Affiliation(s)
- Vinayak Palve
- Department of Drug Discovery, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, 33612, USA
| | - Yi Liao
- Department of Drug Discovery, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, 33612, USA
| | - Lily L Remsing Rix
- Department of Drug Discovery, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, 33612, USA
| | - Uwe Rix
- Department of Drug Discovery, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, 33612, USA.
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29
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Georgoulia PS, Bjelic S, Friedman R. Deciphering the molecular mechanism of FLT3 resistance mutations. FEBS J 2020; 287:3200-3220. [PMID: 31943770 DOI: 10.1111/febs.15209] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 09/13/2019] [Accepted: 01/09/2020] [Indexed: 12/18/2022]
Abstract
FMS-like tyrosine kinase 3 (FLT3) has been found to be mutated in ~ 30% of acute myeloid leukaemia patients. Small-molecule inhibitors targeting FLT3 that are currently approved or still undergoing clinical trials are subject to drug resistance due to FLT3 mutations. How these mutations lead to drug resistance is hitherto poorly understood. Herein, we studied the molecular mechanism of the drug resistance mutations D835N, Y842S and M664I, which confer resistance against the most advanced inhibitors, quizartinib and PLX3397 (pexidartinib), using enzyme kinetics and computer simulations. In vitro kinase assays were performed to measure the comparative catalytic activity of the native protein and the mutants, using a bacterial expression system developed to this aim. Our results reveal that the differential drug sensitivity profiles can be rationalised by the dynamics of the protein-drug interactions and perturbation of the intraprotein contacts upon mutations. Drug binding induced a single conformation in the native protein, whereas multiple conformations were observed otherwise (in the mutants or in the absence of drugs). The end-point kinetics measurements indicated that the three resistant mutants conferred catalytic activity that is at least as high as that of the reference without such mutations. Overall, our calculations and measurements suggest that the structural dynamics of the drug-resistant mutants that affect the active state and the increased conformational freedom of the remaining inactive drug-bound population are the two major factors that contribute to drug resistance in FLT3 harbouring cancer cells. Our results explain the mechanism of drug resistance mutations and can aid to the design of more effective tyrosine kinase inhibitors.
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Affiliation(s)
| | - Sinisa Bjelic
- Department of Chemistry and Biomedical Sciences, Linnaeus University, Kalmar, Sweden
| | - Ran Friedman
- Department of Chemistry and Biomedical Sciences, Linnaeus University, Kalmar, Sweden
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30
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Zhang D, Liu Y, Luo Z, Chen Y, Xu A, Liang Y, Wu B, Tong X, Liu X, Shen H, Liu L, Wei Y, Zhou H, Liu Y, Zhou F. The novel thioredoxin reductase inhibitor A-Z2 triggers intrinsic apoptosis and shows efficacy in the treatment of acute myeloid leukemia. Free Radic Biol Med 2020; 146:275-286. [PMID: 31730934 DOI: 10.1016/j.freeradbiomed.2019.11.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 11/10/2019] [Indexed: 11/24/2022]
Abstract
Chemoresistance and high incidence of relapse in acute myeloid leukemia (AML) patients are associated with thioredoxin (Trx) overexpression. Thus, targeting the Trx system has emerged as a promising approach to treating AML. Both arsenicals and azelaic acid (AZA) are thioredoxin reductase (TrxR) inhibitors and possess antileukemic effects. In this study, to exploit agents with higher potency and lower toxicity, we got some organic arsenicals and further synthesized a series of targeted compounds by binding AZA to organic arsenicals, and then screened the most effective one, N-(4-(1, 3, 2-dithiarsinan-2-yl) phenyl)-azelamide (A-Z2). A-Z2 showed a stronger inhibitory effect against TrxR activity and in AML cell lines than did AZA or arsenicals. Additionally, A-Z2 was less toxic to healthy cells compared with traditional chemotherapeutic drugs. A-Z2 induces apoptosis by collapsing of mitochondrial membrane potential, reducing ATP level, releasing of cytochrome c and TNF-α, activating of caspase 9, 8 and 3. Analysis of the mechanism revealed that A-Z2 activates the intrinsic apoptotic pathway by directly selectively targeting TrxR/Trx and indirectly inhibiting NF-κB. A-Z2's better efficacy and safety profile against arsenicals and azelaic acid were also evident in vivo. A-Z2 had better plasma stability and biological activity in rats. A-Z2-treated mice displayed significant symptom relief and prolonged survival in a patient-derived xenograft (PDX) AML model. Herein, our study provides a novel antitumor candidate and approach for treating AML.
