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Jen WY, Kantarjian H, Kadia TM, DiNardo CD, Issa GC, Short NJ, Yilmaz M, Borthakur G, Ravandi F, Daver NG. Combination therapy with novel agents for acute myeloid leukaemia: Insights into treatment of a heterogenous disease. Br J Haematol 2024; 205:30-47. [PMID: 38724457 DOI: 10.1111/bjh.19519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/27/2024] [Indexed: 07/13/2024]
Abstract
The treatment landscape of acute myeloid leukaemia (AML) is evolving rapidly. Venetoclax in combination with intensive chemotherapy or doublets or triplets with targeted or immune therapies is the focus of numerous ongoing trials. The development of mutation-targeted therapies has greatly enhanced the treatment armamentarium, with FLT3 inhibitors and isocitrate dehydrogenase inhibitors improving outcomes in frontline and relapsed/refractory (RR) AML, and menin inhibitors showing efficacy in RR NPM1mut and KMT2A-rearranged AML. With so many new drugs approved, the number of potential combinatorial approaches to leverage the maximal benefit of these agents has increased dramatically, while at the same time introducing clinical challenges, such as key preclinical and clinical data supporting the development of combinatorial therapy, how to optimally combine or sequence these novel agents, how to optimise dose and duration to maintain safety while enhancing efficacy, the optimal duration of therapy and the role of measurable residual disease in decision-making in both intensive and low-intensity therapy settings. In this review, we will outline the evidence leading to the approval of key agents in AML, their on-label current approvals and how they may be optimally combined in a safe and deliverable fashion to further improve outcomes in AML.
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Affiliation(s)
- Wei-Ying Jen
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ghayas C Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Lap CJ, Abrahim MS, Nassereddine S. Perspectives and challenges of small molecule inhibitor therapy for FLT3-mutated acute myeloid leukemia. Ann Hematol 2024; 103:2215-2229. [PMID: 37975931 DOI: 10.1007/s00277-023-05545-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
Acute myeloid leukemia (AML) is a heterogeneous clonal disease characterized overall by an aggressive clinical course. The underlying genetic abnormalities present in leukemic cells contribute significantly to the AML phenotype. Mutations in FMS-like tyrosine kinase 3 (FLT3) are one of the most common genetic abnormalities identified in AML, and the presence of these mutations strongly influences disease presentation and negatively impacts prognosis. Since mutations in FLT3 were identified in AML, they have been recognized as a valid therapeutic target resulting in decades of research to develop effective small molecule inhibitor treatment that could improve outcome for these patients. Despite the approval of several FLT3 inhibitors over the last couple of years, the treatment of patients with FLT3-mutated AML remains challenging and many questions still need to be addressed. This review will provide an up-to-date overview of our current understanding of FLT3-mutated AML and discuss what the current status is of the available FLT3 inhibitors for the day-to-day management of this aggressive disease.
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Affiliation(s)
- Coen J Lap
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Marwa Sh Abrahim
- The George Washington Cancer Center, George Washington University, Washington, DC, USA
| | - Samah Nassereddine
- The George Washington Cancer Center, George Washington University, Washington, DC, USA.
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Bruzzese A, Vigna E, Martino EA, Labanca C, Mendicino F, Lucia E, Olivito V, Stanzione G, Zimbo A, Lugli E, Neri A, Morabito F, Gentile M. The potential of triplet combination therapies for patients with FLT3-ITD -mutated acute myeloid leukemia. Expert Rev Hematol 2024; 17:241-253. [PMID: 38748404 DOI: 10.1080/17474086.2024.2356258] [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: 01/28/2024] [Accepted: 05/13/2024] [Indexed: 05/21/2024]
Abstract
INTRODUCTION Acute myeloid leukemia (AML) encompasses a heterogeneous group of aggressive myeloid malignancies, where FMS-like tyrosine kinase 3 (FLT3) mutations are prevalent, accounting for approximately 25-30% of adult patients. The presence of this mutation is related to a dismal prognosis and high relapse rates. In the lasts years many FLT3 inhibitors have been developed. AREAS COVERED This review provides a comprehensive overview of FLT3mut AML, summarizing the state of art of current treatment and available data about combination strategies including an FLT3 inhibitor. EXPERT OPINION In addition, the review discusses the emergence of drug resistance and the need for a nuanced approaches in treating patients who are ineligible for or resistant to intensive chemotherapy. Specifically, it explores the historical context of FLT3 inhibitors (FLT3Is) and their impact on treatment outcomes, emphasizing the pivotal role of midostaurin, as well as gilteritinib and quizartinib, and providing detailed insights into ongoing trials exploring the safety and efficacy of novel triplet combinations involving FLT3Is in different AML settings.
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Affiliation(s)
| | - Ernesto Vigna
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | | | | | | | - Eugenio Lucia
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | | | - Gaia Stanzione
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
- Division of Hematology, Azienda Policlinico-S. Marco, University of Catania, Catania, Italy
| | - Annamaria Zimbo
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
- UOC Laboratorio Analisi Cliniche, Biomolecolari e Genetica, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | - Elisabetta Lugli
- Ematologia Azienda USL-IRCSS Reggio Emilia, Emilia-Romagna, Italy
| | - Antonino Neri
- Scientific Directorate IRCCS of Reggio Emilia, Emilia-Romagna, Reggio Emilia, Italy
| | | | - Massimo Gentile
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
- Department of Pharmacy, Health and Nutritional Science, University of Calabria, Rende, Italy
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4
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Tecik M, Adan A. Emerging DNA Methylome Targets in FLT3-ITD-Positive Acute Myeloid Leukemia: Combination Therapy with Clinically Approved FLT3 Inhibitors. Curr Treat Options Oncol 2024; 25:719-751. [PMID: 38696033 PMCID: PMC11222205 DOI: 10.1007/s11864-024-01202-7] [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] [Accepted: 04/01/2024] [Indexed: 07/04/2024]
Abstract
OPINION STATEMENT The internal tandem duplication (ITD) mutation of the FMS-like receptor tyrosine kinase 3 (FLT3-ITD) is the most common mutation observed in approximately 30% of acute myeloid leukemia (AML) patients. It represents poor prognosis due to continuous activation of downstream growth-promoting signaling pathways such as STAT5 and PI3K/AKT. Hence, FLT3 is considered an attractive druggable target; selective small FLT3 inhibitors (FLT3Is), such as midostaurin and quizartinib, have been clinically approved. However, patients possess generally poor remission rates and acquired resistance when FLT3I used alone. Various factors in patients could cause these adverse effects including altered epigenetic regulation, causing mainly abnormal gene expression patterns. Epigenetic modifications are required for hematopoietic stem cell (HSC) self-renewal and differentiation; however, critical driver mutations have been identified in genes controlling DNA methylation (such as DNMT3A, TET2, IDH1/2). These regulators cause leukemia pathogenesis and affect disease diagnosis and prognosis when they co-occur with FLT3-ITD mutation. Therefore, understanding the role of different epigenetic alterations in FLT3-ITD AML pathogenesis and how they modulate FLT3I's activity is important to rationalize combinational treatment approaches including FLT3Is and modulators of methylation regulators or pathways. Data from ongoing pre-clinical and clinical studies will further precisely define the potential use of epigenetic therapy together with FLT3Is especially after characterized patients' mutational status in terms of FLT3 and DNA methlome regulators.
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Affiliation(s)
- Melisa Tecik
- Bioengineering Program, Graduate School of Engineering and Science, Abdullah Gul University, Kayseri, Turkey
| | - Aysun Adan
- Department of Molecular Biology and Genetics, Faculty of Life and Natural Sciences, Abdullah Gul University, Kayseri, Turkey.
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Bhatia K, Sandhu V, Wong MH, Iyer P, Bhatt S. Therapeutic biomarkers in acute myeloid leukemia: functional and genomic approaches. Front Oncol 2024; 14:1275251. [PMID: 38410111 PMCID: PMC10894932 DOI: 10.3389/fonc.2024.1275251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/17/2024] [Indexed: 02/28/2024] Open
Abstract
Acute myeloid leukemia (AML) is clinically and genetically a heterogeneous disease characterized by clonal expansion of abnormal hematopoietic progenitors. Genomic approaches to precision medicine have been implemented to direct targeted therapy for subgroups of AML patients, for instance, IDH inhibitors for IDH1/2 mutated patients, and FLT3 inhibitors with FLT3 mutated patients. While next generation sequencing for genetic mutations has improved treatment outcomes, only a fraction of AML patients benefit due to the low prevalence of actionable targets. In recent years, the adoption of newer functional technologies for quantitative phenotypic analysis and patient-derived avatar models has strengthened the potential for generalized functional precision medicine approach. However, functional approach requires robust standardization for multiple variables such as functional parameters, time of drug exposure and drug concentration for making in vitro predictions. In this review, we first summarize genomic and functional therapeutic biomarkers adopted for AML therapy, followed by challenges associated with these approaches, and finally, the future strategies to enhance the implementation of precision medicine.
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Affiliation(s)
- Karanpreet Bhatia
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
| | - Vedant Sandhu
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
| | - Mei Hsuan Wong
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
| | - Prasad Iyer
- Children's Blood and Cancer Centre, KK Women's and Children's Hospital, Singapore, Singapore
- Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore
| | - Shruti Bhatt
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
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Kennedy VE, Smith CC. FLT3 targeting in the modern era: from clonal selection to combination therapies. Int J Hematol 2023:10.1007/s12185-023-03681-0. [PMID: 38112995 DOI: 10.1007/s12185-023-03681-0] [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: 06/21/2023] [Revised: 10/14/2023] [Accepted: 11/14/2023] [Indexed: 12/21/2023]
Abstract
Fms-like tyrosine kinase 3 (FLT3) is the most frequently mutated gene in acute myeloid leukemia (AML). Modern targeting of FLT3 with inhibitors has improved clinical outcomes and FLT3 inhibitors have been incorporated into the treatment of AML in all phases of the disease, including the upfront, relapsed/refractory and maintenance settings. This review will discuss the current understanding of FLT3 biology, the clinical use of FLT3 inhibitors, resistance mechanisms and emerging combination treatment strategies.
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Affiliation(s)
- Vanessa E Kennedy
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, 505 Parnassus Ave, Box 1270, San Francisco, CA, 94143, USA
| | - Catherine C Smith
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, 505 Parnassus Ave, Box 1270, San Francisco, CA, 94143, USA.
- Helen Diller Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA.
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7
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Eide CA, Kurtz SE, Kaempf A, Long N, Joshi SK, Nechiporuk T, Huang A, Dibb CA, Taylor A, Bottomly D, McWeeney SK, Minnier J, Lachowiez CA, Saultz JN, Swords RT, Agarwal A, Chang BH, Druker BJ, Tyner JW. Clinical Correlates of Venetoclax-Based Combination Sensitivities to Augment Acute Myeloid Leukemia Therapy. Blood Cancer Discov 2023; 4:452-467. [PMID: 37698624 PMCID: PMC10618724 DOI: 10.1158/2643-3230.bcd-23-0014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/17/2023] [Accepted: 09/06/2023] [Indexed: 09/13/2023] Open
Abstract
The BCL2 inhibitor venetoclax combined with the hypomethylating agent azacytidine shows significant clinical benefit in a subset of patients with acute myeloid leukemia (AML); however, resistance limits response and durability. We prospectively profiled the ex vivo activity of 25 venetoclax-inclusive combinations on primary AML patient samples to identify those with improved potency and synergy compared with venetoclax + azacytidine (Ven + azacytidine). Combination sensitivities correlated with tumor cell state to discern three patterns: primitive selectivity resembling Ven + azacytidine, monocytic selectivity, and broad efficacy independent of cell state. Incorporation of immunophenotype, mutation, and cytogenetic features further stratified combination sensitivity for distinct patient subtypes. We dissect the biology underlying the broad, cell state-independent efficacy for the combination of venetoclax plus the JAK1/2 inhibitor ruxolitinib. Together, these findings support opportunities for expanding the impact of venetoclax-based drug combinations in AML by leveraging clinical and molecular biomarkers associated with ex vivo responses. SIGNIFICANCE By mapping drug sensitivity data to clinical features and tumor cell state, we identify novel venetoclax combinations targeting patient subtypes who lack sensitivity to Ven + azacytidine. This provides a framework for a taxonomy of AML informed by readily available sets of clinical and genetic features obtained as part of standard care. See related commentary by Becker, p. 437 . This article is featured in Selected Articles from This Issue, p. 419.
