1
|
Bruno S, Borsi E, Patuelli A, Bandini L, Mancini M, Forte D, Nanni J, Barone M, Grassi A, Cristiano G, Venturi C, Robustelli V, Atzeni G, Mosca C, De Santis S, Monaldi C, Poletti A, Terragna C, Curti A, Cavo M, Soverini S, Ottaviani E. Tracking Response and Resistance in Acute Myeloid Leukemia through Single-Cell DNA Sequencing Helps Uncover New Therapeutic Targets. Int J Mol Sci 2024; 25:10002. [PMID: 39337490 PMCID: PMC11432296 DOI: 10.3390/ijms251810002] [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: 07/30/2024] [Revised: 09/04/2024] [Accepted: 09/14/2024] [Indexed: 09/30/2024] Open
Abstract
Acute myeloid leukemia (AML) is an aggressive hematologic neoplasia with a complex polyclonal architecture. Among driver lesions, those involving the FLT3 gene represent the most frequent mutations identified at diagnosis. The development of tyrosine kinase inhibitors (TKIs) has improved the clinical outcomes of FLT3-mutated patients (Pt). However, overcoming resistance to these drugs remains a challenge. To unravel the molecular mechanisms underlying therapy resistance and clonal selection, we conducted a longitudinal analysis using a single-cell DNA sequencing approach (MissionBioTapestri® platform, San Francisco, CA, USA) in two patients with FLT3-mutated AML. To this end, samples were collected at the time of diagnosis, during TKI therapy, and at relapse or complete remission. For Pt #1, disease resistance was associated with clonal expansion of minor clones, and 2nd line TKI therapy with gilteritinib provided a proliferative advantage to the clones carrying NRAS and KIT mutations, thereby responsible for relapse. In Pt #2, clonal architecture was less complex, and 1st line TKI therapy with midostaurin was able to eradicate the leukemic clones. Our results corroborate previous findings about clonal selection driven by TKIs, highlighting the importance of a deeper characterization of individual clonal architectures for choosing the best treatment plan for personalized approaches aimed at optimizing outcomes.
Collapse
Affiliation(s)
- Samantha Bruno
- Department of Medical and Surgical Science (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Enrica Borsi
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero, Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", 940138 Bologna, Italy
| | - Agnese Patuelli
- Department of Medical and Surgical Science (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Lorenza Bandini
- Department of Medical and Surgical Science (DIMEC), University of Bologna, 40138 Bologna, Italy
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero, Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", 940138 Bologna, Italy
| | - Manuela Mancini
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero, Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", 940138 Bologna, Italy
| | - Dorian Forte
- Department of Medical and Surgical Science (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Jacopo Nanni
- Department of Medical and Surgical Science (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Martina Barone
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero, Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", 940138 Bologna, Italy
| | - Alessandra Grassi
- Department of Medical and Surgical Science (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Gianluca Cristiano
- Department of Medical and Surgical Science (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Claudia Venturi
- Department of Medical and Surgical Science (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Valentina Robustelli
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero, Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", 940138 Bologna, Italy
| | - Giulia Atzeni
- Department of Medical and Surgical Science (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Cristina Mosca
- Department of Medical and Surgical Science (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Sara De Santis
- Department of Medical and Surgical Science (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Cecilia Monaldi
- Department of Medical and Surgical Science (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Andrea Poletti
- Department of Medical and Surgical Science (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Carolina Terragna
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero, Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", 940138 Bologna, Italy
| | - Antonio Curti
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero, Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", 940138 Bologna, Italy
| | - Michele Cavo
- Department of Medical and Surgical Science (DIMEC), University of Bologna, 40138 Bologna, Italy
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero, Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", 940138 Bologna, Italy
| | - Simona Soverini
- Department of Medical and Surgical Science (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Emanuela Ottaviani
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero, Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", 940138 Bologna, Italy
| |
Collapse
|
2
|
Gordon J, Bravo-Perez C, Guarnera L, Unlu S, Kawashima N, Ahmed A, Haddad C, Kubota Y, Nautiyal I, Ullah F, Dima D, Williams ND, Kewan T, Bahaj W, Carraway HE, Yang CY, Gurnari C, Visconte V, Maciejewski JP. Non-canonical FLT3 alterations reveal novel germline FLT3 variants leading to somatic gene rescue mutations. Blood Cancer J 2024; 14:125. [PMID: 39080258 PMCID: PMC11289469 DOI: 10.1038/s41408-024-01104-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 07/05/2024] [Accepted: 07/15/2024] [Indexed: 08/02/2024] Open
Affiliation(s)
- Jaymeson Gordon
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Carlos Bravo-Perez
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Hematology and Medical Oncology, Hospital Universitario Morales Meseguer, University of Murcia, IMIB-Pascual Parrilla, CIBERER - Instituto de Salud Carlos III, Murcia, Spain
| | - Luca Guarnera
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Serhan Unlu
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Naomi Kawashima
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Arooj Ahmed
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Christopher Haddad
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Yasuo Kubota
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ishani Nautiyal
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Fauzia Ullah
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Danai Dima
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nakisha D Williams
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tariq Kewan
- Department of Hematology and Medical Oncology, Yale University, New Haven, CT, USA
| | - Waled Bahaj
- Division of Medical Oncology & Hematology, School of Medicine University of Louisville, Louisville, KY, USA
| | - Hetty E Carraway
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Chao-Yie Yang
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Valeria Visconte
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jaroslaw P Maciejewski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
| |
Collapse
|
3
|
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.