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Affiliation(s)
- Dongdong Zhang
- Department of Hematology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan, 4300071, Hubei Province, China
| | - Yujiao Liu
- State Key Laboratory of Virology, College of Chemistry and Molecular Sciences, Wuhan University, Wuhan, 430072, China
| | - Ziyi Luo
- Department of Hematology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan, 4300071, Hubei Province, China
| | - Yanling Chen
- Department of Hematology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan, 4300071, Hubei Province, China
| | - Anjie Xu
- Department of Hematology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan, 4300071, Hubei Province, China
| | - Yuxing Liang
- Department of Hematology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan, 4300071, Hubei Province, China
| | - Balu Wu
- Department of Hematology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan, 4300071, Hubei Province, China
| | - Xiqin Tong
- Department of Hematology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan, 4300071, Hubei Province, China
| | - Xiaoyan Liu
- Department of Hematology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan, 4300071, Hubei Province, China
| | - Hui Shen
- Department of Hematology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan, 4300071, Hubei Province, China
| | - Li Liu
- Department of Hematology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan, 4300071, Hubei Province, China
| | - Yongchang Wei
- Department of Radiation and Medical Oncology, Zhongnan Hospital, Wuhan University, Wuhan, 430071, China
| | - Haibing Zhou
- State Key Laboratory of Virology, Wuhan University School of Pharmaceutical Sciences, Wuhan, 430071, China
| | - Yi Liu
- State Key Laboratory of Virology, College of Chemistry and Molecular Sciences, Wuhan University, Wuhan, 430072, China
| | - Fuling Zhou
- Department of Hematology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan, 4300071, Hubei Province, China.
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31
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Smith CC. The growing landscape of FLT3 inhibition in AML. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:539-547. [PMID: 31808872 PMCID: PMC6913436 DOI: 10.1182/hematology.2019000058] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Midostaurin and gilteritinib are FLT3 inhibitors that have been recently approved for use in FLT3-mutant acute myeloid leukemia (AML). These approved drugs represent a new standard of care for patients with FLT3 mutations in both the first-line and salvage settings. The success of midostaurin used in combination with induction chemotherapy has prompted exploration of newer, more potent and targeted inhibitors (including gilteritinib) in the first-line setting in combination with chemotherapy. At the same time, the success of gilteritinib and other newer FLT3 inhibitors as monotherapy in the salvage setting has been tempered by the development of resistance because of diverse mechanisms. Investigational strategies that incorporate FLT3 inhibitors in combination with hypomethylating agents and as maintenance therapy after allogeneic stem cell transplantation have shown promise. Other novel combination strategies are also undergoing clinical investigation. In this article, we review the current landscape of approved and investigational FLT3 inhibitors in AML, including the current standard of care and investigational strategies.
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Affiliation(s)
- Catherine C Smith
- Divsion of Hematology/Oncology, Department of Medicine, University of California, San Francisco, CA
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32
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Montesinos P, Bergua J, Infante J, Esteve J, Guimaraes JE, Sierra J, Sanz MÁ. Update on management and progress of novel therapeutics for R/R AML: an Iberian expert panel consensus. Ann Hematol 2019; 98:2467-2483. [PMID: 31667544 DOI: 10.1007/s00277-019-03820-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 10/08/2019] [Indexed: 12/19/2022]
Abstract
A significant proportion of adult patients with acute myeloid leukemia (AML) fail to achieve complete remission or will relapse later on after achieving it. Prognosis for relapsed or refractory (R/R) AML patients remains discouraging, with the main curative option still relying on hematopoietic stem cell transplant (HSCT) for those who are eligible. Beyond morphological bone marrow and peripheral blood assessment, evaluation of patient performance status and comorbidities, as well as genetic/molecular characterization, is crucial to make an accurate diagnosis and prognosis, which will be useful to select the most appropriate treatment. Emerging strategies are mainly focusing on the development of immune- and molecular-based approaches. Novel targeted therapies are generally well tolerated, potentially allowing them to be administered alone or in combination with classical chemotherapy agents. Enrolment in clinical trials should be considered first option for R/R AML patients, either as a bridge to HSCT or to benefit from novel therapies that eventually may prolong survival and improve quality of life. An Iberian expert panel has reviewed the recent advances in the management of R/R AML with the aim to develop updated evidence and expert opinion-based recommendations.
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Affiliation(s)
- Pau Montesinos
- Hematology Department, Hospital Universitari I Politècnic La Fe, Av. Fernando Abril Martorell, 106, 46026, Valencia, Spain. .,CIBERONC, Instituto de Salud Carlos III, Madrid, Spain.