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Affiliation(s)
- Christopher A. Eide
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Stephen E. Kurtz
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
- Division of Oncological Sciences, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Andy Kaempf
- Biostatistics Shared Resource, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Nicola Long
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Sunil Kumar Joshi
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Tamilla Nechiporuk
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Ariane Huang
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Charles A. Dibb
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Akosha Taylor
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Daniel Bottomly
- Division of Bioinformatics and Computational Biomedicine, Department of Medical Informatics and Clinical Epidemiology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Shannon K. McWeeney
- Division of Bioinformatics and Computational Biomedicine, Department of Medical Informatics and Clinical Epidemiology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Jessica Minnier
- Biostatistics Shared Resource, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Curtis A. Lachowiez
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Jennifer N. Saultz
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Ronan T. Swords
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Anupriya Agarwal
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Bill H. Chang
- Division of Pediatric Hematology and Oncology, Knight Cancer Institute, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, Oregon
| | - Brian J. Druker
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
- Division of Oncological Sciences, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Jeffrey W. Tyner
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
- Department of Cell, Developmental, and Cancer Biology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
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8
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Zimmer M, Kadia T. Approach to the Older Patient with Acute Myeloid Leukemia. Curr Oncol Rep 2023; 25:1203-1211. [PMID: 37688738 DOI: 10.1007/s11912-023-01450-0] [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] [Accepted: 08/04/2023] [Indexed: 09/11/2023]
Abstract
PURPOSE OF REVIEW This study aims to review the challenges of treating AML in older patients, the spectrum of genomic aberrancies in this cohort, and discuss treatment options for newly diagnosed AML in this patient population. RECENT FINDINGS Greater understanding of biological underpinnings of AML and availability of newer, effective, targeted therapies have allowed us to move away from intensification of chemotherapy, to prioritize better tolerability while still maintaining efficacy. Increasing knowledge of the genomic complexity and adverse karyotypes in older AML patients drives the need for ongoing investigations of targeted and lower-intensity therapies in the frontline, relapsed/refractory setting, and post-remission.
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Affiliation(s)
- Markie Zimmer
- Division of Hematology/Oncology, Henry Ford Health System, Detroit, MI, USA
| | - Tapan Kadia
- Department of Leukemia, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Box 428, Houston, TX, 77030, USA.
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Liberatore C, Di Ianni M. Novel Approaches to Treatment of Acute Myeloid Leukemia Relapse Post Allogeneic Stem Cell Transplantation. Int J Mol Sci 2023; 24:15019. [PMID: 37834466 PMCID: PMC10573608 DOI: 10.3390/ijms241915019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/05/2023] [Accepted: 10/07/2023] [Indexed: 10/15/2023] Open
Abstract
The management of patients with acute myeloid leukemia (AML) relapsed post allogeneic hematopoietic stem cell transplantation (HSCT) remains a clinical challenge. Intensive treatment approaches are limited by severe toxicities in the early post-transplantation period. Therefore, hypomethylating agents (HMAs) have become the standard therapeutic approach due to favorable tolerability. Moreover, HMAs serve as a backbone for additional anti-leukemic agents. Despite discordant results, the addition of donor lymphocytes infusions (DLI) generally granted improved outcomes with manageable GvHD incidence. The recent introduction of novel targeted drugs in AML gives the opportunity to add a third element to salvage regimens. Those patients harboring targetable mutations might benefit from IDH1/2 inhibitors Ivosidenib and Enasidenib as well as FLT3 inhibitors Sorafenib and Gilteritinib in combination with HMA and DLI. Conversely, patients lacking targetable mutations actually benefit from the addition of Venetoclax. A second HSCT remains a valid option, especially for fit patients and for those who achieve a complete disease response with salvage regimens. Overall, across studies, higher response rates and longer survival were observed in cases of pre-emptive intervention for molecular relapse. Future perspectives currently rely on the development of adoptive immunotherapeutic strategies mainly represented by CAR-T cells.
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Affiliation(s)
- Carmine Liberatore
- Hematology Unit, Department of Oncology and Hematology, Santo Spirito Hospital, 65124 Pescara, Italy;
| | - Mauro Di Ianni
- Hematology Unit, Department of Oncology and Hematology, Santo Spirito Hospital, 65124 Pescara, Italy;
- Department of Medicine and Sciences of Aging, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
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10
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Wang Q, Zhang N, Liu L, Ma L, Tan Y, Liu X, Wu J, Chen G, Li X, Liang Y, Zhou F. Comprehensive analysis of clinical prognostic features and tumor microenvironment landscape of CD11b +CD64 + patients with acute myeloid leukemia. Cell Oncol (Dordr) 2023; 46:1253-1268. [PMID: 37071330 DOI: 10.1007/s13402-023-00808-7] [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] [Accepted: 03/28/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Immunophenotyping surface molecules detected in the clinic are mainly applied in diagnostic confirmation and subtyping. However, the immunomodulatory molecules CD11b and CD64, are highly associated with leukemogenesis. Hence, the prognostic value of them and their potential biological functions merit further investigation. METHODS Flow cytometry was operated to detect immunophenotypic molecules from AML bone marrow samples. Multivariate cox regression, Kaplan-Meier analyses, and nomogram were conducted to predict survival. Transcriptomic data, lymphocyte subsets, and immunohistochemical staining were incorporated to identify potential biological functions of prognostic immunophenotype in acute myeloid leukemia (AML). RESULTS We classified 315 newly diagnosed AML patients of our center based on the expression of CD11b and CD64. The CD11b+CD64+ populations were identified as independent risk factors for overall survival and event-free survival of AML, exhibiting specific clinicopathological features. The predictive models based on CD11b+CD64+ showed high classification performance. In addition, the CD11b+CD64+ subset, characterized by high inhibitory immune checkpoints, M2-macrophage infiltration, low anti-tumor effector cells infiltration, as well as abnormal somatic mutation landscape, presented a distinctive tumor microenvironmental landscape. The CD11b+CD64+ population showd a higher expression of BCL2, and the drug sensitivity indicated that they presented a lower half-maximal inhibitory concentration value for BCL2 inhibitor, and could benefit more from the above medicine. CONCLUSIONS This work might be of benefit to enhanced understanding of CD11b+CD64+ in the prognosis and leukemogenesis, and yielded novel biomarkers to guide immunotherapy and targeted therapy for AML.
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Affiliation(s)
- Qian Wang
- Department of Hematology, Zhongnan Hospital of Wuhan University, No.169 Donghu Road, Wuhan, 430072, China
| | - Nan Zhang
- Department of Hematology, Zhongnan Hospital of Wuhan University, No.169 Donghu Road, Wuhan, 430072, China
| | - Li Liu
- Department of Hematology, Zhongnan Hospital of Wuhan University, No.169 Donghu Road, Wuhan, 430072, China
| | - Linlu Ma
- Department of Hematology, Zhongnan Hospital of Wuhan University, No.169 Donghu Road, Wuhan, 430072, China
| | - Yuxin Tan
- Department of Hematology, Zhongnan Hospital of Wuhan University, No.169 Donghu Road, Wuhan, 430072, China
| | - Xiaoyan Liu
- Department of Hematology, Zhongnan Hospital of Wuhan University, No.169 Donghu Road, Wuhan, 430072, China
| | - Jinxian Wu
- Department of Hematology, Zhongnan Hospital of Wuhan University, No.169 Donghu Road, Wuhan, 430072, China
| | - Guopeng Chen
- Department of Hematology, Zhongnan Hospital of Wuhan University, No.169 Donghu Road, Wuhan, 430072, China
| | - Xinqi Li
- Department of Hematology, Zhongnan Hospital of Wuhan University, No.169 Donghu Road, Wuhan, 430072, China
| | - Yuxing Liang
- Department of Hematology, Zhongnan Hospital of Wuhan University, No.169 Donghu Road, Wuhan, 430072, China
| | - Fuling Zhou
- Department of Hematology, Zhongnan Hospital of Wuhan University, No.169 Donghu Road, Wuhan, 430072, China.
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11
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Halpern AB, Rodríguez-Arbolí E, Othus M, Garcia KLA, Percival MEM, Cassaday RD, Oehler VG, Becker PS, Appelbaum JS, Abkowitz JL, Orozco JJ, Keel SB, Hendrie PC, Scott BL, Ghiuzeli MC, Estey EH, Walter RB. Phase 1/2 study of sorafenib added to cladribine, high-dose cytarabine, G-CSF, and mitoxantrone in untreated AML. Blood Adv 2023; 7:4950-4961. [PMID: 37339483 PMCID: PMC10463192 DOI: 10.1182/bloodadvances.2023010392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/22/2023] Open
Abstract
The multikinase inhibitor sorafenib improves event-free survival (EFS) when used with 7 + 3 in adults with newly-diagnosed acute myeloid leukemia (AML), irrespective of the FLT3-mutation status. Here, we evaluated adding sorafenib to cladribine, high-dose cytarabine, granulocyte colony-stimulating factor, and mitoxantrone (CLAG-M) in a phase 1/2 trial of 81 adults aged ≤60 years with newly diagnosed AML. Forty-six patients were treated in phase 1 with escalating doses of sorafenib and mitoxantrone. No maximum tolerated dose was reached, and a regimen including mitoxantrone 18 mg/m2 per day and sorafenib 400 mg twice daily was declared the recommended phase 2 dose (RP2D). Among 41 patients treated at RP2D, a measurable residual disease-negative complete remission (MRD- CR) rate of 83% was obtained. Four-week mortality was 2%. One-year overall survival (OS) and EFS were 80% and 76%, without differences in MRD- CR rates, OS, or EFS between patients with or without FLT3-mutated disease. Comparing outcomes using CLAG-M/sorafenib with those of a matched cohort of 76 patients treated with CLAG-M alone, multivariable-adjusted survival estimates were improved for 41 patients receiving CLAG-M/sorafenib at RP2D (OS: hazard ratio,0.24 [95% confidence interval, 0.07-0.82]; P = .023; EFS: hazard ratio, 0.16 [95% confidence interval, 0.05-0.53]; P = .003). Benefit was limited to patients with intermediate-risk disease (univariate analysis: P = .01 for OS; P = .02 for EFS). These data suggest that CLAG-M/sorafenib is safe and improves OS and EFS relative to CLAG-M alone, with benefits primarily in patients with intermediate-risk disease. The trial was registered at www.clinicaltrials.gov as #NCT02728050.
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Affiliation(s)
- Anna B. Halpern
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Eduardo Rodríguez-Arbolí
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
- Department of Hematology, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío, University of Seville, Seville, Spain
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA
| | | | - Mary-Elizabeth M. Percival
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Ryan D. Cassaday
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Vivian G. Oehler
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Pamela S. Becker
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Jacob S. Appelbaum
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
| | - Janis L. Abkowitz
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
| | - Johnnie J. Orozco
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA
| | - Siobán B. Keel
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
| | - Paul C. Hendrie
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
| | - Bart L. Scott
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA
| | - M. Cristina Ghiuzeli
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Elihu H. Estey
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Roland B. Walter
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
- Department of Laboratory Medicine & Pathology, University of Washington, Seattle, WA
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12
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Short NJ, Nguyen D, Ravandi F. Treatment of older adults with FLT3-mutated AML: Emerging paradigms and the role of frontline FLT3 inhibitors. Blood Cancer J 2023; 13:142. [PMID: 37696819 PMCID: PMC10495326 DOI: 10.1038/s41408-023-00911-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/09/2023] [Accepted: 08/24/2023] [Indexed: 09/13/2023] Open
Abstract
FLT3 is the most frequently mutated gene in acute myeloid leukemia (AML), with FLT3 internal tandem duplication (ITD) mutations being associated with a more aggressive clinical course. While two large, randomized clinical trials have shown a survival benefit with the frontline use of an oral FLT3 inhibitor (midostaurin or quizartinib) in patients with FLT3-mutated AML, the role of FLT3 inhibitors in older adults with newly diagnosed FLT3-mutated AML remains unclear. A definitive improvement in survival has not been observed in intensively treated patients over 60 years of age receiving frontline FLT3 inhibitors. Furthermore, many patients with FLT3-mutated AML are unsuitable for intensive chemotherapy due to age and/or comorbidities, and this population represents a particular unmet need. For these older patients who are unfit for intensive approaches, azacitidine + venetoclax is a new standard of care and is used by many clinicians irrespective of FLT3 mutation status. However, FLT3-ITD mutations confer resistance to venetoclax and are a well-established mechanism of relapse to lower-intensity venetoclax-based regimens, leading to short durations of remission and poor survival. Preclinical and clinical data suggest synergy between FLT3 inhibitors and venetoclax, providing rationale for their combination. Novel strategies to safely incorporate FLT3 inhibitors into the standard hypomethylating agent + venetoclax backbone are now being explored in this older, less fit population with newly diagnosed FLT3-mutated AML, with encouraging early results. Herein, we discuss the frontline use of FLT3 inhibitors in older adults with FLT3-mutated AML, including the potential role of FLT3 inhibitors in combination with intensive chemotherapy and as part of novel, lower-intensity doublet and triplet regimens in this older population.