Collapse
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.
| |
Collapse
|
4
|
Chitluri KK, Emerson IA. The importance of protein domain mutations in cancer therapy. Heliyon 2024; 10:e27655. [PMID: 38509890 PMCID: PMC10950675 DOI: 10.1016/j.heliyon.2024.e27655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 02/28/2024] [Accepted: 03/05/2024] [Indexed: 03/22/2024] Open
Abstract
Cancer is a complex disease that is caused by multiple genetic factors. Researchers have been studying protein domain mutations to understand how they affect the progression and treatment of cancer. These mutations can significantly impact the development and spread of cancer by changing the protein structure, function, and signalling pathways. As a result, there is a growing interest in how these mutations can be used as prognostic indicators for cancer prognosis. Recent studies have shown that protein domain mutations can provide valuable information about the severity of the disease and the patient's response to treatment. They may also be used to predict the response and resistance to targeted therapy in cancer treatment. The clinical implications of protein domain mutations in cancer are significant, and they are regarded as essential biomarkers in oncology. However, additional techniques and approaches are required to characterize changes in protein domains and predict their functional effects. Machine learning and other computational tools offer promising solutions to this challenge, enabling the prediction of the impact of mutations on protein structure and function. Such predictions can aid in the clinical interpretation of genetic information. Furthermore, the development of genome editing tools like CRISPR/Cas9 has made it possible to validate the functional significance of mutants more efficiently and accurately. In conclusion, protein domain mutations hold great promise as prognostic and predictive biomarkers in cancer. Overall, considerable research is still needed to better define genetic and molecular heterogeneity and to resolve the challenges that remain, so that their full potential can be realized.
Collapse
Affiliation(s)
- Kiran Kumar Chitluri
- Bioinformatics Programming Lab, Department of Bio-Sciences, School of Bio Sciences and Technology, Vellore Institute of Technology, Vellore, TN, 632014, India
| | - Isaac Arnold Emerson
- Bioinformatics Programming Lab, Department of Bio-Sciences, School of Bio Sciences and Technology, Vellore Institute of Technology, Vellore, TN, 632014, India
| |
Collapse
|
5
|
Gabellier L, Peterlin P, Thepot S, Hicheri Y, Paul F, Gallego-Hernanz MP, Bertoli S, Turlure P, Pigneux A, Guieze R, Ochmann M, Malfuson JV, Cluzeau T, Thomas X, Tavernier E, Jourdan E, Bonnet S, Tudesq JJ, Raffoux E. Hypomethylating agent monotherapy in core binding factor acute myeloid leukemia: a French multicentric retrospective study. Ann Hematol 2024; 103:759-769. [PMID: 38273140 PMCID: PMC10867066 DOI: 10.1007/s00277-024-05623-0] [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] [Received: 10/26/2023] [Accepted: 01/10/2024] [Indexed: 01/27/2024]
Abstract
Very few data are available about hypomethylating agent (HMA) efficiency in core binding factor acute myeloid leukemias (CBF-AML). Our main objective was to evaluate the efficacy and safety of HMA in the specific subset of CBF-AML. Here, we report the results of a multicenter retrospective French study about efficacy of HMA monotherapy, used frontline or for R/R CBF-AML. Forty-nine patients were included, and received a median of 5 courses of azacitidine (n = 46) or decitabine (n = 3). ORR was 49% for the whole cohort with a median time to response of 112 days. After a median follow-up of 72.3 months, median OS for the total cohort was 10.6 months. In multivariate analysis, hematological relapse of CBF-AML at HMA initiation was significantly associated with a poorer OS (HR: 2.13; 95%CI: 1.04-4.36; p = 0.038). Responders had a significantly improved OS (1-year OS: 75%) compared to non-responders (1-year OS: 15.3%; p < 0.0001). Hematological improvement occurred for respectively 28%, 33% and 48% for patients who were red blood cell or platelet transfusion-dependent, or who experienced grade 3/4 neutropenia at HMA initiation. Adverse events were consistent with the known safety profile of HMA. Our study highlights that HMA is a well-tolerated therapeutic option with moderate clinical activity for R/R CBF-AML and for patients who cannot handle intensive chemotherapy.
Collapse
Affiliation(s)
- Ludovic Gabellier
- Département d'Hématologie Clinique, CHU Montpellier, Université Montpellier-Nîmes, 80, Avenue Augustin Fliche, 34090, Montpellier, France.