| | - Juan Bergua
- Division of Hematology/Oncology, Hospital San Pedro Alcántara, Cáceres, Spain
| | - Joana Infante
- Serviço de Hematologia e Transplantação de Medula Óssea, Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, Lisbon, Portugal
| | - Jordi Esteve
- Department of Hematology, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - José Eduardo Guimaraes
- Serviço de Hematologia Clínica, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Jordi Sierra
- Hematology Department, Hospital de la Santa Creu i Sant Pau, IIB Sant Pau and Jose Carreras Leukemia Research Institutes, Autonomous University of Barcelona, Barcelona, Spain
| | - Miguel Ángel Sanz
- Hematology Department, Hospital Universitari I Politècnic La Fe, Av. Fernando Abril Martorell, 106, 46026, Valencia, Spain
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33
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34
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Heng H, Wang Z, Li H, Huang Y, Lan Q, Guo X, Zhang L, Zhi Y, Cai J, Qin T, Xiang L, Wang S, Chen Y, Lu T, Lu S. Combining structure- and property-based optimization to identify selective FLT3-ITD inhibitors with good antitumor efficacy in AML cell inoculated mouse xenograft model. Eur J Med Chem 2019; 176:248-267. [DOI: 10.1016/j.ejmech.2019.05.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/03/2019] [Accepted: 05/06/2019] [Indexed: 12/11/2022]
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35
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The mutational spectrum of FLT3 gene in acute lymphoblastic leukemia is different from acute myeloid leukemia. Cancer Gene Ther 2019; 27:81-88. [PMID: 31285539 DOI: 10.1038/s41417-019-0120-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 06/18/2019] [Accepted: 06/23/2019] [Indexed: 11/08/2022]
Abstract
Mutations in FMS-like tyrosine kinase 3 (FLT3) gene occur frequently in acute myeloid leukemia (AML) and are rare in acute lymphoblastic leukemia (ALL). We aimed to analyze the incidence and characteristics of FLT3 mutations in ALL. Amplicon-targeted next-generation sequencing of 58 genes was performed on 1571 patients (AML, n = 829; ALL, n = 742). FLT3 mutations were identified in 5.12% (38/742) of ALL patients. Four types of FLT3 mutations were disclosed, including internal tandem duplication (ITD), tyrosine kinase domain (TKD), juxtamembrane insertion and deletion (JM-INDEL), and juxtamembrane point mutation (JM-PM), which were respectively identified in 1.21, 1.89, 0.67, and 1.89% of patients. The incidence of FLT3-JM-PM (1.89 vs 0.48%, P = 0.009) and the proportion of TKD non-D835 mutations that accounted for the total TKD mutations (57.14 vs 18.18%, P = 0.013) were significantly higher in ALL when compared with AML. FLT3-JM-INDEL were mainly found in B-ALL. In addition, FLT3-JM-INDEL and FLT3-JM-PM were first reported in patients with B-ALL. Patients with FLT3 mutations besides of ITD and/or TKD had a potential response to tyrosine kinase inhibitors. We showed that the mutation spectrum of FLT3 gene in ALL is distinct from AML that will facilitated an in-depth understand of the pathogenesis and provide a guidance for treatment.
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36
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Clinical considerations for the use of FLT3 inhibitors in acute myeloid leukemia. Crit Rev Oncol Hematol 2019; 141:125-138. [PMID: 31279288 DOI: 10.1016/j.critrevonc.2019.06.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 05/22/2019] [Accepted: 06/21/2019] [Indexed: 12/18/2022] Open
Abstract
Internal tandem duplications and tyrosine kinase mutations in the fms-like tyrosine kinase 3 (FLT3) receptor can occur in acute myeloid leukemia (AML) and portend a poor prognosis. Midostaurin, a multikinase inhibitor that targets FLT3, demonstrated a survival benefit in FLT3-mutated AML in combination with front-line chemotherapy. Despite this advancement, the use of FLT3 inhibitors in clinical practice is complicated by significant drug-drug interactions and uncertainty about optimal timing, duration, and sequencing of therapy. As monotherapy, the utility of FLT3 inhibitors was initially limited by incomplete and transient clinical responses and the development of acquired resistance. This led to the development of more potent and selective FLT3 inhibitors designed to overcome common resistance mechanisms. One of these second generation FLT3 inhibitors, gilteritinib, is now FDA-approved for the treatment of relapsed or refractory AML. Now that multiple FLT3 inhibitors are commercially available, it is important to further delineate the role of these agents in the AML population. This review aims to provide a comprehensive overview of the role of FLT3 inhibitors in AML and apply the current literature to clinical practice.
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37
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Comprehensive structure-activity-relationship of azaindoles as highly potent FLT3 inhibitors. Bioorg Med Chem 2019; 27:692-699. [DOI: 10.1016/j.bmc.2019.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 01/08/2019] [Accepted: 01/10/2019] [Indexed: 12/13/2022]
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38
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Naganna N, Opoku-Temeng C, Choi EY, Larocque E, Chang ET, Carter-Cooper BA, Wang M, Torregrosa-Allen SE, Elzey BD, Lapidus RG, Sintim HO. Amino alkynylisoquinoline and alkynylnaphthyridine compounds potently inhibit acute myeloid leukemia proliferation in mice. EBioMedicine 2019; 40:231-239. [PMID: 30686755 PMCID: PMC6413339 DOI: 10.1016/j.ebiom.2019.01.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 01/02/2019] [Accepted: 01/07/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Acute myeloid leukemia (AML) remains one of the most lethal, rarely cured cancers, despite decades of active development of AML therapeutics. Currently, the 5-year survival of AML patients is about 30% and for elderly patients, the rate drops to <10%. About 30% of AML patients harbor an activating mutation in the tyrosine kinase domain (TKD) of Fms-Like Tyrosine kinase 3 (FLT3) or a FLT3 internal tandem duplication (FLT3-ITD). Inhibitors of FLT3, such as Rydapt that was recently approved by the FDA, have shown good initial response but patients often relapse due to secondary mutations in the FLT3 TKD, like D835Y and F691 L mutations. METHODS Alkynyl aminoisoquinoline and naphthyridine compounds were synthesized via Sonogashira coupling. The compounds were evaluated for their in vitro and in vivo effects on leukemia growth. FINDINGS The compounds inhibited FLT3 kinase activity at low nanomolar concentrations. The lead compound, HSN431, also inhibited Src kinase activity. The compounds potently inhibited the viability of MV4-11 and MOLM-14 AML cells with IC50 values <1 nM. Furthermore, the viability of drug-resistant AML cells harboring the D835Y and F691 L mutations were potently inhibited. In vivo efficacy studies in mice demonstrated that the compounds could drastically reduce AML proliferation in mice. INTERPRETATION Compounds that inhibit FLT3 and downstream targets like Src (for example HSN431) are good leads for development as anti-AML agents. FUND: Purdue University, Purdue Institute for Drug Discovery (PIDD), Purdue University Center for Cancer Research, Elks Foundation and NIH P30 CA023168.