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Affiliation(s)
- Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Daniel Nguyen
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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13
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Takahashi S. Combination Therapies with Kinase Inhibitors for Acute Myeloid Leukemia Treatment. Hematol Rep 2023; 15:331-346. [PMID: 37367084 DOI: 10.3390/hematolrep15020035] [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: 12/05/2022] [Revised: 03/10/2023] [Accepted: 05/19/2023] [Indexed: 06/28/2023] Open
Abstract
Targeting kinase activity is considered to be an attractive therapeutic strategy to overcome acute myeloid leukemia (AML) since aberrant activation of the kinase pathway plays a pivotal role in leukemogenesis through abnormal cell proliferation and differentiation block. Although clinical trials for kinase modulators as single agents remain scarce, combination therapies are an area of therapeutic interest. In this review, the author summarizes attractive kinase pathways for therapeutic targets and the combination strategies for these pathways. Specifically, the review focuses on combination therapies targeting the FLT3 pathways, as well as PI3K/AKT/mTOR, CDK and CHK1 pathways. From a literature review, combination therapies with the kinase inhibitors appear more promising than monotherapies with individual agents. Therefore, the development of efficient combination therapies with kinase inhibitors may result in effective therapeutic strategies for AML.
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Affiliation(s)
- Shinichiro Takahashi
- Division of Laboratory Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai 983-8536, Japan
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14
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Cuesta-Casanovas L, Delgado-Martínez J, Cornet-Masana JM, Carbó JM, Banús-Mulet A, Guijarro F, Esteve J, Risueño RM. Prolactin receptor signaling induces acquisition of chemoresistance and reduces clonogenicity in acute myeloid leukemia. Cancer Cell Int 2023; 23:97. [PMID: 37208719 DOI: 10.1186/s12935-023-02944-4] [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: 02/21/2023] [Accepted: 05/11/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Development of precision medicine requires the identification of easily detectable and druggable biomarkers. Despite recent targeted drug approvals, prognosis of acute myeloid leukemia (AML) patients needs to be greatly improved, as relapse and refractory disease are still difficult to manage. Thus, new therapeutic approaches are needed. Based on in silico-generated preliminary data and the literature, the role of the prolactin (PRL)-mediated signaling was interrogated in AML. METHODS Protein expression and cell viability were determined by flow cytometry. Repopulation capacity was studied in murine xenotransplantation assays. Gene expression was measured by qPCR and luciferase-reporters. SA-β-Gal staining was used as a senescence marker. RESULTS The prolactin receptor (PRLR) was upregulated in AML cells, as compared to their healthy counterpart. The genetic and molecular inhibition of this receptor reduced the colony-forming potential. Disruption of the PRLR signaling, either using a mutant PRL or a dominant-negative isoform of PRLR, reduced the leukemia burden in vivo, in xenotransplantation assays. The expression levels of PRLR directly correlated with resistance to cytarabine. Indeed, acquired cytarabine resistance was accompanied with the induction of PRLR surface expression. The signaling associated to PRLR in AML was mainly mediated by Stat5, in contrast to the residual function of Stat3. In concordance, Stat5 mRNA was significantly overexpressed at mRNA levels in relapse AML samples. A senescence-like phenotype, measured by SA-β-gal staining, was induced upon enforced expression of PRLR in AML cells, partially dependent on ATR. Similar to the previously described chemoresistance-induced senescence in AML, no cell cycle arrest was observed. Additionally, the therapeutic potential of PRLR in AML was genetically validated. CONCLUSIONS These results support the role of PRLR as a therapeutic target for AML and the further development of drug discovery programs searching for specific PRLR inhibitors.
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Affiliation(s)
- Laia Cuesta-Casanovas
- Josep Carreras Leukaemia Research Institute (IJC), Campus ICO-GTP, Crta Can Ruti, Camí de les Escoles, s/n, 08916, Badalona, Barcelona, Spain
- Faculty of Biosciences, Autonomous University of Barcelona, Barcelona, Spain
| | - Jennifer Delgado-Martínez
- Josep Carreras Leukaemia Research Institute (IJC), Campus ICO-GTP, Crta Can Ruti, Camí de les Escoles, s/n, 08916, Badalona, Barcelona, Spain
- Faculty of Pharmacy, University of Barcelona, Barcelona, Spain
| | - Josep M Cornet-Masana
- Josep Carreras Leukaemia Research Institute (IJC), Campus ICO-GTP, Crta Can Ruti, Camí de les Escoles, s/n, 08916, Badalona, Barcelona, Spain
| | - José M Carbó
- Josep Carreras Leukaemia Research Institute (IJC), Campus ICO-GTP, Crta Can Ruti, Camí de les Escoles, s/n, 08916, Badalona, Barcelona, Spain
| | - Antònia Banús-Mulet
- Josep Carreras Leukaemia Research Institute (IJC), Campus ICO-GTP, Crta Can Ruti, Camí de les Escoles, s/n, 08916, Badalona, Barcelona, Spain
| | - Francesca Guijarro
- Josep Carreras Leukaemia Research Institute (IJC), Campus ICO-GTP, Crta Can Ruti, Camí de les Escoles, s/n, 08916, Badalona, Barcelona, Spain
- Department of Hematology, Hospital Clínic, Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Jordi Esteve
- Josep Carreras Leukaemia Research Institute (IJC), Campus ICO-GTP, Crta Can Ruti, Camí de les Escoles, s/n, 08916, Badalona, Barcelona, Spain
- Department of Hematology, Hospital Clínic, Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ruth M Risueño
- Josep Carreras Leukaemia Research Institute (IJC), Campus ICO-GTP, Crta Can Ruti, Camí de les Escoles, s/n, 08916, Badalona, Barcelona, Spain.
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15
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Zhao Y, Tian Y, Pang X, Li G, Shi S, Yan A. Classification of FLT3 inhibitors and SAR analysis by machine learning methods. Mol Divers 2023:10.1007/s11030-023-10640-8. [PMID: 37142889 DOI: 10.1007/s11030-023-10640-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/17/2023] [Indexed: 05/06/2023]
Abstract
FMS-like tyrosine kinase 3 (FLT3) is a type III receptor tyrosine kinase, which is an important target for anti-cancer therapy. In this work, we conducted a structure-activity relationship (SAR) study on 3867 FLT3 inhibitors we collected. MACCS fingerprints, ECFP4 fingerprints, and TT fingerprints were used to represent the inhibitors in the dataset. A total of 36 classification models were built based on support vector machine (SVM), random forest (RF), eXtreme Gradient Boosting (XGBoost), and deep neural networks (DNN) algorithms. Model 3D_3 built by deep neural networks (DNN) and TT fingerprints performed best on the test set with the highest prediction accuracy of 85.83% and Matthews correlation coefficient (MCC) of 0.72 and also performed well on the external test set. In addition, we clustered 3867 inhibitors into 11 subsets by the K-Means algorithm to figure out the structural characteristics of the reported FLT3 inhibitors. Finally, we analyzed the SAR of FLT3 inhibitors by RF algorithm based on ECFP4 fingerprints. The results showed that 2-aminopyrimidine, 1-ethylpiperidine,2,4-bis(methylamino)pyrimidine, amino-aromatic heterocycle, [(2E)-but-2-enyl]dimethylamine, but-2-enyl, and alkynyl were typical fragments among highly active inhibitors. Besides, three scaffolds in Subset_A (Subset 4), Subset_B, and Subset_C showed a significant relationship to inhibition activity targeting FLT3.
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Affiliation(s)
- Yunyang Zhao
- State Key Laboratory of Chemical Resource Engineering, Department of Pharmaceutical Engineering, Beijing University of Chemical Technology, 15 BeiSanHuan East Road, P.O. Box 53, Beijing, 100029, People's Republic of China
| | - Yujia Tian
- State Key Laboratory of Chemical Resource Engineering, Department of Pharmaceutical Engineering, Beijing University of Chemical Technology, 15 BeiSanHuan East Road, P.O. Box 53, Beijing, 100029, People's Republic of China
| | - Xiaoyang Pang
- State Key Laboratory of Chemical Resource Engineering, Department of Pharmaceutical Engineering, Beijing University of Chemical Technology, 15 BeiSanHuan East Road, P.O. Box 53, Beijing, 100029, People's Republic of China
| | - Guo Li
- State Key Laboratory of Chemical Resource Engineering, Department of Pharmaceutical Engineering, Beijing University of Chemical Technology, 15 BeiSanHuan East Road, P.O. Box 53, Beijing, 100029, People's Republic of China
| | - Shenghui Shi
- College of Information Science and Technology, Beijing University of Chemical Technology, 15 BeiSanHuan East Road, Beijing, 100029, People's Republic of China.
| | - Aixia Yan
- State Key Laboratory of Chemical Resource Engineering, Department of Pharmaceutical Engineering, Beijing University of Chemical Technology, 15 BeiSanHuan East Road, P.O. Box 53, Beijing, 100029, People's Republic of China.
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16
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Bhansali RS, Pratz KW, Lai C. Recent advances in targeted therapies in acute myeloid leukemia. J Hematol Oncol 2023; 16:29. [PMID: 36966300 PMCID: PMC10039574 DOI: 10.1186/s13045-023-01424-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 03/14/2023] [Indexed: 03/27/2023] Open
Abstract
Acute myeloid leukemia (AML) is the most common acute leukemia in adults. While survival for younger patients over the last several decades has improved nearly sixfold with the optimization of intensive induction chemotherapy and allogeneic stem cell transplantation (alloHSCT), this effect has been largely mitigated in older and less fit patients as well as those with adverse-risk disease characteristics. However, the last 10 years has been marked by major advances in the molecular profiling of AML characterized by a deeper understanding of disease pathobiology and therapeutic vulnerabilities. In this regard, the classification of AML subtypes has recently evolved from a morphologic to a molecular and genetic basis, reflected by recent updates from the World Health Organization and the new International Consensus Classification system. After years of stagnation in new drug approvals for AML, there has been a rapid expansion of the armamentarium against this disease since 2017. Low-intensity induction therapy with hypomethylating agents and venetoclax has substantially improved outcomes, including in those previously considered to have a poor prognosis. Furthermore, targeted oral therapies against driver mutations in AML have been added to the repertoire. But with an accelerated increase in treatment options, several questions arise such as how to best sequence therapy, how to combine therapies, and if there is a role for maintenance therapy in those who achieve remission and cannot undergo alloHSCT. Moreover, certain subtypes of AML, such as those with TP53 mutations, still have dismal outcomes despite these recent advances, underscoring an ongoing unmet need and opportunity for translational advances. In this review, we will discuss recent updates in the classification and risk stratification of AML, explore the literature regarding low-intensity and novel oral combination therapies, and briefly highlight investigative agents currently in early clinical development for high-risk disease subtypes.