| | - Pierre Peterlin
- Département d'Hématologie Clinique, CHU Nantes, Université de Nantes, Nantes, France
| | - Sylvain Thepot
- Département d'Hématologie Clinique, CHU Angers, Université d'Angers, Angers, France
| | - Yosr Hicheri
- Département d'Hématologie Clinique, Institut Paoli-Calmettes, Marseille, France
| | - Franciane Paul
- Département d'Hématologie Clinique, CHU Montpellier, Université Montpellier-Nîmes, 80, Avenue Augustin Fliche, 34090, Montpellier, France
| | | | - Sarah Bertoli
- Service d'Hématologie Clinique, CHU Toulouse, Institut Universitaire du Cancer de Toulouse - Oncopôle, Université Toulouse III - Paul Sabatier, Toulouse, France
| | - Pascal Turlure
- Département d'Hématologie Clinique, CHU Limoges, Université de Limoges, Limoges, France
| | - Arnaud Pigneux
- Département d'Hématologie Clinique, CHU Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Romain Guieze
- Département d'Hématologie Clinique, CHU Clermont-Ferrand, Université de Clermont-Ferrand, Clermont-Ferrand, France
| | - Marlène Ochmann
- Département d'Hématologie Clinique, Orléans, Orléans, CH, France
| | - Jean-Valère Malfuson
- Département d'Hématologie Clinique, Hôpital d'instruction Des Armées, Percy, France
| | - Thomas Cluzeau
- Département d'Hématologie Clinique, CHU Nice, Université de Nice, Nice, France
| | - Xavier Thomas
- Département d'Hématologie Clinique, Hospices Civils de Lyon, CHU Lyon, Université de Lyon, Lyon, France
| | - Emmanuelle Tavernier
- Département d'Hématologie Clinique, Institut de Cancérologie Lucien Neuwirth, Université de Saint-Etienne, Saint-Etienne, France
| | - Eric Jourdan
- Département d'Hématologie Clinique, CHU Nîmes, Université de Montpellier-Nîmes, Nîmes, France
| | - Sarah Bonnet
- Département d'Hématologie Clinique, CHU Montpellier, Université Montpellier-Nîmes, 80, Avenue Augustin Fliche, 34090, Montpellier, France
| | - Jean-Jacques Tudesq
- Département d'Hématologie Clinique, CHU Montpellier, Université Montpellier-Nîmes, 80, Avenue Augustin Fliche, 34090, Montpellier, France
| | - Emmanuel Raffoux
- Département d'Hématologie Clinique Adultes, Hôpital Saint-Louis, APHP, Université Paris Diderot, Paris, France
| |
Collapse
|
6
|
Brown A, Batra S. Rare Hematologic Malignancies and Pre-Leukemic Entities in Children and Adolescents Young Adults. Cancers (Basel) 2024; 16:997. [PMID: 38473358 DOI: 10.3390/cancers16050997] [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: 02/05/2024] [Revised: 02/27/2024] [Accepted: 02/27/2024] [Indexed: 03/14/2024] Open
Abstract
There are a variety of rare hematologic malignancies and germline predispositions syndromes that occur in children and adolescent young adults (AYAs). These entities are important to recognize, as an accurate diagnosis is essential for risk assessment, prognostication, and treatment. This descriptive review summarizes rare hematologic malignancies, myelodysplastic neoplasms, and germline predispositions syndromes that occur in children and AYAs. We discuss the unique biology, characteristic genomic aberrations, rare presentations, diagnostic challenges, novel treatments, and outcomes associated with these rare entities.
Collapse
Affiliation(s)
- Amber Brown
- Division of Pediatric Hematology, Oncology and Stem Cell Transplant, Department of Pediatrics, Riley Hospital for Children, 705 Riley Hospital Drive, Indianapolis, IN 46202, USA
| | - Sandeep Batra
- Division of Pediatric Hematology, Oncology and Stem Cell Transplant, Department of Pediatrics, Riley Hospital for Children, 705 Riley Hospital Drive, Indianapolis, IN 46202, USA
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Eisfeld AK, Mardis ER. Acute Myeloid Leukemia Genomics: Impact on Care and Remaining Challenges. Clin Chem 2024; 70:4-12. [PMID: 38175584 DOI: 10.1093/clinchem/hvad171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/03/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Ann-Kathrin Eisfeld
- Division of Hematology, The Ohio State University College of Medicine, Columbus, OH, United States
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH, United States
| | - Elaine R Mardis
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
- Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, United States
| |
Collapse
|
9
|
Jimenez-Chillon C, Dillon R, Russell N. Optimal Post-Remission Consolidation Therapy in Patients with AML. Acta Haematol 2023; 147:147-158. [PMID: 38008085 PMCID: PMC10997264 DOI: 10.1159/000535457] [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: 07/13/2023] [Accepted: 11/20/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND Despite recent advances, 40-85% of patients with acute myeloid leukaemia (AML) achieve complete remission after intensive chemotherapy. However, without optimal treatment after remission, the risk of relapse remains high. SUMMARY A variable number of consolidation cycles consisting of intermediate doses of cytarabine are the most commonly used regimens in low-intermediate-risk AML, while patients at higher risk of relapse should consolidate response by proceeding to HSCT. Different post-consolidation (maintenance therapies) have demonstrated their benefit in prolonging relapse-free survival, and others are still under investigation. Careful consideration should be given to which patients benefit most from each of these interventions, considering that the risk of relapse is dynamic. KEY MESSAGES Patients consolidated with chemotherapy should receive either 2 courses of HDAC or no more than 3-4 cycles of IDAC with dose reduction in patients over 60 years. Patients with mutated FLT3 AML benefit from post-consolidation maintenance with FLT3 inhibitors, and selected patients not fit for adequate consolidation may benefit from CC-468 maintenance. Patients at higher risk of relapse should proceed to allogeneic SCT as soon as possible, opting for a more intensive conditioning in patients younger than 55 years. However, autologous HSCT may still have role in favourable-risk MRD-negative AML. Multiple treatment options targeting MRD are emerging, either as definitive treatment or as a bridge to allogeneic transplantation, and are likely to become increasingly relevant.
Collapse
Affiliation(s)
- Carlos Jimenez-Chillon
- Servicio de Hematologia y Hemoterapia, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Department of Medical and Molecular Genetics, King’s College, London, UK
| | - Richard Dillon
- Department of Medical and Molecular Genetics, King’s College, London, UK
- Guy’s and St Thomas Hospital, London, UK
| | | |
Collapse
|
10
|
Ruhnke L, Röllig C, Herold S, Sauer T, Brandts CH, Steffen B, Schäfer-Eckart K, Krause SW, Hänel M, Reichle A, Scholl S, Neubauer A, Mikesch JH, Schetelig J, Stölzel F, Kramer M, Haake A, Frimmel J, Krämer A, Schlenk R, Platzbecker U, Serve H, Baldus CD, Müller-Tidow C, Aust D, Bornhäuser M, Ehninger G, Thiede C. Midostaurin in addition to intensive chemotherapy in acute myeloid leukemia with t(8;21) and KIT and/or FLT3- ITD mutations: results of the SAL MIDOKIT trial. Haematologica 2023; 108:2520-2525. [PMID: 36779591 PMCID: PMC10483343 DOI: 10.3324/haematol.2022.281636] [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: 09/10/2020] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
Not available.