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Affiliation(s)
- N Naganna
- Purdue Institute for Drug Discovery, West Lafayette, IN 47907, USA; Department of Chemistry, Purdue University, West Lafayette, IN 47907, USA
| | - Clement Opoku-Temeng
- Purdue Institute for Drug Discovery, West Lafayette, IN 47907, USA; Department of Chemistry, Purdue University, West Lafayette, IN 47907, USA; Graduate Program in Biochemistry, University of Maryland, College Park, MD 20742, USA
| | - Eun Yong Choi
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Elizabeth Larocque
- Purdue Institute for Drug Discovery, West Lafayette, IN 47907, USA; Department of Chemistry, Purdue University, West Lafayette, IN 47907, USA
| | | | | | - Modi Wang
- Purdue Institute for Drug Discovery, West Lafayette, IN 47907, USA; Department of Chemistry, Purdue University, West Lafayette, IN 47907, USA
| | | | - Bennett D Elzey
- Purdue University Center for Cancer Research, Purdue University, West Lafayette, IN 47907, USA; Department of Comparative Pathobiology, Purdue University, West Lafayette, IN 47907, USA
| | - Rena G Lapidus
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Herman O Sintim
- Purdue Institute for Drug Discovery, West Lafayette, IN 47907, USA; Department of Chemistry, Purdue University, West Lafayette, IN 47907, USA; Purdue University Center for Cancer Research, Purdue University, West Lafayette, IN 47907, USA.
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39
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Zhang H, Savage S, Schultz AR, Bottomly D, White L, Segerdell E, Wilmot B, McWeeney SK, Eide CA, Nechiporuk T, Carlos A, Henson R, Lin C, Searles R, Ho H, Lam YL, Sweat R, Follit C, Jain V, Lind E, Borthakur G, Garcia-Manero G, Ravandi F, Kantarjian HM, Cortes J, Collins R, Buelow DR, Baker SD, Druker BJ, Tyner JW. Clinical resistance to crenolanib in acute myeloid leukemia due to diverse molecular mechanisms. Nat Commun 2019; 10:244. [PMID: 30651561 PMCID: PMC6335421 DOI: 10.1038/s41467-018-08263-x] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 12/21/2018] [Indexed: 12/19/2022] Open
Abstract
FLT3 mutations are prevalent in AML patients and confer poor prognosis. Crenolanib, a potent type I pan-FLT3 inhibitor, is effective against both internal tandem duplications and resistance-conferring tyrosine kinase domain mutations. While crenolanib monotherapy has demonstrated clinical benefit in heavily pretreated relapsed/refractory AML patients, responses are transient and relapse eventually occurs. Here, to investigate the mechanisms of crenolanib resistance, we perform whole exome sequencing of AML patient samples before and after crenolanib treatment. Unlike other FLT3 inhibitors, crenolanib does not induce FLT3 secondary mutations, and mutations of the FLT3 gatekeeper residue are infrequent. Instead, mutations of NRAS and IDH2 arise, mostly as FLT3-independent subclones, while TET2 and IDH1 predominantly co-occur with FLT3-mutant clones and are enriched in crenolanib poor-responders. The remaining patients exhibit post-crenolanib expansion of mutations associated with epigenetic regulators, transcription factors, and cohesion factors, suggesting diverse genetic/epigenetic mechanisms of crenolanib resistance. Drug combinations in experimental models restore crenolanib sensitivity. FLT3 is commonly mutated in acute myeloid leukaemia and treatment with FLT3 inhibitors often ends with relapse. Here, the authors perform exome sequencing of samples from patients treated with the FLT3 inhibitor, crenolanib, to show that resistance occurs due to diverse molecular mechanisms, not primarily due to secondary FLT3 mutations.