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Affiliation(s)
- Rahul S Bhansali
- Division of Hematology/Oncology, Department of Medicine, Hospital of the University of Pennsylvania, South Pavilion, 12th Floor, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Keith W Pratz
- Division of Hematology/Oncology, Department of Medicine, Hospital of the University of Pennsylvania, South Pavilion, 12th Floor, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Catherine Lai
- Division of Hematology/Oncology, Department of Medicine, Hospital of the University of Pennsylvania, South Pavilion, 12th Floor, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
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17
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Anderson NR, Sheth V, Li H, Harris MW, Qiu S, Crossman DK, Kumar H, Agarwal P, Nagasawa T, Paterson AJ, Welner RS, Bhatia R. Microenvironmental CXCL12 deletion enhances Flt3-ITD acute myeloid leukemia stem cell response to therapy by reducing p38 MAPK signaling. Leukemia 2023; 37:560-570. [PMID: 36550214 PMCID: PMC10750268 DOI: 10.1038/s41375-022-01798-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
Fms-like tyrosine kinase 3 (Flt3) tyrosine kinase inhibitors (Flt3-TKI) have improved outcomes for patients with Flt3-mutated acute myeloid leukemia (AML) but are limited by resistance and relapse, indicating persistence of leukemia stem cells (LSC). Here utilizing a Flt3-internal tandem duplication (Flt3-ITD) and Tet2-deleted AML genetic mouse model we determined that FLT3-ITD AML LSC were enriched within the primitive ST-HSC population. FLT3-ITD LSC showed increased expression of the CXCL12 receptor CXCR4. CXCL12-abundant reticular (CAR) cells were increased in Flt3-ITD AML marrow. CXCL12 deletion from the microenvironment enhanced targeting of AML cells by Flt3-TKI plus chemotherapy treatment, including enhanced LSC targeting. Both treatment and CXCL12 deletion partially reduced p38 mitogen-activated protein kinase (p38) signaling in AML cells and further reduction was seen after treatment in CXCL12 deleted mice. p38 inhibition reduced CXCL12-dependent and -independent maintenance of both murine and human Flt3-ITD AML LSC by MSC and enhanced their sensitivity to treatment. p38 inhibition in combination with chemotherapy plus TKI treatment leads to greater depletion of Flt3-ITD AML LSC compared with CXCL12 deletion. Our studies support roles for CXCL12 and p38 signaling in microenvironmental protection of AML LSC and provide a rationale for inhibiting p38 signaling to enhance Flt3-ITD AML targeting.
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Affiliation(s)
- Nicholas R Anderson
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Vipul Sheth
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hui Li
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mason W Harris
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Shaowei Qiu
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
| | - David K Crossman
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Harish Kumar
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Puneet Agarwal
- Division of Experimental Hematology & Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Takashi Nagasawa
- Laboratory of Stem Cell Biology & Developmental Immunology, Graduate School of Frontier Biosciences, Osaka University, Osaka, Japan
| | - Andrew J Paterson
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert S Welner
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ravi Bhatia
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
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18
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Mohty R, El Hamed R, Brissot E, Bazarbachi A, Mohty M. New drugs before, during, and after hematopoietic stem cell transplantation for patients with acute myeloid leukemia. Haematologica 2023; 108:321-341. [PMID: 36722403 PMCID: PMC9890036 DOI: 10.3324/haematol.2022.280798] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 09/02/2022] [Indexed: 02/02/2023] Open
Abstract
The treatment of acute myeloid leukemia (AML) has evolved over the past few years with the advent of next-generation sequencing. Targeted therapies alone or in combination with low-dose or high-intensity chemotherapy have improved the outcome of patients with AML treated in the frontline and relapsed/refractory settings. Despite these advances, allogeneic stem cell transplantation (allo-HCT) remains essential as consolidation therapy following frontline treatment in intermediate-and adverse-risk and relapsed/refractory disease. However, many patients relapse, with limited treatment options, hence the need for post-transplant strategies to mitigate relapse risk. Maintenance therapy following allo-HCT was developed for this specific purpose and can exploit either a direct anti-leukemia effect and/or enhance the bona fide graft-versus-leukemia effect without increasing the risk of graft-versus-host disease. In this paper, we summarize novel therapies for AML before, during, and after allo-HCT and review ongoing studies.
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Affiliation(s)
- Razan Mohty
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL
| | - Rama El Hamed
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Eolia Brissot
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, Paris, France; INSERM, Saint-Antoine Research Center, Paris
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, Paris, France; INSERM, Saint-Antoine Research Center, Paris.
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19
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Garciaz S, Hospital MA. FMS-Like Tyrosine Kinase 3 Inhibitors in the Treatment of Acute Myeloid Leukemia: An Update on the Emerging Evidence and Safety Profile. Onco Targets Ther 2023; 16:31-45. [PMID: 36698434 PMCID: PMC9869913 DOI: 10.2147/ott.s236740] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 01/11/2023] [Indexed: 01/19/2023] Open
Abstract
FMS-like tyrosine kinase 3 (FLT3) is one of the most frequently mutated genes in acute myeloid leukemia (AML). Approximately 30% of the adult cases harbor an internal tandem duplication (FLT3-ITD) and 5-10% a tyrosine kinase domain (TKD) amino acid substitution (FLT3-TKD). The treatment paradigm of AML patients harboring FLT3 mutations (30%) has been modified by the discovery of tyrosine kinase inhibitors. First- and second-generation inhibitors classify FLT3 inhibitors according to FLT3 specificity: first-generation FLT3 inhibitors include sorafenib and midostaurin and second-generation inhibitors are represented by quizartinib, gilteritinib and crenolanib, among others. Activity of these inhibitors depends on their mechanism of receptor binding (active vs inactive conformation) and efficacy against the FLT3-ITD and -TKD mutations (type 1 inhibitors are active both on FLT3-ITD and TKD, whereas type 2 inhibitors are active only on FLT3-ITD). The FLT3 inhibitors sorafenib, midostaurin, quizartinib and gilteritinib have been tested in monotherapy in several settings including refractory or relapsed AML (R/R AML), post-transplant maintenance as well as in combination with intensive chemotherapy (ICT) or non-intensity regimens. The results of published randomized studies support the use of sorafenib in a post-transplant setting (SORMAIN trial), midostaurin in combination with ICT based (RATIFY trial) and gilteritinib for R/R AML (ADMIRAL trial). Gilteritinib in combination with hypomethylating agent as well as quizartinib are not supported by solid randomized trial results for their use in FLT3-mutated AML patients.
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Affiliation(s)
- Sylvain Garciaz
- Department of Hematology, Institut Paoli-Calmettes, Aix-Marseille Université, Centre National de la Recherche Scientifique, UMR7258, Centre de Recherche en Cancérologie de Marseille, INSERM U1068, Marseille, France,Correspondence: Sylvain Garciaz, Institut Paoli-Calmettes, Hematology Department, 232 Bd Sainte-Marguerite, Marseille, 13009, France, Tel + 33 4 91 22 37 54, Fax + 33 4 91 22 30 63, Email
| | - Marie-Anne Hospital
- Department of Hematology, Institut Paoli-Calmettes, Aix-Marseille Université, Centre National de la Recherche Scientifique, UMR7258, Centre de Recherche en Cancérologie de Marseille, INSERM U1068, Marseille, France
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20
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Tecik M, Adan A. Therapeutic Targeting of FLT3 in Acute Myeloid Leukemia: Current Status and Novel Approaches. Onco Targets Ther 2022; 15:1449-1478. [PMID: 36474506 PMCID: PMC9719701 DOI: 10.2147/ott.s384293] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/19/2022] [Indexed: 08/13/2023] Open
Abstract
FMS-like tyrosine kinase 3 (FLT3) is mutated in approximately 30% of acute myeloid leukemia (AML) patients. The presence of FLT3-ITD (internal tandem duplication, 20-25%) mutation and, to a lesser extent, FLT3-TKD (tyrosine kinase domain, 5-10%) mutation is associated with poorer diagnosis and therapy response since the leukemic cells become hyperproliferative and resistant to apoptosis after continuous activation of FLT3 signaling. Targeting FLT3 has been the focus of many pre-clinical and clinical studies. Hence, many small-molecule FLT3 inhibitors (FLT3is) have been developed, some of which are approved such as midostaurin and gilteritinib to be used in different clinical settings, either in combination with chemotherapy or alone. However, many questions regarding the best treatment strategy remain to be answered. On the other hand, various FLT3-dependent and -independent resistance mechanisms could be evolved during FLT3i therapy which limit their clinical impact. Therefore, identifying molecular mechanisms of resistance and developing novel strategies to overcome this obstacle is a current interest in the field. In this review, recent studies of approved FLT3i and knowledge about major resistance mechanisms of clinically approved FLT3i's will be discussed together with novel treatment approaches such as designing novel FLT3i and dual FLT3i and combination strategies including approved FLT3i plus small-molecule agents targeting altered molecules in the resistant cells to abrogate resistance. Moreover, how to choose an appropriate FLT3i for the patients will be summarized based on what is currently known from available clinical data. In addition, strategies beyond FLT3i's including immunotherapeutics, small-molecule FLT3 degraders, and flavonoids will be summarized to highlight potential alternatives in FLT3-mutated AML therapy.
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Affiliation(s)
- Melisa Tecik
- Bioengineering Program, Graduate School of Engineering and Science, Abdullah Gul University, Kayseri, Turkey
| | - Aysun Adan
- Department of Molecular Biology and Genetics, Faculty of Life and Natural Sciences, Abdullah Gul University, Kayseri, Turkey
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21
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Wang ES, Montesinos P, Minden MD, Lee JH, Heuser M, Naoe T, Chou WC, Laribi K, Esteve J, Altman JK, Havelange V, Watson AM, Gambacorti-Passerini C, Patkowska E, Liu S, Wu R, Philipose N, Hill JE, Gill SC, Rich ES, Tiu RV. Phase 3 trial of gilteritinib plus azacitidine vs azacitidine for newly diagnosed FLT3mut+ AML ineligible for intensive chemotherapy. Blood 2022; 140:1845-1857. [PMID: 35917453 PMCID: PMC10653009 DOI: 10.1182/blood.2021014586] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 07/12/2022] [Indexed: 11/20/2022] Open
Abstract
Treatment results for patients with newly diagnosed FMS-like tyrosine kinase 3 (FLT3)-mutated (FLT3mut+) acute myeloid leukemia (AML) ineligible for intensive chemotherapy are disappointing. This multicenter, open-label, phase 3 trial randomized (2:1) untreated adults with FLT3mut+ AML ineligible for intensive induction chemotherapy to receive gilteritinib (120 mg/d orally) and azacitidine (GIL + AZA) or azacitidine (AZA) alone. The primary end point was overall survival (OS). At the interim analysis (August 26, 2020), a total of 123 patients were randomized to treatment (GIL + AZA, n = 74; AZA, n = 49). Subsequent AML therapy, including FLT3 inhibitors, was received by 20.3% (GIL + AZA) and 44.9% (AZA) of patients. Median OS was 9.82 (GIL + AZA) and 8.87 (AZA) months (hazard ratio, 0.916; 95% CI, 0.529-1.585; P = .753). The study was closed based on the protocol-specified boundary for futility. Median event-free survival was 0.03 month in both arms. Event-free survival defined by using composite complete remission (CRc) was 4.53 months for GIL + AZA and 0.03 month for AZA (hazard ratio, 0.686; 95% CI, 0.433-1.087; P = .156). CRc rates were 58.1% (GIL + AZA) and 26.5% (AZA) (difference, 31.4%; 95% CI, 13.1-49.7; P < .001). Adverse event (AE) rates were similar for GIL + AZA (100%) and AZA (95.7%); grade ≥3 AEs were 95.9% and 89.4%, respectively. Common AEs with GIL + AZA included pyrexia (47.9%) and diarrhea (38.4%). Gilteritinib steady-state trough concentrations did not differ between GIL + AZA and gilteritinib. GIL + AZA resulted in significantly higher CRc rates, although similar OS compared with AZA. Results support the safety/tolerability and clinical activity of upfront therapy with GIL + AZA in older/unfit patients with FLT3mut+ AML. This trial was registered at www.clinicaltrials.gov as #NCT02752035.
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Affiliation(s)
| | - Pau Montesinos
- Hospital Universitari i Politècnic La Fe, Valencia & CIBERONC, Instituto Carlos III, Madrid, Spain
| | | | | | | | - Tomoki Naoe
- National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | | | - Kamel Laribi
- Hematology Department, Centre Hospitalier Du Mans, Le Mans, France
| | | | | | | | | | | | - Elzbieta Patkowska
- Hematology Department, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
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22
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Song MK, Park BB, Uhm JE. Clinical Efficacies of FLT3 Inhibitors in Patients with Acute Myeloid Leukemia. Int J Mol Sci 2022; 23:ijms232012708. [PMID: 36293564 PMCID: PMC9604443 DOI: 10.3390/ijms232012708] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/13/2022] [Accepted: 10/19/2022] [Indexed: 11/16/2022] Open
Abstract
FLT3 mutations are the most common genomic alteration detected in acute myeloid leukemia (AML) with a worse clinical prognosis. The highly frequent FLT3 mutations, together with the side effects associated with clinical prognosis, make FLT3 promising treatment targets and have provoked the advancement of FLT3 inhibitors. Recently, numerous FLT3 inhibitors were actively developed, and thus the outcomes of this aggressive subtype of AML were significantly improved. Recently, midostaurin and gilteritinib were approved as frontline treatment of AML and as therapeutic agents in the recurred disease by the United States Food and Drug Administration. Recently, numerous promising clinical trials attempted to seek appropriate management in frontline settings, in relapsed/refractory disease, or after stem cell transplantation in AML. This review follows numerous clinical trials about the usefulness of FLT3 inhibitors as frontline therapy, as relapsed/refractory conditioning, and as maintenance therapy of stem cell transplantation. The cumulative data of FLT3 inhibitors would be important clinical evidence for further management with FLT3 inhibitors in AML patients with FLT3 mutations.