Collapse
Affiliation(s)
- Leo Ruhnke
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden.
| | - Christoph Röllig
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden
| | - Sylvia Herold
- Institute of Pathology, University Hospital Dresden, Dresden
| | - Tim Sauer
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany and German Cancer Research Center (DKFZ), Heidelberg
| | - Christian H Brandts
- Department of Internal Medicine II, University Hospital Frankfurt, Frankfurt
| | - Björn Steffen
- Department of Internal Medicine II, University Hospital Frankfurt, Frankfurt
| | - Kerstin Schäfer-Eckart
- Department of Internal Medicine V, Nuremberg Hospital North, Paracelsus Medical University, Nuremberg
| | - Stefan W Krause
- Department of Internal Medicine V, University Hospital Erlangen, Erlangen
| | - Mathias Hänel
- Department of Internal Medicine III, Chemnitz Hospital, Chemnitz
| | - Albrecht Reichle
- Department of Internal Medicine III, Hematology and Internal Oncology, University Hospital Regensburg, Regensburg
| | - Sebastian Scholl
- Department of Internal Medicine II, Hematology and Internal Oncology, University Hospital Jena, Jena
| | - Andreas Neubauer
- Department of Internal Medicine, Hematology, Oncology and Immunology, University Hospital Marburg, Marburg
| | | | - Johannes Schetelig
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden, Germany; DKMS Clinical Trials Unit, Dresden
| | - Friedrich Stölzel
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden
| | - Michael Kramer
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden
| | - Annett Haake
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden
| | - Julia Frimmel
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden
| | - Alwin Krämer
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany and German Cancer Research Center (DKFZ), Heidelberg
| | - Richard Schlenk
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany and German Cancer Research Center (DKFZ), Heidelberg
| | - Uwe Platzbecker
- Department of Internal Medicine I, Hematology and Cellular Therapy, University Hospital Leipzig, Leipzig
| | - Hubert Serve
- Department of Internal Medicine II, University Hospital Frankfurt, Frankfurt
| | - Claudia D Baldus
- Department of Hematology and Oncology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel
| | | | - Daniela Aust
- Institute of Pathology, University Hospital Dresden, Dresden
| | - Martin Bornhäuser
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden, Germany; German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany and German Cancer Research Center (DKFZ), Heidelberg, Germany; National Center for Tumor Diseases (NCT) Dresden, Dresden
| | - Gerhard Ehninger
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden
| | - Christian Thiede
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden, Germany; Agendix GmbH, Dresden
| |
Collapse
|
11
|
Perrone S, Ottone T, Zhdanovskaya N, Molica M. How acute myeloid leukemia (AML) escapes from FMS-related tyrosine kinase 3 (FLT3) inhibitors? Still an overrated complication? CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2023; 6:223-238. [PMID: 37457126 PMCID: PMC10344728 DOI: 10.20517/cdr.2022.130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 03/21/2023] [Accepted: 04/11/2023] [Indexed: 07/18/2023]
Abstract
FMS-related tyrosine kinase 3 (FLT3) mutations, present in about 25%-30% of acute myeloid leukemia (AML) patients, constitute one of the most frequently detected mutations in these patients. The binding of FLT3L to FLT3 activates the phosphatidylinositol 3-kinase (PI3K) and RAS pathways, producing increased cell proliferation and the inhibition of apoptosis. Two types of FLT3 mutations exist: FLT3-ITD and FLT3-TKD (point mutations in D835 and I836 or deletion of codon I836). A class of drugs, tyrosine-kinase inhibitors (TKI), targeting mutated FLT3, is already available with 1st and 2nd generation molecules, but only midostaurin and gilteritinib are currently approved. However, the emergence of resistance or the selection of clones not responding to FLT3 inhibitors has become an important clinical dilemma, as the duration of clinical responses is generally limited to a few months. This review analyzes the insights into mechanisms of resistance to TKI and poses a particular view on the clinical relevance of this phenomenon. Has resistance been overlooked? Indeed, FLT3 inhibitors have significantly contributed to reducing the negative impact of FLT3 mutations on the prognosis of AML patients who are no longer considered at high risk by the European LeukemiaNet (ELN) 2022. Finally, several ongoing efforts to overcome resistance to FLT3-inhibitors will be presented: new generation FLT3 inhibitors in monotherapy or combined with standard chemotherapy, hypomethylating drugs, or IDH1/2 inhibitors, Bcl2 inhibitors; novel anti-human FLT3 monoclonal antibodies (e.g., FLT3/CD3 bispecific antibodies); FLT3-CAR T-cells; CDK4/6 kinase inhibitor (e.g., palbociclib).