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Affiliation(s)
- Haijiao Zhang
- Department of Cell, Developmental & Cancer Biology, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA.,Division of Hematology and Medical Oncology, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA
| | - Samantha Savage
- Department of Cell, Developmental & Cancer Biology, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA.,Division of Hematology and Medical Oncology, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA
| | - Anna Reister Schultz
- Department of Cell, Developmental & Cancer Biology, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA.,Division of Hematology and Medical Oncology, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA
| | - Daniel Bottomly
- Division of Bioinformatics and Computational Biology, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA
| | - Libbey White
- Division of Bioinformatics and Computational Biology, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA
| | - Erik Segerdell
- Division of Bioinformatics and Computational Biology, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA
| | - Beth Wilmot
- Division of Bioinformatics and Computational Biology, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA
| | - Shannon K McWeeney
- Division of Bioinformatics and Computational Biology, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA
| | - Christopher A Eide
- Division of Hematology and Medical Oncology, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA.,Howard Hughes Medical Institute, Portland, 97239, OR, USA
| | - Tamilla Nechiporuk
- Department of Cell, Developmental & Cancer Biology, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA.,Division of Hematology and Medical Oncology, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA
| | - Amy Carlos
- Integrated Genomics, Knight Cancer Institute, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA
| | - Rachel Henson
- Integrated Genomics, Knight Cancer Institute, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA
| | - Chenwei Lin
- Integrated Genomics, Knight Cancer Institute, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA
| | - Robert Searles
- Integrated Genomics, Knight Cancer Institute, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA
| | - Hoang Ho
- AROG Pharmaceuticals, Dallas, 75240, TX, USA
| | | | | | | | - Vinay Jain
- AROG Pharmaceuticals, Dallas, 75240, TX, USA
| | - Evan Lind
- Molecular Microbiology & Immunology, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA
| | - Gautam Borthakur
- The University of Texas MD Anderson Cancer Center, Houston, 77030, TX, USA
| | | | - Farhad Ravandi
- The University of Texas MD Anderson Cancer Center, Houston, 77030, TX, USA
| | - Hagop M Kantarjian
- The University of Texas MD Anderson Cancer Center, Houston, 77030, TX, USA
| | - Jorge Cortes
- The University of Texas MD Anderson Cancer Center, Houston, 77030, TX, USA
| | - Robert Collins
- University of Texas Southwestern Medical Center, Dallas, 75390, TX, USA
| | - Daelynn R Buelow
- The Ohio State University College of Pharmacy and Comprehensive Cancer Center, Columbus, 43210, OH, USA
| | - Sharyn D Baker
- The Ohio State University College of Pharmacy and Comprehensive Cancer Center, Columbus, 43210, OH, USA
| | - Brian J Druker
- Division of Hematology and Medical Oncology, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA.,Howard Hughes Medical Institute, Portland, 97239, OR, USA
| | - Jeffrey W Tyner
- Department of Cell, Developmental & Cancer Biology, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA. .,Division of Hematology and Medical Oncology, Oregon Health & Science University Knight Cancer Institute, Portland, 97239, OR, USA.
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Burslem GM, Song J, Chen X, Hines J, Crews CM. Enhancing Antiproliferative Activity and Selectivity of a FLT-3 Inhibitor by Proteolysis Targeting Chimera Conversion. J Am Chem Soc 2018; 140:16428-16432. [DOI: 10.1021/jacs.8b10320] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- George M. Burslem
- Department of Molecular, Cellular and Developmental Biology, Yale University, New Haven, Connecticut 06511, United States
| | - Jayoung Song
- Department of Molecular, Cellular and Developmental Biology, Yale University, New Haven, Connecticut 06511, United States
| | - Xin Chen
- Arvinas Inc., New Haven, Connecticut 06511, United States
| | - John Hines
- Department of Molecular, Cellular and Developmental Biology, Yale University, New Haven, Connecticut 06511, United States
| | - Craig M. Crews
- Department of Molecular, Cellular and Developmental Biology, Yale University, New Haven, Connecticut 06511, United States
- Departments of Chemistry and Pharmacology, Yale University, New Haven, Connecticut 06520, United States
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Recent Studies on Ponatinib in Cancers Other Than Chronic Myeloid Leukemia. Cancers (Basel) 2018; 10:cancers10110430. [PMID: 30423915 PMCID: PMC6267038 DOI: 10.3390/cancers10110430] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/24/2018] [Accepted: 11/07/2018] [Indexed: 02/08/2023] Open
Abstract
Ponatinib is a third line drug for the treatment of chronic myeloid leukemia patients, especially those that develop the gatekeeper mutation T315I, which is resistant to the first and the second line drugs imatinib, nilotinib, dasatinib and bosutinib. The compound was first identified as a pan Bcr-Abl and Src kinase inhibitor. Further studies have indicated that it is a multitargeted inhibitor that is active on FGFRs, RET, AKT, ERK1/2, KIT, MEKK2 and other kinases. For this reason, the compound has been evaluated on several cancers in which these kinases play important roles, including thyroid, breast, ovary and lung cancer, neuroblastoma, rhabdoid tumours and in myeloproliferative disorders. Ponatinib is also being tested in clinical trials to evaluate its activity in FLT3-ITD acute myelogenous leukemia, head and neck cancers, certain type of lung cancer, gastrointestinal stromal tumours and other malignancies. In this review we report the most recent preclinical and clinical studies on ponatinib in cancers other than CML, with the aim of giving a complete overview of this interesting compound.