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Affiliation(s)
- Moo-Kon Song
- Department of Hematology-Oncology, Hanyang University Hanmaeum Changwon Hospital, Changwon 51497, Korea
| | - Byeong-Bae Park
- Division of Hematology-Oncology, Department of Internal Medicine, Hanyang University College of Medicine, Hanyang University Seoul Hospital, Seoul 04763, Korea
- Correspondence: ; Tel.: +82-2-2290-8114; Fax: +82-2-2290-7112
| | - Ji-Eun Uhm
- Division of Hematology-Oncology, Department of Internal Medicine, Hanyang University College of Medicine, Hanyang University Seoul Hospital, Seoul 04763, Korea
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23
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Ge SS, Liu SB, Xue SL. Developments and challenges of FLT3 inhibitors in acute myeloid leukemia. Front Oncol 2022; 12:996438. [PMID: 36185253 PMCID: PMC9515417 DOI: 10.3389/fonc.2022.996438] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
FLT3 mutations are one of the most common genetic alterations in acute myeloid leukemia (AML) and are identified in approximately one-third of newly diagnosed patients. Aberrant FLT3 receptor signaling has important implications for the biology and clinical management of AML. In recent years, targeting FLT3 has been a part of every course of treatment in FLT3-ITD/TKD-mutated AML and contributes to substantially prolonged survival. At the same time, wide application of next-generation sequencing (NGS) technology has revealed a series of non-canonical FLT3 mutations, including point mutations and small insertions/deletions. Some of these mutations may be able to influence downstream phosphorylation and sensitivity to FLT3 inhibitors, while the correlation with clinical outcomes remains unclear. Exploration of FLT3-targeted therapy has made substantial progress, but resistance to FLT3 inhibitors has become a pressing issue. The mechanisms underlying FLT3 inhibitor tolerance can be roughly divided into primary resistance and secondary resistance. Primary resistance is related to abnormalities in signaling factors, such as FL, CXCL12, and FGF2, and secondary resistance mainly involves on-target mutations and off-target aberrations. To overcome this problem, novel agents such as FF-10101 have shown promising potential. Multitarget strategies directed at FLT3 and anomalous signaling factors simultaneously are in active clinical development and show promising results.
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Affiliation(s)
- Shuai-Shuai Ge
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Song-Bai Liu
- Suzhou Key Laboratory of Medical Biotechnology, Suzhou Vocational Health College, Suzhou, China
- *Correspondence: Song-Bai Liu, ; Sheng-Li Xue,
| | - Sheng-Li Xue
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- *Correspondence: Song-Bai Liu, ; Sheng-Li Xue,
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24
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[Analysis of the efficacy of azacitidine combined with homoharringtonine and cytarabine in induction and salvage therapy of acute myeloid leukemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:778-780. [PMID: 36709173 PMCID: PMC9613494 DOI: 10.3760/cma.j.issn.0253-2727.2022.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Numan Y, Abaza Y, Altman JK, Platanias LC. Advances in the pharmacological management of acute myeloid leukemia in adults. Expert Opin Pharmacother 2022; 23:1535-1543. [PMID: 35938317 PMCID: PMC9648129 DOI: 10.1080/14656566.2022.2111212] [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: 03/12/2022] [Accepted: 08/05/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION With advances in molecular medicine and precision approaches, there has been significant improvement in the treatment of acute myeloid leukemia (AML) in recent years. This reflects better understanding of molecular and metabolic pathways in leukemia cells, including BCL2 upregulation that prevents apoptosis, FLT3 tyrosine kinase activating mutations that allow uncontrolled proliferation, and IDH mutations that result in differentiation block. AREAS COVERED We performed a compressive review of important pre-clinical studies in AML that involve major molecular and metabolic pathways in AML, and we discussed standard therapeutic modalities and ongoing clinical trials for patients with AML, as well as an overall update of recent efforts in this area. EXPERT OPINION Targeting these pathways has resulted in improvement in the overall survival of some groups of AML patients. Secondary AML and TP53 mutated AML remain challenging subtypes of AML with limited treatment options and represent areas of unmet research need. Ongoing work with menin inhibitors in MLL rearranged leukemia, which comprise a large portion of secondary AML cases, the development of CAR T cell products and targeting the CD47 receptor on macrophages in myeloid neoplasms including in TP53 mutated AML have provided hope for these challenging subtypes of AML.
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Affiliation(s)
- Yazan Numan
- Division of Hematology Oncology, Department of Internal
Medicine, Northwestern University-Feinberg School of Medicine, Chicago, IL
- Robert H. Lurie Comprehensive Cancer Center of Northwestern
University, Chicago, IL
| | - Yasmin Abaza
- Division of Hematology Oncology, Department of Internal
Medicine, Northwestern University-Feinberg School of Medicine, Chicago, IL
- Robert H. Lurie Comprehensive Cancer Center of Northwestern
University, Chicago, IL
| | - Jessica K Altman
- Division of Hematology Oncology, Department of Internal
Medicine, Northwestern University-Feinberg School of Medicine, Chicago, IL
- Robert H. Lurie Comprehensive Cancer Center of Northwestern
University, Chicago, IL
| | - Leonidas C Platanias
- Division of Hematology Oncology, Department of Internal
Medicine, Northwestern University-Feinberg School of Medicine, Chicago, IL
- Robert H. Lurie Comprehensive Cancer Center of Northwestern
University, Chicago, IL
- Department of Medicine, Jesse Brown VA Medical Center,
Chicago, IL
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26
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Yuan W, Zhang S, Zhu H. Advances in clinical studies of FLT3 inhibitors in acute myeloid leukemia. Zhejiang Da Xue Xue Bao Yi Xue Ban 2022; 51:507-514. [PMID: 37202100 DOI: 10.3724/zdxbyxb-2022-0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Acute myeloid leukemia (AML) is a highly heterogeneous hematological malignancy. AML patients with FLT3 mutations tend to have a high relapse rate and poor outcome, so FLT3 gene has become an important target for AML treatment, and a series of FLT3 inhibitors have been developed. According to the characteristics of FLT3 inhibitors, they can be divided into first-generation FLT3 inhibitors and second-generation FLT3 inhibitors. So far, totally eight FLT3 inhibitors have been undergone clinical trials and only three were approved for the treatment of AML patients, including Midostourin, Quizartinib and Gilteritinib. FLT3 inhibitors can improve the response rate of patients by combining with standard chemotherapy; in the follow-up maintenance treatment, FLT3 inhibitors can also reduce the disease recurrence rate and improve the overall prognosis of patients. However, the primary drug resistance caused by the bone marrow microenvironment, as well as secondary resistance caused by other mutations may result in poor efficacy of FLT3 inhibitors. For such patients, the combination of FLT3 inhibitor with other drugs may reduce the occurrence of drug resistance and improve the subsequent efficacy of patients. This article reviews the current status of FLT3 inhibitors in clinical research of AML patients and the treatment of FLT3-resistant patients to provide reference for clinicians.
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Affiliation(s)
- Wei Yuan
- 1. Medical College of China Three Gorges University, Yichang 443000, Hubei Province, China
- 2. Third-grade Pharmacological Laboratory on Traditional Chinese Medicine, China Three Gorges University, Yichang 443000, Hubei Province, China
| | - Shizhong Zhang
- 1. Medical College of China Three Gorges University, Yichang 443000, Hubei Province, China
- 2. Third-grade Pharmacological Laboratory on Traditional Chinese Medicine, China Three Gorges University, Yichang 443000, Hubei Province, China
| | - Honghu Zhu
- 3. Department of Hematology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
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27
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Pollard JA, Alonzo TA, Gerbing R, Brown P, Fox E, Choi J, Fisher B, Hirsch B, Kahwash S, Getz K, Levine J, Brodersen LE, Loken MR, Raimondi S, Tarlock K, Wood A, Sung L, Kolb EA, Gamis A, Meshinchi S, Aplenc R. Sorafenib in Combination With Standard Chemotherapy for Children With High Allelic Ratio FLT3/ITD+ Acute Myeloid Leukemia: A Report From the Children's Oncology Group Protocol AAML1031. J Clin Oncol 2022; 40:2023-2035. [PMID: 35349331 PMCID: PMC9197362 DOI: 10.1200/jco.21.01612] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/05/2022] [Accepted: 02/03/2022] [Indexed: 01/17/2023] Open
Abstract
PURPOSE High allelic ratio (HAR) FLT3/ITD (AR > 0.4) mutations confer poor prognosis in pediatric acute myeloid leukemia (AML). COG AAML1031 studied the feasibility and efficacy of adding sorafenib, a multikinase tyrosine kinase inhibitor to standard chemotherapy and as single-agent maintenance therapy in this population. MATERIALS AND METHODS Patients were treated in three cohorts. The initial safety phase defined the maximum tolerated dose of sorafenib starting in induction 2. Cohorts 2 and 3 added sorafenib in induction and as single-agent maintenance. Clinical outcome analysis was limited to n = 72 patients in cohorts 2/3 and compared with n = 76 HAR FLT3/ITD+ AML patients who received identical chemotherapy without sorafenib. Sorafenib pharmacokinetics and plasma inhibitory activity were measured in a subset of patients. RESULTS The maximum tolerated dose of sorafenib was 200 mg/m2 once daily; dose-limiting toxicities included rash (n = 2; 1 grade 3 and 1 grade 2), grade 2 hand-foot syndrome, and grade 3 fever. Pharmacokinetics/plasma inhibitory activity data demonstrated that measured plasma concentrations were sufficient to inhibit phosphorylated FLT3. Although outcomes were superior with sorafenib in cohorts 2 and 3, patients treated with sorafenib also underwent hematopoietic stem-cell transplant more frequently than the comparator population. Multivariable analysis that accounted for both hematopoietic stem-cell transplant and favorable co-occurring mutations confirmed sorafenib's benefit. Specifically, risk of an event was approximately two-fold higher in HAR FLT3/ITD+ patients who did not receive sorafenib (event-free survival from study entry: hazard ratio [HR] 2.37, 95% CI, 1.45 to 3.88, P < .001, disease-free survival from complete remission: HR 2.28, 95% CI, 1.08 to 4.82, P = .032, relapse risk from complete remission: HR 3.03, 95% CI 1.31 to 7.04, P = .010). CONCLUSION Sorafenib can be safely added to conventional AML chemotherapy and may improve outcomes in pediatric HAR FLT3/ITD+ AML.
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Affiliation(s)
- Jessica A. Pollard
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Todd A. Alonzo
- University of Southern California Keck School of Medicine, Los Angeles, CA
| | | | - Patrick Brown
- Johns Hopkins Kimmel Comprehensive Cancer Center, Baltimore, MD
| | | | - John Choi
- University of Alabama, Birmingham AL
| | - Brian Fisher
- Children's Hospital of Philadelphia, Philadelphia, PA
| | | | | | - Kelly Getz
- University of Pennsylvania, Department of Epidemiology, Biostatistics and Informatics, Philadelphia, PA
| | | | | | | | | | - Katherine Tarlock
- Fred Hutchinson Cancer Research Center, Seattle, WA
- Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Andrew Wood
- University of Auckland, Auckland, New Zealand
| | | | | | - Alan Gamis
- Children's Mercy Hospital and Clinics, Kansas City, MO
| | - Soheil Meshinchi
- Fred Hutchinson Cancer Research Center, Seattle, WA
- Seattle Children's Hospital, University of Washington, Seattle, WA
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28
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Raslan O, Garcia-Horton A. Azacitidine and its role in the upfront treatment of acute myeloid leukemia. Expert Opin Pharmacother 2022; 23:873-884. [PMID: 35695017 DOI: 10.1080/14656566.2022.2082284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Acute myeloid leukemia (AML) predominantly affects elderly population. This poses challenges in management, as patients are frequently not candidates for intensive therapy given comorbidities or frailty. Currently, azacitidine (AZA), either as monotherapy or in combination regimens, is the backbone treatment in this group of patients. AREAS COVERED We review the mechanism of action, pharmacology, clinical efficacy, and safety of AZA. It reviews current combination therapies of AZA with other targeted therapies for the treatment of newly diagnosed AML. EXPERT OPINION AZA is a cornerstone for the treatment of patients considered ineligible for intensive chemotherapy induction, but better results and therapies are required for these patients. AZA has shown synergistic properties when combined with other medications. Its safety profile and few drug interactions make it a suitable medication to use as backbone. Newer therapies are being combined with AZA, demonstrating safety and in cases, improved responses, and survival. AZA/venetoclax has emerged as the standard of care for patients who are ineligible for intensive chemotherapy. Doublet and triplet combinations are increasingly being studied. With the results observed in elderly patients, the intensive chemotherapy paradigm might be put to test in younger populations, with AZA combinations being at the forefront.