Collapse
Affiliation(s)
- Salvatore Perrone
- Hematology, Polo Universitario Pontino, S.M. Goretti Hospital, Latina 04100, Italy
| | - Tiziana Ottone
- Department of Biomedicine and Prevention, the University of Rome “Tor Vergata”, Rome 00100 Italy
- Neuro-Oncohematology, Santa Lucia Foundation, I.R.C.C.S., Rome 00100, Italy
| | - Nadezda Zhdanovskaya
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome 00161, Italy
| | - Matteo Molica
- Hematology Unit, S. Eugenio Hospital, ASL Roma 2, Rome 00144, Italy
| |
Collapse
|
12
|
Chianese U, Papulino C, Megchelenbrink W, Tambaro FP, Ciardiello F, Benedetti R, Altucci L. Epigenomic machinery regulating pediatric AML: clonal expansion mechanisms, therapies, and future perspectives. Semin Cancer Biol 2023; 92:84-101. [PMID: 37003397 DOI: 10.1016/j.semcancer.2023.03.009] [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: 12/15/2022] [Revised: 03/07/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023]
Abstract
Acute myeloid leukemia (AML) is a heterogeneous disease with a genetic, epigenetic, and transcriptional etiology mainly presenting somatic and germline abnormalities. AML incidence rises with age but can also occur during childhood. Pediatric AML (pAML) accounts for 15-20% of all pediatric leukemias and differs considerably from adult AML. Next-generation sequencing technologies have enabled the research community to "paint" the genomic and epigenomic landscape in order to identify pathology-associated mutations and other prognostic biomarkers in pAML. Although current treatments have improved the prognosis for pAML, chemoresistance, recurrence, and refractory disease remain major challenges. In particular, pAML relapse is commonly caused by leukemia stem cells that resist therapy. Marked patient-to-patient heterogeneity is likely the primary reason why the same treatment is successful for some patients but, at best, only partially effective for others. Accumulating evidence indicates that patient-specific clonal composition impinges significantly on cellular processes, such as gene regulation and metabolism. Although our understanding of metabolism in pAML is still in its infancy, greater insights into these processes and their (epigenetic) modulation may pave the way toward novel treatment options. In this review, we summarize current knowledge on the function of genetic and epigenetic (mis)regulation in pAML, including metabolic features observed in the disease. Specifically, we describe how (epi)genetic machinery can affect chromatin status during hematopoiesis, leading to an altered metabolic profile, and focus on the potential value of targeting epigenetic abnormalities in precision and combination therapy for pAML. We also discuss the possibility of using alternative epidrug-based therapeutic approaches that are already in clinical practice, either alone as adjuvant treatments and/or in combination with other drugs.
Collapse
Affiliation(s)
- Ugo Chianese
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy.
| | - Chiara Papulino
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy.
| | - Wout Megchelenbrink
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy; Princess Máxima Center, Heidelberglaan 25, 3584 CS, Utrecht, the Netherlands.
| | - Francesco Paolo Tambaro
- Bone Marrow Transplant Unit, Pediatric Oncology Department AORN Santobono Pausilipon, 80129, Naples Italy.
| | - Fortunato Ciardiello
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy.
| | - Rosaria Benedetti
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy.
| | - Lucia Altucci
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy; Biogem Institute of Molecular and Genetic Biology, 83031 Ariano Irpino, Italy; IEOS, Institute for Endocrinology and Oncology "Gaetano Salvatore" (IEOS), 80131 Naples, Italy.
| |
Collapse
|
13
|
Bystrom R, Levis MJ. An Update on FLT3 in Acute Myeloid Leukemia: Pathophysiology and Therapeutic Landscape. Curr Oncol Rep 2023; 25:369-378. [PMID: 36808557 DOI: 10.1007/s11912-023-01389-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2022] [Indexed: 02/21/2023]
Abstract
PURPOSE OF REVIEW This review aims to summarize the pathophysiology, clinical presentation, and management of acute myeloid leukemia (AML) with FMS-like tyrosine kinase-3 (FLT3) mutations. RECENT FINDINGS The recent European Leukemia Net (ELN2022) recommendations re-classified AML with FLT3 internal tandem duplications (FLT3-ITD) as intermediate risk regardless of Nucleophosmin 1 (NPM1) co-mutation or the FLT3 allelic ratio. Allogeneic hematopoietic cell transplantation (alloHCT) is now recommended for all eligible patients with FLT3-ITD AML. This review outlines the role of FLT3 inhibitors in induction and consolidation, as well as for post-alloHCT maintenance. It outlines the unique challenges and advantages of assessing FLT3 measurable residual disease (MRD) and discusses the pre-clinical basis for the combination of FLT3 and menin inhibitors. And, for the older or unfit patient ineligible for upfront intensive chemotherapy, it discusses the recent clinical trials incorporating FLT3 inhibitors into azacytidine- and venetoclax-based regimens. Finally, it proposes a rational sequential approach for integrating FLT3 inhibitors into less intensive regimens, with a focus on improved tolerability in the older and unfit patient population. The management of AML with FLT3 mutation remains a challenge in clinical practice. This review provides an update on the pathophysiology and therapeutic landscape of FLT3 AML, as well as a clinical management framework for managing the older or unfit patient ineligible for intensive chemotherapy.
Collapse
Affiliation(s)
- Rebecca Bystrom
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mark J Levis
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA.
| |
Collapse
|
14
|
Jaramillo S, Schlenk RF. Update on current treatments for adult acute myeloid leukemia: to treat acute myeloid leukemia intensively or non-intensively? That is the question. Haematologica 2023; 108:342-352. [PMID: 36722404 PMCID: PMC9890037 DOI: 10.3324/haematol.2022.280802] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Indexed: 02/02/2023] Open
Abstract
For several decades, the treatment for acute myeloid leukemia (AML) has been a dichotomous choice between intensive chemotherapy strategies with curative intent and non-intensive options including supportive care. Patients' age and fitness, as well as comorbidities, primarily influenced this choice. However, the therapeutic armamentarium is evolving, so that there are highly effective and increasingly specific drugs, fitting the mutational profile of a patient's leukemia. There is now a spectrum of treatment options that are less intense and can be administered in an outpatient setting and to a substantial extent are equally or even more effective than standard intensive therapy. We are, therefore, witnessing a radical change in the treatment landscape of AML. In this review, we examine the current treatment options for patients with AML, considering the molecular spectrum of the disease on the background of patient-related factors.