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Thomas CM, Campbell P. FLT3 inhibitors in acute myeloid leukemia: Current and future. J Oncol Pharm Pract 2018; 25:163-171. [PMID: 30270754 DOI: 10.1177/1078155218802620] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
FMS-like tyrosine kinase 3 (FLT3) is a receptor tyrosine kinase that is responsible for the proliferation and survival of hematopoietic stem cells in acute myeloid leukemia. Although patients with FLT3 mutations have similar rates of remission following induction chemotherapy, relapse rates are significantly higher and patients with FLT3 mutations have significantly worse outcomes for overall survival and disease-free survival. Early FLT3 inhibitors, such as sorafenib, were non-selective and inhibited several tyrosine kinase receptors resulting in significant toxicity. The treatment of FLT3-positive acute myeloid leukemia has advanced recently with the development of a several FLT3-targeting agents that are either approved or in development. Midostaurin represents the first FDA-approved treatment targeted against FLT3, and there are several promising agents currently undergoing clinical trials. Although certain mutations confer resistance to earlier generation FLT3-targeted tyrosine kinase inhibitors, newer agents show activity in the presence of these mutations.
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Affiliation(s)
- Christan M Thomas
- Hematology/Oncology, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Peter Campbell
- Hematology/Oncology, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
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43
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Katayama K, Noguchi K, Sugimoto Y. Heat shock protein 90 inhibitors overcome the resistance to Fms-like tyrosine kinase 3 inhibitors in acute myeloid leukemia. Oncotarget 2018; 9:34240-34258. [PMID: 30344940 PMCID: PMC6188142 DOI: 10.18632/oncotarget.26045] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 08/17/2018] [Indexed: 11/25/2022] Open
Abstract
Internal tandem duplication (ITD) in Fms-like tyrosine kinase 3 (FLT3) is frequently observed in acute myeloid leukemia (AML). Quizartinib, gilteritinib, and midostaurin are inhibitors against FLT3-ITD that have good efficacy for FLT3-ITD-positive AML patients. Long-term administration leads to drug resistance through acquired tyrosine kinase domain (TKD) mutations in FLT3-ITD, such as N676K, F691L, D835V, and Y842C. Here, our screen to detect inhibitors capable of overcoming resistance to FLT3 inhibitors identified heat shock protein (HSP) 90 inhibitors as potential candidates. Although Ba/F3 cells expressing FLT3-ITD with TKD mutations (Ba/F3-ITD+N676K, Ba/F3-ITD+F691L, Ba/F3-ITD+D835V, and Ba/F3-ITD+Y842C) showed various resistance patterns to FLT3 inhibitors compared with Ba/F3-ITD cells that express FLT3-ITD lacking TKD mutations, they were more sensitive to HSP90 inhibitors than Ba/F3 cells. Notably, the Ba/F3-ITD+D835V cells were the most sensitive to HSP90 inhibitors. Treatment with HSP90 inhibitors downregulated FLT3 and its downstream signaling and induced G1 arrest followed by apoptosis in Ba/F3-ITD+N676K, Ba/F3-ITD+F691L, Ba/F3-ITD+Y842C, and especially Ba/F3-ITD+D835V cells at lower concentrations compared with Ba/F3-ITD cells. The downregulation of FLT3-ITD+D835V was caused by rapid proteolysis in autophagy. Similar results were also observed in the quizartinib-resistant MV4-11 cells, QR1 and QR2, which were established by culturing cells in the presence of quizartinib and harbored FLT3-ITD+D835H and FLT3-ITD+D835V, respectively, in a single allele. Interestingly, the efficacies of HSP90 inhibitors in QR cells are reversely correlated with that of quizartib, but not to gilteritinib and midostaurin. Collectively, HSP90 inhibitors are good candidates to overcome drug resistance in AML with various FLT3-ITD TKD mutations.
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Affiliation(s)
- Kazuhiro Katayama
- Division of Chemotherapy, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Kohji Noguchi
- Division of Chemotherapy, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Yoshikazu Sugimoto
- Division of Chemotherapy, Faculty of Pharmacy, Keio University, Tokyo, Japan
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Wang R, Li Y, Gong P, Gabrilove J, Waxman S, Jing Y. Arsenic Trioxide and Sorafenib Induce Synthetic Lethality of FLT3-ITD Acute Myeloid Leukemia Cells. Mol Cancer Ther 2018; 17:1871-1880. [PMID: 29959200 DOI: 10.1158/1535-7163.mct-17-0298] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 01/05/2018] [Accepted: 06/20/2018] [Indexed: 11/16/2022]
Abstract
Acute myeloid leukemia (AML) with Fms-related tyrosine kinase 3 internal tandem duplication (FLT3-ITD) mutation is notoriously hard to treat. We identified two drugs that together form an effective combination therapy against FLT3-ITD AML. One of the drugs, Sorafenib, an inhibitor of FLT3-ITD and other kinase activity, produces an impressive but short-lived remission in FLT3-ITD AML patients. The second, arsenic trioxide (ATO), at therapeutically achievable concentrations, reduces the level of FLT3-ITD and Mcl-1 proteins, and induces apoptosis in leukemic cell lines and in primary cells expressing FLT3-ITD. We linked this relative sensitivity to ATO to low levels of reduced glutathione. While producing proapoptotic effects, ATO treatment also has an unwanted effect whereby it causes the accumulation of the phosphorylated (inactive) form of glycogen synthase kinase 3β (GSK3β), a kinase necessary for apoptosis. When ATO is combined with Sorafenib, GSK3β is activated, Mcl-1 is further reduced, and proapoptotic proteins Bak and Bax are activated. Mice xenografted with FLT3-ITD MOLM13 cell line treated with the Sorafenib/ATO combination have significantly improved survival. This combination has potential to improve the therapeutic outcome of FLT3-ITD-targeted therapy of AML patients. Mol Cancer Ther; 17(9); 1871-80. ©2018 AACR.