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Affiliation(s)
- Omar Raslan
- Department of Oncology, Juravinski Cancer Centre - Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, Division of Hematology, University of Jeddah, College of Medicine, Jeddah, Saudi Arabia
| | - Alejandro Garcia-Horton
- Department of Oncology, Juravinski Cancer Centre - Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
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29
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FLT3-targeted treatment for acute myeloid leukemia. Int J Hematol 2022; 116:351-363. [DOI: 10.1007/s12185-022-03374-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 12/17/2022]
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30
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Ahn JS, Kim HJ. FLT3 mutations in acute myeloid leukemia: a review focusing on clinically applicable drugs. Blood Res 2022; 57:32-36. [PMID: 35483923 PMCID: PMC9057665 DOI: 10.5045/br.2022.2022017] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/28/2022] [Accepted: 02/28/2022] [Indexed: 12/19/2022] Open
Abstract
FMS-like tyrosine kinase 3 (FLT3) mutations, the most frequently detected genetic aberrations in patients with acute myeloid leukemia (AML), are identified in approximately 30% of patients with newly diagnosed AML and are more common in patients with normal karyotypes. Since the discovery of FLT3 mutations in AML, clinical trials have been actively conducted in patients with FLT3 mutated AML, and FLT3 inhibitors have been introduced into clinical practice. The current standard treatment for patients with newly diagnosed FLT3-mutated AML is 7+3 induction chemotherapy combined with midostaurin. Additionally, gilteritinib is more effective than salvage chemotherapy for relapsed or refractory FLT3-mutated AML. Ongoing trials are expected to provide additional treatment options depending on the disease state and patient vulnerability. This review summarizes information on clinically available FLT3 inhibitors for the management of AML with FLT3 mutations.
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Affiliation(s)
- Jae-Sook Ahn
- Department of Internal Medicine, Chonnam National University Hwasun Hospital, Chonnam National University, Gwangju, Korea.,Genomic Research Center for Hematopoietic Diseases, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Hyeoung-Joon Kim
- Department of Internal Medicine, Chonnam National University Hwasun Hospital, Chonnam National University, Gwangju, Korea.,Genomic Research Center for Hematopoietic Diseases, Chonnam National University Hwasun Hospital, Hwasun, Korea
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31
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Perl AE. Pediatric Acute Myeloid Leukemia Enters the Molecularly Targeted Era Via FLT3 Inhibition. J Clin Oncol 2022; 40:2058-2060. [DOI: 10.1200/jco.22.00499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Alexander E. Perl
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
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32
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Kropp EM, Li Q. Mechanisms of Resistance to Targeted Therapies for Relapsed or Refractory Acute Myeloid Leukemia. Exp Hematol 2022; 111:13-24. [PMID: 35417742 PMCID: PMC10116852 DOI: 10.1016/j.exphem.2022.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/29/2022] [Accepted: 04/02/2022] [Indexed: 11/29/2022]
Abstract
Acute myeloid leukemia (AML) is an aggressive disease of clonal hematopoiesis with a high rate of relapse and refractory disease despite intensive therapy. Traditionally, relapsed or refractory AML has increased therapeutic resistance and poor long-term survival. In recent years, advancements in the mechanistic understanding of leukemogenesis have allowed for the development of targeted therapies. These therapies offer novel alternatives to intensive chemotherapy and have prolonged survival in relapsed or refractory AML. Unfortunately, a significant portion of patients do not respond to these therapies and relapse occurs in most patients who initially responded. This review focuses on the mechanisms of resistance to targeted therapies in relapsed or refractory AML.
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Affiliation(s)
- Erin M Kropp
- Department of Internal Medicine, University of Michigan-Ann Arbor, Ann Arbor, MI
| | - Qing Li
- Department of Internal Medicine, University of Michigan-Ann Arbor, Ann Arbor, MI.
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33
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Exploring the Resistance Mechanisms of Distal D835V Mutation in FLT3 to Inhibitors. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:3720026. [PMID: 35387260 PMCID: PMC8979743 DOI: 10.1155/2022/3720026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/29/2022] [Accepted: 02/24/2022] [Indexed: 12/13/2022]
Abstract
Objective FMS-like tyrosine kinase 3 (FLT3) is an attractive therapeutic target in acute myeloid leukemia. Unfortunately, secondary FLT3 mutations that developed resistance to inhibitors have become a severe problem. Specifically, ASP-835 (D835F/H/V/Y) mutant within the activation loop of FLT3 is the most commonly encountered drug-resistant and observed secondary FLT3 mutations. In this study, we carried out a set of computational approaches to explore how this mutation influenced the conformation and dynamics of DFG motif in a manner altered inhibitors' susceptibility. Methods Molecular dynamics (MD) simulation, dynamic cross-correlation (DCC) analysis, surface area (SASA), binding free energy (MM-GBSA), and structural analysis were used to compare the severe and minor D835V mutation-induced impact to sorafenib and crenolanib, respectively. Results The A-loop of the FLT3 protein may experience conformational change in the presence of the resistant mutation, which were mainly positioned at PHE-830. The protein-inhibitor interactions displayed that the motions of PHE-830 influenced that of sorafenib, but not to crenolanib. Conclusions These findings indicated that the structural impact brought by D835V mutation should be considered in designing novel drugs to overcome resistance to FLT3-D835V.
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Chen X, Huang J, Xu N, Fan Z, Nie D, Huang F, Sun Q, Zhang X, Liang X, Shi P, Wang Z, Liu H, Xu J, Dai M, Yu G, Zhang Y, Sun J, Liu Q, Xuan L. A phase 2 study of sorafenib combined with conventional therapies in refractory central nervous system leukemia. Cancer 2022; 128:2138-2147. [PMID: 35315510 DOI: 10.1002/cncr.34182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/28/2022] [Accepted: 02/18/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Patients with refractory central nervous system leukemia (CNSL) have a dismal prognosis and lack effective therapy. Case reports have shown that sorafenib is effective against brain metastases, including leukemia. METHODS To explore the efficacy of sorafenib combined with conventional therapies for refractory CNSL, a phase 2 study was conducted. The primary end point was the complete remission rate (CRR) within 8 weeks of treatment. Secondary end points included the overall response rate (ORR), event-free survival (EFS), overall survival (OS), and adverse events (AEs). RESULTS Twenty-six patients with refractory CNSL were enrolled; they included 17 with isolated CNSL, 7 with hematological relapse, and 2 with another extramedullary relapse. After 8 weeks of treatment, 21 patients achieved complete remission, 2 achieved partial remission, and 3 achieved no remission for a CRR of 80.8% (95% CI, 62.1%-91.5%) and an ORR of 88.5% (95% CI, 71.0%-96.0%). Twenty patients survived, and 6 died. The 2-year EFS and OS rates were 75.0% (95% CI, 54.5%-88.3%) and 76.9% (95% CI, 54.2%-90.4%), respectively. Six patients experienced grade 3 or 4 treatment-related AEs, including moderate chronic graft-vs-host disease (n = 3), grade 3 or 4 acute graft-vs-host disease (n = 2), and grade 3 skin rash (n = 1). No treatment-related deaths occurred during the therapy of refractory CNSL. CONCLUSIONS Sorafenib combined with conventional therapies is effective and safe for refractory CNSL. LAY SUMMARY Sorafenib combined with conventional therapies is effective and safe for refractory central nervous system leukemia.
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Affiliation(s)
- Xiaoxia Chen
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Junwei Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Na Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhiping Fan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Danian Nie
- Department of Hematology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qixin Sun
- Department of Geriatrics, Hematology and Oncology Ward, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Xinyou Zhang
- Department of Hematology, Shenzhen People's Hospital, Shenzhen, China
| | - Xinquan Liang
- Department of Hematology, First People's Hospital of Chenzhou, Chenzhou, China
| | - Pengcheng Shi
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhixiang Wang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hui Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jun Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Min Dai
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Guopan Yu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yu Zhang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Li Xuan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Senapati J, Kadia TM. Which FLT3 Inhibitor for Treatment of AML? Curr Treat Options Oncol 2022; 23:359-380. [PMID: 35258791 DOI: 10.1007/s11864-022-00952-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2022] [Indexed: 12/17/2022]
Abstract
OPINION STATEMENT Treatment options in acute myeloid leukemia (AML) have improved significantly over the last decade with better understanding of disease biology and availability of a multitude of targeted therapies. The use of FLT3 inhibitors (FLT3i) in FLT3-mutated (FLT3mut) AML is one such development; however, the clinical decisions that govern their use and dictate the choice of the FLT3i are evolving. Midostaurin and gilteritinib are FDA-approved in specific situations; however, available data from clinical trials also shed light on the utility of sorafenib maintenance post-allogeneic stem cell transplantation (allo-SCT) and quizartinib as part of combination therapy in FLT3mut AML. The knowledge of the patient's concurrent myeloid mutations, type of FLT3 mutation, prior FLT3i use, and eligibility for allo-SCT helps to refine the choice of FLT3i. Data from ongoing studies will further precisely define their use and help in making more informed choices. Despite improvements in FLT3i therapy, the definitive aim is to enable the eligible patient with FLT3mut AML (esp. ITD) to proceed to allo-SCT with regimens containing FLT3i incorporated prior to SCT and as maintenance after SCT.
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Affiliation(s)
- Jayastu Senapati
- Department of Leukemia, MD Anderson Cancer Center, 1515 Holcombe Blvd. - Unit 428, Houston, 77030, USA
| | - Tapan Mahendra Kadia
- Department of Leukemia, MD Anderson Cancer Center, 1515 Holcombe Blvd. - Unit 428, Houston, 77030, USA.
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Shimony S, Stone RM, Stahl M. Venetoclax combination therapy in acute myeloid leukemia and myelodysplastic syndromes. Curr Opin Hematol 2022; 29:63-73. [PMID: 34966123 DOI: 10.1097/moh.0000000000000698] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Venetoclax is a BCL-2 inhibitor that was approved in combination therapy with hypomethylating agents or low dose cytarabine for newly diagnosed acute myeloid leukemia (AML). The purpose of this review is to outline the most recent venetoclax-based combination therapies in newly diagnosed or relapsed myelodysplastic syndrome (MDS) and AML patients. RECENT FINDING Venetoclax has been incorporated in various therapeutic regimens - either with chemotherapy, immunotherapy or targeted therapies. These combinations achieve high remission rates with deep molecular responses, as suggested by measurable residual disease measurements. There are concerns regarding the incomplete count recovery, prolonged cytopenia and infection rates, especially when combined with chemotherapy. There is also limited data concerning durability of these remissions, and the effectiveness in high-risk population (i.e. p53-mutated AML patients). SUMMARY Venetoclax-based combination therapies encompass novel therapeutic possibilities in MDS and AML with encouraging initial results. However, the exact role of each combination therapy and the long-term effects on patients' outcome are yet to be defined.