Collapse
Affiliation(s)
- Sonia Jaramillo
- Department of Internal Medicine V, Heidelberg University Hospital
| | - Richard F. Schlenk
- Department of Internal Medicine V, Heidelberg University Hospital,NCT-Trial Center, National Center of Tumor Diseases, Heidelberg University Hospital and German Cancer Research Center, Heidelberg, Germany,F. Schlenk_Richard
| |
Collapse
|
15
|
The evolution of targeted therapy in pediatric AML: gemtuzumab ozogamicin, FLT3/IDH/BCL2 inhibitors, and other therapies. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:603-610. [PMID: 36485125 PMCID: PMC9819987 DOI: 10.1182/hematology.2022000358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Despite the maximum intensification of chemotherapy and the increased use of hematopoietic stem cell transplantation (HCT) in pediatric patients with acute myeloid leukemia (AML), nearly 40% of patients still experience relapse, and cure in this setting remains a significant challenge. Recent improvements in AML characterization, including advances in flow cytometry and comprehensive genomic sequencing, have led to a better understanding of AML biology and the identification of multiple potential therapeutic targets. Novel agents targeting genomic lesions, cell surface antigens, and other mechanisms that permit oncogenesis or immune escape are being incorporated into current treatment strategies or are under investigation in efforts to improve outcomes and decrease the toxicities and late effects associated with traditional intensive chemotherapeutic and HCT treatment. However, multiple challenges still exist, including the biologic and immunophenotypic heterogeneity of childhood AML, the differences in underlying biology as compared to adult AML, and the significant potential for on-target/off-tumor toxicity associated with therapies directed at targets common to myeloid cells, both leukemic and normal. This article reviews the current landscape of genomic and cell surface targets for children with AML with a focus on the currently available targeted therapeutic agents, those in active clinical investigation, and those still in development.
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
Döhner H, Wei AH, Roboz GJ, Montesinos P, Thol FR, Ravandi F, Dombret H, Porkka K, Sandhu I, Skikne B, See WL, Ugidos M, Risueño A, Chan ET, Thakurta A, Beach CL, Lopes de Menezes D. Prognostic impact of NPM1 and FLT3 mutations in patients with AML in first remission treated with oral azacitidine. Blood 2022; 140:1674-1685. [PMID: 35960871 PMCID: PMC10653004 DOI: 10.1182/blood.2022016293] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/27/2022] [Indexed: 11/20/2022] Open
Abstract
The randomized, placebo-controlled, phase 3 QUAZAR AML-001 trial (ClinicalTrials.gov identifier: NCT01757535) evaluated oral azacitidine (Oral-AZA) in patients with acute myeloid leukemia (AML) in first remission after intensive chemotherapy (IC) who were not candidates for hematopoietic stem cell transplantation. Eligible patients were randomized 1:1 to Oral-AZA 300 mg or placebo for 14 days per 28-day cycle. We evaluated relapse-free survival (RFS) and overall survival (OS) in patient subgroups defined by NPM1 and FLT3 mutational status at AML diagnosis and whether survival outcomes in these subgroups were influenced by presence of post-IC measurable residual disease (MRD). Gene mutations at diagnosis were collected from patient case report forms; MRD was determined centrally by multiparameter flow cytometry. Overall, 469 of 472 randomized patients (99.4%) had available mutational data; 137 patients (29.2%) had NPM1 mutations (NPM1mut), 66 patients (14.1%) had FLT3 mutations (FLT3mut; with internal tandem duplications [ITD], tyrosine kinase domain mutations [TKDmut], or both), and 30 patients (6.4%) had NPM1mut and FLT3-ITD at diagnosis. Among patients with NPM1mut, OS and RFS were improved with Oral-AZA by 37% (hazard ratio [HR], 0.63; 95% confidence interval [CI], 0.41-0.98) and 45% (HR, 0.55; 95% CI, 0.35-0.84), respectively, vs placebo. Median OS was improved numerically with Oral-AZA among patients with NPM1mut whether without MRD (48.6 months vs 31.4 months with placebo) or with MRD (46.1 months vs 10.0 months with placebo) post-IC. Among patients with FLT3mut, Oral-AZA improved OS and RFS by 37% (HR, 0.63; 95% CI, 0.35-1.12) and 49% (HR, 0.51; 95% CI, 0.27-0.95), respectively, vs placebo. Median OS with Oral-AZA vs placebo was 28.2 months vs 16.2 months, respectively, for patients with FLT3mut and without MRD and 24.0 months vs 8.0 months for patients with FLT3mut and MRD. In multivariate analyses, Oral-AZA significantly improved survival independent of NPM1 or FLT3 mutational status, cytogenetic risk, or post-IC MRD status.