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Affiliation(s)
- Rui Wang
- Division of Hematology/Oncology, Department of Medicine, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Ying Li
- Department of Pharmacology, Shenyang Pharmaceutical University, Shenyang, China
| | - Ping Gong
- Department of Pharmacology, Shenyang Pharmaceutical University, Shenyang, China
| | - Janice Gabrilove
- Division of Hematology/Oncology, Department of Medicine, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Samuel Waxman
- Division of Hematology/Oncology, Department of Medicine, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Yongkui Jing
- Division of Hematology/Oncology, Department of Medicine, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York City, New York. .,Department of Pharmacology, Shenyang Pharmaceutical University, Shenyang, China
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Weir MC, Shu ST, Patel RK, Hellwig S, Chen L, Tan L, Gray NS, Smithgall TE. Selective Inhibition of the Myeloid Src-Family Kinase Fgr Potently Suppresses AML Cell Growth in Vitro and in Vivo. ACS Chem Biol 2018; 13:1551-1559. [PMID: 29763550 DOI: 10.1021/acschembio.8b00154] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute myelogenous leukemia (AML) is the most common hematologic malignancy in adults and is often associated with constitutive tyrosine kinase signaling. These pathways involve the nonreceptor tyrosine kinases Fes, Syk, and the three Src-family kinases expressed in myeloid cells (Fgr, Hck, and Lyn). In this study, we report remarkable anti-AML efficacy of an N-phenylbenzamide kinase inhibitor, TL02-59. This compound potently suppressed the proliferation of bone marrow samples from 20 of 26 AML patients, with a striking correlation between inhibitor sensitivity and expression levels of the myeloid Src family kinases Fgr, Hck, and Lyn. No correlation was observed with Flt3 expression or mutational status, with the four most sensitive patient samples being wild-type for Flt3. Kinome-wide target specificity profiling coupled with in vitro kinase assays demonstrated a narrow overall target specificity profile for TL02-59, with picomolar potency against the myeloid Src-family member Fgr. In a mouse xenograft model of AML, oral administration of TL02-59 for 3 weeks at 10 mg/kg completely eliminated leukemic cells from the spleen and peripheral blood while significantly reducing bone marrow engraftment. These results identify Fgr as a previously unrecognized kinase inhibitor target in AML and TL02-59 as a possible lead compound for clinical development in AML cases that overexpress this kinase independent of Flt3 mutations.
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Affiliation(s)
- Mark C. Weir
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Sherry T. Shu
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Ravi K. Patel
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Sabine Hellwig
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Li Chen
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Li Tan
- Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School and Department of Cancer Biology, Dana-Farber Cancer Institute, 250 Longwood Avenue, Boston, Massachusetts 02115, United States
| | - Nathanael S. Gray
- Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School and Department of Cancer Biology, Dana-Farber Cancer Institute, 250 Longwood Avenue, Boston, Massachusetts 02115, United States
| | - Thomas E. Smithgall
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
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Abstract
Acute myeloid leukemia (AML) is one of the best studied malignancies, and significant progress has been made in understanding the clinical implications of its disease biology. Unfortunately, drug development has not kept pace, as the '7+3' induction regimen remains the standard of care for patients fit for intensive therapy 40 years after its first use. Temporal improvements in overall survival were mostly confined to younger patients and driven by improvements in supportive care and use of hematopoietic stem cell transplantation. Multiple forms of novel therapy are currently in clinical trials and are attempting to bring bench discoveries to the bedside to benefit patients. These novel therapies include improved chemotherapeutic agents, targeted molecular inhibitors, cell cycle regulators, pro-apoptotic agents, epigenetic modifiers, and metabolic therapies. Immunotherapies in the form of vaccines; naked, conjugated and bispecific monoclonal antibodies; cell-based therapy; and immune checkpoint inhibitors are also being evaluated in an effort to replicate the success seen in other malignancies. Herein, we review the scientific basis of these novel therapeutic approaches, summarize the currently available evidence, and look into the future of AML therapy by highlighting key clinical studies and the challenges the field continues to face.
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Tsitsipatis D, Jayavelu AK, Müller JP, Bauer R, Schmidt-Arras D, Mahboobi S, Schnöder TM, Heidel F, Böhmer FD. Synergistic killing of FLT3ITD-positive AML cells by combined inhibition of tyrosine-kinase activity and N-glycosylation. Oncotarget 2018; 8:26613-26624. [PMID: 28460451 PMCID: PMC5432283 DOI: 10.18632/oncotarget.15772] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 02/16/2017] [Indexed: 01/05/2023] Open
Abstract
Fms-like tyrosine kinase 3 (FLT3) with internal tandem duplications (ITD) is a major oncoprotein in acute myeloid leukemia (AML), and confers an unfavorable prognosis. Interference with FLT3ITD signaling is therefore pursued as a promising therapeutic strategy. In this study we show that abrogation of FLT3ITD glycoprotein maturation using low doses of the N-glycosylation inhibitor tunicamycin has anti-proliferative and pro-apoptotic effects on FLT3ITD-expressing human and murine cell lines. This effect is mediated in part by arresting FLT3ITD in an underglycosylated state and thereby attenuating FLT3ITD-driven AKT and ERK signaling. In addition, tunicamycin caused pronounced endoplasmatic reticulum stress and apoptosis through activation of protein kinase RNA-like endoplasmic reticulum kinase (PERK) and activation of the gene encoding CCAAT-enhancer-binding protein homologous protein (CHOP). PERK inhibition with a small molecule attenuated CHOP induction and partially rescued cells from apoptosis. Combination of tunicamycin with potent FLT3ITD kinase inhibitors caused synergistic cell killing, which was highly selective for cell lines and primary AML cells expressing FLT3ITD. Although tunicamycin is currently not a clinically applicable drug, we propose that mild inhibition of N-glycosylation may have therapeutic potential in combination with FLT3 kinase inhibitors for FLT3ITD-positive AML.