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Affiliation(s)
- Shai Shimony
- Leukemia Division, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Zhao JC, Agarwal S, Ahmad H, Amin K, Bewersdorf JP, Zeidan AM. A review of FLT3 inhibitors in acute myeloid leukemia. Blood Rev 2022; 52:100905. [PMID: 34774343 PMCID: PMC9846716 DOI: 10.1016/j.blre.2021.100905] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 01/26/2023]
Abstract
FLT3 mutations are the most common genetic aberrations found in acute myeloid leukemia (AML) and associated with poor prognosis. Since the discovery of FLT3 mutations and their prognostic implications, multiple FLT3-targeted molecules have been evaluated. Midostaurin is approved in the U.S. and Europe for newly diagnosed FLT3 mutated AML in combination with standard induction and consolidation chemotherapy based on data from the RATIFY study. Gilteritinib is approved for relapsed or refractory FLT3 mutated AML as monotherapy based on the ADMIRAL study. Although significant progress has been made in the treatment of AML with FLT3-targeting, many challenges remain. Several drug resistance mechanisms have been identified, including clonal selection, stromal protection, FLT3-associated mutations, and off-target mutations. The benefit of FLT3 inhibitor maintenance therapy, either post-chemotherapy or post-transplant, remains controversial, although several studies are ongoing.
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Affiliation(s)
- Jennifer C Zhao
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Sonal Agarwal
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Hiba Ahmad
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Kejal Amin
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Jan Philipp Bewersdorf
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA.
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Role of Biomarkers in FLT3 AML. Cancers (Basel) 2022; 14:cancers14051164. [PMID: 35267471 PMCID: PMC8909069 DOI: 10.3390/cancers14051164] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 12/19/2022] Open
Abstract
Simple Summary Genetically heterogeneous disorder acute myeloid leukemia (AML) is marked by recurring mutations in FLT3. Current FLT3 inhibitors and other emerging inhibitors have helped in the improvement of the quality of standard of care therapies; however, the overall survival of the patients remains static. This is due to numerous mutations in FLT3, which causes resistance against these FLT3 inhibitors. For effective treatment of AML patients, alternative approaches are required to overcome this resistance. Here, we will summarize the biomarkers for FLT3 inhibitors in AML, as well as the alternative measures to overcome resistance to the current therapies. Abstract Acute myeloid leukemia is a disease characterized by uncontrolled proliferation of clonal myeloid blast cells that are incapable of maturation to leukocytes. AML is the most common leukemia in adults and remains a highly fatal disease with a five-year survival rate of 24%. More than 50% of AML patients have mutations in the FLT3 gene, rendering FLT3 an attractive target for small-molecule inhibition. Currently, there are several FLT3 inhibitors in the clinic, and others remain in clinical trials. However, these inhibitors face challenges due to lack of efficacy against several FLT3 mutants. Therefore, the identification of biomarkers is vital to stratify AML patients and target AML patient population with a particular FLT3 mutation. Additionally, there is an unmet need to identify alternative approaches to combat the resistance to FLT3 inhibitors. Here, we summarize the current knowledge on the utilization of diagnostic, prognostic, predictive, and pharmacodynamic biomarkers for FLT3-mutated AML. The resistance mechanisms to various FLT3 inhibitors and alternative approaches to combat this resistance are also discussed and presented.
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Ciotti G, Marconi G, Martinelli G. Hypomethylating Agent-Based Combination Therapies to Treat Post-Hematopoietic Stem Cell Transplant Relapse of Acute Myeloid Leukemia. Front Oncol 2022; 11:810387. [PMID: 35071015 PMCID: PMC8770807 DOI: 10.3389/fonc.2021.810387] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 12/10/2021] [Indexed: 12/23/2022] Open
Abstract
Allogeneic stem cell transplantation still represents the best curative option for most patients with acute myeloid leukemia, but relapse is still dramatically high. Due to their immunologic activity and safety profile, hypomethylating agents (HMAs) represent an interesting backbone for combination therapies. This review reports mechanism of action, safety, and efficacy data on combination strategies based on HMAs in the setting of post-allogeneic stem cell transplant relapse. Several studies highlighted how HMAs and donor lymphocyte infusion (DLI) combination may be advantageous. The combination strategy of HMA with venetoclax, possibly in association with DLI, is showing excellent results in terms of response rate, including molecular responses. Lenalidomide, despite its well-known high rates of severe graft-versus-host disease in post-transplant settings, is showing an acceptable safety profile in association with HMAs with a competitive response rate. Regarding FLT3 internal tandem duplication (ITD) mutant AML, tyrosine kinase inhibitors and particularly sorafenib have promising results as monotherapy and in combination with HMAs. Conversely, combination strategies with gemtuzumab ozogamicin or immune checkpoint inhibitors did not show competitive response rates and seem to be currently less attractive strategies. Associations with histone deacetylase inhibitors and isocitrate dehydrogenase 1 and 2 (IDH1/2) inhibitors represent new possible strategies that need to be better investigated.
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Affiliation(s)
- Giulia Ciotti
- Ematologia, Dipartimento di Medicina Traslazionale e di Precisione, Università La Sapienza, Azienda Ospedaliera Policlinico Umberto I, Rome, Italy
| | - Giovanni Marconi
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Giovanni Martinelli
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
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Webster JA, Luznik L, Gojo I. Treatment of AML Relapse After Allo-HCT. Front Oncol 2022; 11:812207. [PMID: 34976845 PMCID: PMC8716583 DOI: 10.3389/fonc.2021.812207] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/25/2021] [Indexed: 01/02/2023] Open
Abstract
With advances in allogeneic hematopoietic stem cell transplant (allo-HCT), disease relapse has replaced transplant-related mortality as the primary cause of treatment failure for patients with acute myeloid leukemia (AML). The efficacy of allo-HCT in AML is a consequence of a graft-versus-leukemia (GVL) effect that is mediated by T lymphocytes, and unique mechanisms of immune evasion underlying post-allo-HCT AML relapses have recently been characterized. Relapsed AML following allo-HCT presents a particularly vexing clinical challenge because transplant-related toxicities, such as graft-versus-host (GVHD) and infections, increase the risk of treatment-related morbidity and mortality. In general, the prognosis of relapsed AML following allo-HCT is poor with most patients failing to achieve a subsequent remission and 2-year survival consistently <15%. The two factors that have been found to predict a better prognosis are a longer duration of post-transplant remission prior to relapse and a lower disease burden at the time of relapse. When considered in combination with a patient's age; co-morbidities; and performance status, these factors can help to inform the appropriate therapy for the treatment of post-transplant relapse. This review discusses the options for the treatment of post-transplant AML relapse with a focus on the options to achieve a subsequent remission and consolidation with cellular immunotherapy, such as a second transplant or donor lymphocyte infusion (DLI). While intensive reinduction therapy and less intensive approaches with hypomethylating agents have long represented the two primary options for the initial treatment of post-transplant relapse, molecularly targeted therapies and immunotherapy are emerging as potential alternative options to achieve remission. Herein, we highlight response and survival outcomes achieved specifically in the post-transplant setting using each of these approaches and discuss how some therapies may overcome the immunologic mechanisms that have been implicated in post-transplant relapse. As long-term survival in post-transplant relapse necessarily involves consolidation with cellular immunotherapy, we present data on the efficacy and toxicity of both DLI and second allo-HCT including when such therapies are integrated with reinduction. Finally, we provide our general approach to the treatment of post-transplant relapse, integrating both novel therapies and our improved understanding of the mechanisms underlying post-transplant relapse.
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Affiliation(s)
- Jonathan A Webster
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Leo Luznik
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ivana Gojo
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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41
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Evolution of Therapy for Older Patients With Acute Myeloid Leukemia. Cancer J 2022; 28:67-72. [PMID: 35072376 PMCID: PMC10123925 DOI: 10.1097/ppo.0000000000000574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Most patients with newly diagnosed acute myeloid leukemia (AML) are 65 years or older. The treatment of AML in older patients has been characterized by distinct patient- and disease-related challenges that have impeded the meaningful progress that has been observed in younger patients with AML. Higher rates of comorbidities and frailty contribute to higher rates of treatment-related complications, whereas adverse disease features such as poor-risk genomics and secondary AML are associated with therapeutic resistance and shortened survival. Intensive chemotherapy and allogeneic stem cell transplant, although still considered standard for many newly diagnosed patients with AML, may not be appropriate for a larger subset of older patients with AML. Lower-intensity approaches such as hypomethylating agents have been widely applied for newly diagnosed older and unfit patients with AML, improving tolerability among this subset, but providing more modest response rates. Numerous analyses have attempted to tackle the utility of higher- versus lower-intensity therapy in older AML and identify the factors that can help choose the approach that best optimizes tolerability and efficacy. Recently, a greater understanding of the genomic and biologic heterogeneity of AML has led to better risk stratification and has contributed to the development of specific targeted therapies that are starting to narrow the gap between safety and efficacy. Newly approved agents, such FLT3 (FMS-like tyrosine kinase 3) inhibitors, IDH1 and IDH2 inhibitors, and the BCL2 inhibitor venetoclax, as well postremission maintenance therapy with CC-486 (oral 5-azacitidine), are being systematically incorporated into the evolving treatment of older patients with newly diagnosed AML.
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42
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Incorporation of FLT3 Inhibitors Into the Treatment Regimens for FLT3 Mutated Acute Myeloid Leukemia. Cancer J 2022; 28:14-20. [DOI: 10.1097/ppo.0000000000000576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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43
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Maillard M, Louveau B, Vilquin P, Goldwirt L, Thomas F, Mourah S. Pharmacogenomics in solid cancers and hematologic malignancies: Improving personalized drug prescription. Therapie 2021; 77:171-183. [PMID: 34922740 DOI: 10.1016/j.therap.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 09/29/2021] [Indexed: 11/30/2022]
Abstract
The discovery of molecular alterations involved in oncogenesis is evolving rapidly and has led to the development of new innovative targeted therapies in oncology. High-throughput sequencing techniques help to identify genomic targets and to provide predictive molecular biomarkers of response to guide alternative therapeutic strategies. Besides the emergence of these theranostic markers for the new targeted treatments, pharmacogenetic markers (corresponding to genetic variants existing in the constitutional DNA, i.e., the host genome) can help to optimize the use of chemotherapy. In this review, we present the current clinical applications of constitutional PG and the recent concepts and advances in pharmacogenomics, a rapidly evolving field that focuses on various molecular alterations identified on constitutional or somatic (tumor) genome.
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Affiliation(s)
- Maud Maillard
- Institut Claudius-Regaud, Institut universitaire du cancer de Toulouse, IUCT-Oncopole, 31059 Toulouse, France; Centre de recherches en cancérologie de Toulouse CRCT, 31037 Toulouse, France; Université Paul-Sabatier Toulouse III, 31062 Toulouse, France
| | - Baptiste Louveau
- Inserm, UMR_S976, 75475 Paris, France; Université de Paris, 75010 Paris, France; Pharmacogenomics department, Hôpital Saint-Louis, AP-HP, 75010 Paris, France
| | - Paul Vilquin
- Inserm, UMR_S976, 75475 Paris, France; Université de Paris, 75010 Paris, France; Pharmacogenomics department, Hôpital Saint-Louis, AP-HP, 75010 Paris, France
| | - Lauriane Goldwirt
- Inserm, UMR_S976, 75475 Paris, France; Université de Paris, 75010 Paris, France; Pharmacogenomics department, Hôpital Saint-Louis, AP-HP, 75010 Paris, France
| | - Fabienne Thomas
- Institut Claudius-Regaud, Institut universitaire du cancer de Toulouse, IUCT-Oncopole, 31059 Toulouse, France; Centre de recherches en cancérologie de Toulouse CRCT, 31037 Toulouse, France; Université Paul-Sabatier Toulouse III, 31062 Toulouse, France
| | - Samia Mourah
- Inserm, UMR_S976, 75475 Paris, France; Université de Paris, 75010 Paris, France; Pharmacogenomics department, Hôpital Saint-Louis, AP-HP, 75010 Paris, France.
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Fleischmann M, Schnetzke U, Hochhaus A, Scholl S. Management of Acute Myeloid Leukemia: Current Treatment Options and Future Perspectives. Cancers (Basel) 2021; 13:5722. [PMID: 34830877 PMCID: PMC8616498 DOI: 10.3390/cancers13225722] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/07/2021] [Accepted: 11/12/2021] [Indexed: 12/19/2022] Open
Abstract
Treatment of acute myeloid leukemia (AML) has improved in recent years and several new therapeutic options have been approved. Most of them include mutation-specific approaches (e.g., gilteritinib for AML patients with activating FLT3 mutations), or are restricted to such defined AML subgroups, such as AML-MRC (AML with myeloid-related changes) or therapy-related AML (CPX-351). With this review, we aim to present a comprehensive overview of current AML therapy according to the evolved spectrum of recently approved treatment strategies. We address several aspects of combined epigenetic therapy with the BCL-2 inhibitor venetoclax and provide insight into mechanisms of resistance towards venetoclax-based regimens, and how primary or secondary resistance might be circumvented. Furthermore, a detailed overview on the current status of AML immunotherapy, describing promising concepts, is provided. This review focuses on clinically important aspects of current and future concepts of AML treatment, but will also present the molecular background of distinct targeted therapies, to understand the development and challenges of clinical trials ongoing in AML patients.