Collapse
Affiliation(s)
- Hartmut Döhner
- Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany
| | - Andrew H Wei
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Australia
| | - Gail J Roboz
- Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY
- Division of Hematology & Medical Oncology, New York Presbyterian Hospital, New York, NY
| | - Pau Montesinos
- Servicio de Hematología y Hemoterapia, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Felicitas R Thol
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Medizinische Hochschule Hannover, Hannover, Germany
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hervé Dombret
- Leukemia Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Institut de Recherche Saint Louis, Université de Paris, Paris, France
| | - Kimmo Porkka
- Hematology Research Unit Helsinki, HUS Comprehensive Cancer Center, and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki, Finland
| | - Irwindeep Sandhu
- Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Barry Skikne
- University of Kansas Medical Center, Kansas City, KS
- Bristol Myers Squibb, Princeton, NJ
| | - Wendy L See
- Translational Medicine, Bristol Myers Squibb, Summit, NJ
| | - Manuel Ugidos
- BMS Center for Innovation and Translational Research Europe (CITRE), a Bristol-Myers Squibb Company, Seville, Spain
| | - Alberto Risueño
- BMS Center for Innovation and Translational Research Europe (CITRE), a Bristol-Myers Squibb Company, Seville, Spain
| | | | - Anjan Thakurta
- Translational Medicine, Bristol Myers Squibb, Summit, NJ
| | | | | |
Collapse
|
18
|
Prognostic Relevance of NPM1 and FLT3 Mutations in Acute Myeloid Leukaemia, Longterm Follow-Up-A Single Center Experience. Cancers (Basel) 2022; 14:cancers14194716. [PMID: 36230640 PMCID: PMC9562865 DOI: 10.3390/cancers14194716] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/18/2022] [Accepted: 09/23/2022] [Indexed: 11/29/2022] Open
Abstract
The prognosis of acute myeloid leukemia depends on genetic aberrations, particularly NPM1 and FLT3-ITD mutations. The targeted drugs’ availability has renewed interest in FLT3 mutations, but the impact of these genetic alterations using these treatments is yet to be confirmed. Our objective was to evaluate the results obtained with the intensified NILG-AML 01/00 protocol (ClinicalTrials.gov Identifier: NCT 00400673) in 171 unselected patients (median age, 54.5 years, range 15−74) carrying the FLT3 (ITD or TKD) and/or NPM1 mutations. The CR rate and 5-y survival were 88.3% and 58% +/− 4, respectively, significantly higher in the NPM1-mutated (CR 93.9%, p: 0.0001; survival 71% +/− 6, p: 0.0017, respectively). In isolated ITD patients, the CR was lower (66.7%, p: 0.0009), and the 3 years-relapse-free survival worse (24%, p: <0.0002). The presence of ITD, irrespective of the allelic ratio, or TKD mutation, did not significantly affect the survival or relapse-free survival among the NPM1-co-mutated patients. Our data indicate that a high dose of ARAC plus idarubicin consolidation exerts a strong anti-leukemic effect in NPM1-mutated patients both with the FLT3 wild-type and mutated AML, while in the NPM1 wild-type and FLT3-mutated, the therapeutic effect remains unsatisfactory. New strategies incorporating target therapy with second-generation inhibitors will improve these results and their addition to this aggressive chemotherapeutic program merits testing.
Collapse
|
19
|
Knight TE, Edwards H, Meshinchi S, Taub JW, Ge Y. "FLipping" the Story: FLT3-Mutated Acute Myeloid Leukemia and the Evolving Role of FLT3 Inhibitors. Cancers (Basel) 2022; 14:3398. [PMID: 35884458 PMCID: PMC9315611 DOI: 10.3390/cancers14143398] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/07/2022] [Accepted: 07/11/2022] [Indexed: 12/19/2022] Open
Abstract
The treatment of many types of cancers, including acute myeloid leukemia (AML), has been revolutionized by the development of therapeutics targeted at crucial molecular drivers of oncogenesis. In contrast to broad, relatively indiscriminate conventional chemotherapy, these targeted agents precisely disrupt key pathways within cancer cells. FMS-like tyrosine kinase 3 (FLT3)-encoding a critical regulator of hematopoiesis-is the most frequently mutated gene in patients with AML, and these mutations herald reduced survival and increased relapse in these patients. Approximately 30% of newly diagnosed AML carries an FLT3 mutation; of these, approximately three-quarters are internal tandem duplication (ITD) mutations, and the remainder are tyrosine kinase domain (TKD) mutations. In contrast to its usual, tightly controlled expression, FLT3-ITD mutants allow constitutive, "run-away" activation of a large number of key downstream pathways which promote cellular proliferation and survival. Targeted inhibition of FLT3 is, therefore, a promising therapeutic avenue. In April 2017, midostaurin became both the first FLT3 inhibitor and the first targeted therapy of any kind in AML to be approved by the US FDA. The use of FLT3 inhibitors has continued to grow as clinical trials continue to demonstrate the efficacy of this class of agents, with an expanding number available for use as both experimental standard-of-care usage. This review examines the biology of FLT3 and its downstream pathways, the mechanism of FLT3 inhibition, the development of the FLT3 inhibitors as a class and uses of the agents currently available clinically, and the mechanisms by which resistance to FLT3 inhibition may both develop and be overcome.
Collapse
Affiliation(s)
- Tristan E. Knight
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, Seattle, WA 98105, USA;
- Division of Hematology and Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98105, USA
| | - Holly Edwards
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI 48202, USA; (H.E.); (Y.G.)
- Molecular Therapeutics Program, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Soheil Meshinchi
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, Seattle, WA 98105, USA;
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Jeffrey W. Taub
- Division of Hematology/Oncology, Children’s Hospital of Michigan, Detroit, MI 48201, USA;
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI 48202, USA
- Department of Pediatrics, Central Michigan University, Mt. Pleasant, MI 48859, USA
| | - Yubin Ge
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI 48202, USA; (H.E.); (Y.G.)