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Affiliation(s)
- Dimitrios Tsitsipatis
- Institute of Molecular Cell Biology, CMB, Jena University Hospital, Jena, Germany.,Current address: Institute of Nutrition, Department of Nutrigenomics, Friedrich-Schiller-University, Jena, Germany
| | - Ashok Kumar Jayavelu
- Institute of Molecular Cell Biology, CMB, Jena University Hospital, Jena, Germany.,Current address: Max-Planck Institute of Biochemistry, Department of Proteomics and Signal Transduction, Martinsried, Germany
| | - Jörg P Müller
- Institute of Molecular Cell Biology, CMB, Jena University Hospital, Jena, Germany
| | - Reinhard Bauer
- Institute of Molecular Cell Biology, CMB, Jena University Hospital, Jena, Germany
| | - Dirk Schmidt-Arras
- Institute of Biochemistry, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Siavosh Mahboobi
- Institute of Pharmacy, Faculty of Chemistry and Pharmacy, University of Regensburg, Regensburg, Germany
| | - Tina M Schnöder
- Innere Medizin II, Hämatologie und Onkologie, Universitätsklinikum Jena, Jena, Germany.,Leibniz Institute on Aging, Fritz-Lipmann-Institute, Jena, Germany
| | - Florian Heidel
- Innere Medizin II, Hämatologie und Onkologie, Universitätsklinikum Jena, Jena, Germany.,Leibniz Institute on Aging, Fritz-Lipmann-Institute, Jena, Germany
| | - Frank-D Böhmer
- Institute of Molecular Cell Biology, CMB, Jena University Hospital, Jena, Germany
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48
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A novel irreversible FLT3 inhibitor, FF-10101, shows excellent efficacy against AML cells with FLT3 mutations. Blood 2017; 131:426-438. [PMID: 29187377 DOI: 10.1182/blood-2017-05-786657] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 11/03/2017] [Indexed: 11/20/2022] Open
Abstract
An activating mutation of Fms-like tyrosine kinase 3 (FLT3) is the most frequent genetic alteration associated with poor prognosis in acute myeloid leukemia (AML). Although many FLT3 inhibitors have been clinically developed, no first-generation inhibitors have demonstrated clinical efficacy by monotherapy, due to poor pharmacokinetics or unfavorable safety profiles possibly associated with low selectivity against FLT3 kinase. Recently, a selective FLT3 inhibitor, quizartinib, demonstrated favorable outcomes in clinical studies. However, several resistant mutations emerged during the disease progression. To overcome these problems, we developed a novel FLT3 inhibitor, FF-10101, designed to possess selective and irreversible FLT3 inhibition. The co-crystal structure of FLT3 protein bound to FF-10101 revealed the formation of a covalent bond between FF-10101 and the cysteine residue at 695 of FLT3. The unique binding brought high selectivity and inhibitory activity against FLT3 kinase. FF-10101 showed potent growth inhibitory effects on human AML cell lines harboring FLT3 internal tandem duplication (FLT3-ITD), MOLM-13, MOLM-14, and MV4-11, and all tested types of mutant FLT3-expressing 32D cells including quizartinib-resistant mutations at D835, Y842, and F691 residues in the FLT3 kinase domain. In mouse subcutaneous implantation models, orally administered FF-10101 showed significant growth inhibitory effect on FLT3-ITD-D835Y- and FLT3-ITD-F691L-expressing 32D cells. Furthermore, FF-10101 potently inhibited growth of primary AML cells harboring either FLT3-ITD or FLT3-D835 mutation in vitro and in vivo. These results indicate that FF-10101 is a promising agent for the treatment of patients with AML with FLT3 mutations, including the activation loop mutations clinically identified as quizartinib-resistant mutations.
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49
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Gallogly MM, Perl AE, Lazarus HM. Midostaurin and emerging FLT3 inhibitors for the treatment of adults with newly diagnosed acute myeloid leukemia with the FLT3 mutation. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2017. [DOI: 10.1080/23808993.2017.1406798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Molly M. Gallogly
- University Hospitals Cleveland Medical Center, Department of Medicine, Division of Hematology and Oncology, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Alexander E. Perl
- University of Pennsylvania, Division of Hematology Oncology, Perelman Center for Advanced Medicine, Philadelphia, PA, USA
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50
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