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Affiliation(s)
| | | | | | - Sebastian Scholl
- Klinik für Innere Medizin II, Abteilung Hämatologie und Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07740 Jena, Germany; (M.F.); (U.S.); (A.H.)
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Venetoclax in Acute Myeloid Leukemia: Molecular Basis, Evidences for Preclinical and Clinical Efficacy and Strategies to Target Resistance. Cancers (Basel) 2021; 13:cancers13225608. [PMID: 34830763 PMCID: PMC8615921 DOI: 10.3390/cancers13225608] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 10/23/2021] [Accepted: 11/03/2021] [Indexed: 12/27/2022] Open
Abstract
Venetoclax is a BH3-mimetics agent specifically interacting with the antiapoptotic protein BCL-2, facilitating cytochrome c release from mitochondria, subsequent caspases activation, and cell death. Utilization of venetoclax has profoundly changed the landscape of treatment for the poor-prognosis category of AML patients unfit for intensive chemotherapy. In the phase III VIALE-A study, Venetoclax, in combination with the hypomethylating agent azacitidine, showed a 65% overall response rate and 14.7-month overall survival, in comparison with 22% and 8 months in the control arm. These results led to the widespread use of venetoclax in this indication. Other combination regimens, consisting of low-intensity, intensive, or targeted therapies are currently under evaluation. Despite promising results, preventing relapses or resistance to venetoclax is still an unmet clinical need. Numerous studies have been conducted to identify and overcome venetoclax resistance in preclinical models or in clinical trials, including the inhibition of other antiapoptotic proteins, the induction of proapoptotic BH3-only proteins, and/or the targeting of the mitochondrial metabolism and machinery.
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46
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Evolving Therapeutic Approaches for Older Patients with Acute Myeloid Leukemia in 2021. Cancers (Basel) 2021; 13:cancers13205075. [PMID: 34680226 PMCID: PMC8534216 DOI: 10.3390/cancers13205075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/29/2021] [Accepted: 10/04/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary The better understanding of disease biology, the availability of new effective drugs and the increased awareness of patients’ heterogeneity in terms of fitness and personal expectations has made the current treatment paradigm of AML in the elderly very challenging. Here, we discuss the evolving criteria used to define eligibility for induction chemotherapy and transplantation, the introduction of new agents in the treatment of patients with very different clinical conditions, the implications of precision medicine and the importance of quality of life and supportive care, proposing a simplified algorithm that we follow in 2021. Abstract Acute myeloid leukemia (AML) in older patients is characterized by unfavorable prognosis due to adverse disease features and a high rate of treatment-related complications. Classical therapeutic options range from intensive chemotherapy in fit patients, potentially followed by allogeneic hematopoietic cell transplantation (allo-HCT), to hypomethylating agents or palliative care alone for unfit/frail ones. In the era of precision medicine, the treatment paradigm of AML is rapidly changing. On the one hand, a plethora of new targeted drugs with good tolerability profiles are becoming available, offering the possibility to achieve a prolonged remission to many patients not otherwise eligible for more intensive therapies. On the other hand, better tools to assess patients’ fitness and improvements in the selection and management of those undergoing allo-HCT will hopefully reduce treatment-related mortality and complications. Importantly, a detailed genetic characterization of AML has become of paramount importance to choose the best therapeutic option in both intensively treated and unfit patients. Finally, improving supportive care and quality of life is of major importance in this age group, especially for the minority of patients that are still candidates for palliative care because of very poor clinical conditions or unwillingness to receive active treatments. In the present review, we discuss the evolving approaches in the treatment of older AML patients, which is becoming increasingly challenging following the advent of new effective drugs for a very heterogeneous and complex population.
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47
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Novatcheva ED, Anouty Y, Saunders I, Mangan JK, Goodman AM. FMS-Like Tyrosine Kinase 3 Inhibitors for the Treatment of Acute Myeloid Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 22:e161-e184. [PMID: 34649791 DOI: 10.1016/j.clml.2021.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 09/07/2021] [Indexed: 12/18/2022]
Abstract
Acute myeloid leukemia (AML) is the most common acute leukemia of adults, with a five-year survival that remains poor (approximately 25%). Knowledge and understanding of AML genomics have expanded tremendously over the past decade and are now included in AML prognostication and treatment decisions. FMS-like tyrosine kinase 3 (FLT3) is a Class III receptor tyrosine kinase (RTK) expressed primarily in the cell membranes of early hematopoietic progenitor cells, found in 28% of all patients with AML. FLT3 is the second most frequent mutation in adult AML following Nuclear-cytoplasmic shuttling phosphoprotein (NPM1), which is found in 50% of cases.1 FLT3 inhibitors are promising new molecular therapeutics increasingly becoming standard of care for both newly diagnosed and relapsed/refractory FLT3 positive AML. This review will focus on the clinical trials/evidence, similarities, differences, clinical toxicities, and drug interactions relevant to treating clinicians as pertains to 5 FLT3-inhibitors: midostaurin, sorafenib, gilteritinib, crenolanib, and quizartinib.
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Affiliation(s)
| | - Yasmine Anouty
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA
| | - Ila Saunders
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA; UC San Diego Skaggs School of Pharmacy & Pharmaceutical Sciences, La Jolla, CA
| | - James K Mangan
- Department of Medicine, Division of Blood and Marrow Transplantation, University of California San Diego, La Jolla, CA
| | - Aaron M Goodman
- Department of Medicine, Division of Blood and Marrow Transplantation, University of California San Diego, La Jolla, CA.
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Cerchione C, Peleteiro Raíndo A, Mosquera Orgueira A, Mosquera Torre A, Bao Pérez L, Marconi G, Isidori A, Pérez Encinas MM, Martinelli G. Safety of FLT3 inhibitors in patients with acute myeloid leukemia. Expert Rev Hematol 2021; 14:851-865. [PMID: 34424108 DOI: 10.1080/17474086.2021.1969911] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Introduction: Acute myeloblastic leukemia (AML) is the most frequent type of acute leukemia in adults with an incidence of 4.2 cases per 100,000 inhabitants and poor 5-year survival. Patients with mutations in the FMS-like tyrosine kinase 3 (FLT3) gene have poor survival and higher relapse rates compared with wild-type cases.Areas covered: Several FLT3 inhibitors have been proved in FLT3mut AML patients, with differences in their pharmacokinetics, kinase inhibitory and adverse events profiles. First-generation multi-kinase inhibitors (midostaurin, sorafenib, lestaurtinib) target multiple proteins, whereassecond-generation inhibitors (crenolanib, quizartinib, gilteritinib) are more specific and potent inhibitors of FLT3, so they are associated with less off-target toxic effects. All of these drugs have primary and acquired mechanisms of resistance, and therefore their combinations with other drugs (checkpoint inhibitors, hypomethylating agents, standard chemotherapy) and its application in different clinical settings are under study.Expert opinion: The recent clinical development of various FLT3 inhibitors for the treatment of FLT3mut AML is an effective therapeutic strategy. However, there are unique toxicities and drug-drug interactions that need to be resolved. It is necessary to understand the mechanisms of toxicity in order to recognize and manage them adequately.
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Affiliation(s)
- Claudio Cerchione
- Hematology Unit, IRCCS Istituto Scientifico Romagnolo per Lo Studio Dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Andrés Peleteiro Raíndo
- Health Research Institute of Santiago De Compostela (Idis), Santiago De Compostela, Spain.,Division of Hematology, Complejo Hospitalario Universitario De Santiago (Chus), Santiago De Compostela, Spain
| | - Adrián Mosquera Orgueira
- Health Research Institute of Santiago De Compostela (Idis), Santiago De Compostela, Spain.,Division of Hematology, Complejo Hospitalario Universitario De Santiago (Chus), Santiago De Compostela, Spain
| | - Alicia Mosquera Torre
- Health Research Institute of Santiago De Compostela (Idis), Santiago De Compostela, Spain.,Division of Hematology, Complejo Hospitalario Universitario De Santiago (Chus), Santiago De Compostela, Spain
| | - Laura Bao Pérez
- Health Research Institute of Santiago De Compostela (Idis), Santiago De Compostela, Spain.,Division of Hematology, Complejo Hospitalario Universitario De Santiago (Chus), Santiago De Compostela, Spain
| | - Giovanni Marconi
- Hematology Unit, IRCCS Istituto Scientifico Romagnolo per Lo Studio Dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Alessandro Isidori
- Hematology and Stem Cell Transplant Center, Aormn Hospital, Pesaro, Italy
| | - Manuel Mateo Pérez Encinas
- Health Research Institute of Santiago De Compostela (Idis), Santiago De Compostela, Spain.,Division of Hematology, Complejo Hospitalario Universitario De Santiago (Chus), Santiago De Compostela, Spain.,University of Santiago De Compostela, Santiago De Compostela, Spain
| | - Giovanni Martinelli
- Hematology Unit, IRCCS Istituto Scientifico Romagnolo per Lo Studio Dei Tumori (IRST) "Dino Amadori", Meldola, Italy
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49
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Can the New and Old Drugs Exert an Immunomodulatory Effect in Acute Myeloid Leukemia? Cancers (Basel) 2021; 13:cancers13164121. [PMID: 34439275 PMCID: PMC8393879 DOI: 10.3390/cancers13164121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/11/2021] [Accepted: 08/14/2021] [Indexed: 12/30/2022] Open
Abstract
Simple Summary The advent of novel immunotherapeutic strategies has revealed the importance of immune dysregulation and of a tolerogenic microenvironment for acute myeloid leukemia (AML) fitness. We reviewed the “off-target” effects on the immune system of different drugs used in the treatment of AML to explore the advantages of this unexpected interaction. Abstract Acute myeloid leukemia (AML) is considered an immune-suppressive neoplasm capable of evading immune surveillance through cellular and environmental players. Increasing knowledge of the immune system (IS) status at diagnosis seems to suggest ever more attention of the crosstalk between the leukemic clone and its immunologic counterpart. During the last years, the advent of novel immunotherapeutic strategies has revealed the importance of immune dysregulation and suppression for leukemia fitness. Considering all these premises, we reviewed the “off-target” effects on the IS of different drugs used in the treatment of AML, focusing on the main advantages of this interaction. The data reported support the idea that a successful therapeutic strategy should consider tailored approaches for performing leukemia eradication by both direct blasts killing and the engagement of the IS.
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50
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Alahmari B, Alzahrani M, Al Shehry N, Tawfiq O, Alwasaidi T, Alhejazi A, Bakkar M, Al Behainy A, Radwi M, Alaskar A. Management Approach to Acute Myeloid Leukemia Leveraging the Available Resources in View of the Latest Evidence: Consensus of the Saudi Society of Blood and Marrow Transplantation. JCO Glob Oncol 2021; 7:1220-1232. [PMID: 34343012 PMCID: PMC8457782 DOI: 10.1200/go.20.00660] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Acute myeloid leukemia (AML) is the most prevalent acute leukemia in adults and is responsible for the majority of cancer-related mortality. In Saudi Arabia, leukemia is ranked the fifth most prevalent type of malignancy in adults. Our aim is to review existing epidemiologic data in Saudi Arabia and develop consensus guidelines for management of AML.
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Affiliation(s)
- Bader Alahmari
- Department of Oncology, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohsen Alzahrani
- Department of Oncology, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Osamah Tawfiq
- King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Turki Alwasaidi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Medicine Department, Taibah University, Al Madinah Al Munawarrah, Saudi Arabia.,Prince Mohammed Bin Abdulaziz Hospital, Al Madinah, Ministry of National Guard-Health Affairs, Al Madinah, Saudi Arabia
| | - Ayman Alhejazi
- Department of Oncology, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Amal Al Behainy
- King Fahad Hospital, Madinah, Al Madinah Al Munawarrah, Saudi Arabia
| | - Mansour Radwi
- Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Ahmed Alaskar
- Department of Oncology, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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