- Molecular Therapeutics Program, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI 48201, USA
| |
Collapse
|
20
|
Obszański P, Kozłowska A, Wańcowiat J, Twardowska J, Lejman M, Zawitkowska J. Molecular-Targeted Therapy of Pediatric Acute Myeloid Leukemia. MOLECULES (BASEL, SWITZERLAND) 2022; 27:molecules27123911. [PMID: 35745032 PMCID: PMC9230975 DOI: 10.3390/molecules27123911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 11/29/2022]
Abstract
Acute myeloid leukemia (AML) accounts for approximately 15–20% of all childhood leukemia cases. The overall survival of children with acute myeloid leukemia does not exceed 82%, and the 5-year event-free survival rates range from 46% to 69%. Such suboptimal outcomes are the result of numerous mutations and epigenetic changes occurring in this disease that adversely affect the susceptibility to treatment and relapse rate. We describe various molecular-targeted therapies that have been developed in recent years to meet these challenges and were or are currently being studied in clinical trials. First introduced in adult AML, novel forms of treatment are slowly beginning to change the therapeutic approach to pediatric AML. Despite promising results of clinical trials investigating new drugs, further clinical studies involving greater numbers of pediatric patients are still needed to improve the outcomes in childhood AML.
Collapse
Affiliation(s)
- Piotr Obszański
- Student Scientific Society, Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, Gębali 6, 20-093 Lublin, Poland; (P.O.); (A.K.)
| | - Anna Kozłowska
- Student Scientific Society, Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, Gębali 6, 20-093 Lublin, Poland; (P.O.); (A.K.)
| | - Jakub Wańcowiat
- Student Scientific Society, Laboratory of Genetic Diagnostics, Medical University of Lublin, Gębali 6, 20-093 Lublin, Poland; (J.W.); (J.T.)
| | - Julia Twardowska
- Student Scientific Society, Laboratory of Genetic Diagnostics, Medical University of Lublin, Gębali 6, 20-093 Lublin, Poland; (J.W.); (J.T.)
| | - Monika Lejman
- Laboratory of Genetic Diagnostics, Medical University of Lublin, Gębali 6, 20-093 Lublin, Poland;
| | - Joanna Zawitkowska
- Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, Gębali 6, 20-093 Lublin, Poland
- Correspondence:
| |
Collapse
|
21
|
He S, Zhang M, Li J, Zhao W, Yu L, Han Y, Pang Y. The FLT3 Y842D mutation may be highly sensitive to midostaurin: a case report. J Int Med Res 2022; 50:3000605221097774. [PMID: 35549749 PMCID: PMC9251825 DOI: 10.1177/03000605221097774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A Y842D mutation within the activation loop of fms-like tyrosine kinase 3 (FLT3)
has been shown to confer strong resistance to sorafenib in
vitro. Whether this type of mutation exerts clinically significant
effects in patients with acute myeloid leukaemia (AML) remains unclear. Here, a
novel Y842D activating mutation within the kinase domain of FLT3, in a pregnant
patient with de novo hyperleucocyte acute myeloid leukaemia, is described.
Following induction failure with standard dose idarubicin and cytarabine (IA),
the patient received re-induction combined with midostaurin, a promising agent
targeting mutant-FLT3, and IA regimen. Fortunately, morphological remission was
achieved. During the period of midostaurin treatment, the patient exhibited a
symptom that was characteristic of differentiation syndrome, which disappeared
following treatment with methylprednisolone. The present case revealed that
Y842D, an uncommon activating mutation in the activation loop of FLT3, may be a
midostaurin-sensitive mutation type in patients with acute myeloid
leukaemia.
Collapse
Affiliation(s)
- Shujiao He
- Department of Haematology-Oncology, International Cancer Centre, Shenzhen Key Laboratory, Haematology Institution of Shenzhen University, Shenzhen University General Hospital, Shenzhen University Health Science Centre, Shenzhen, China
| | - Minjie Zhang
- Department of Obstetrics, Shenzhen University General Hospital, Shenzhen, China
| | - Jieying Li
- Department of Haematology-Oncology, International Cancer Centre, Shenzhen Key Laboratory, Haematology Institution of Shenzhen University, Shenzhen University General Hospital, Shenzhen University Health Science Centre, Shenzhen, China
| | - Weiqiang Zhao
- Department of Haematology-Oncology, International Cancer Centre, Shenzhen Key Laboratory, Haematology Institution of Shenzhen University, Shenzhen University General Hospital, Shenzhen University Health Science Centre, Shenzhen, China
| | - Li Yu
- Department of Haematology-Oncology, International Cancer Centre, Shenzhen Key Laboratory, Haematology Institution of Shenzhen University, Shenzhen University General Hospital, Shenzhen University Health Science Centre, Shenzhen, China
| | - Ying Han
- Department of Haematology, Affiliated Hospital of Hebei University, Baoding, China
| | - Yanbin Pang
- Department of Haematology-Oncology, International Cancer Centre, Shenzhen Key Laboratory, Haematology Institution of Shenzhen University, Shenzhen University General Hospital, Shenzhen University Health Science Centre, Shenzhen, China
| |
Collapse
|
22
|
Increasing Role of Targeted Immunotherapies in the Treatment of AML. Int J Mol Sci 2022; 23:ijms23063304. [PMID: 35328721 PMCID: PMC8953556 DOI: 10.3390/ijms23063304] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 12/11/2022] Open
Abstract
Acute myeloid leukemia (AML) is the most common acute leukemia in adults. The standard of care in medically and physically fit patients is intensive induction therapy. The majority of these intensively treated patients achieve a complete remission. However, a high number of these patients will experience relapse. In patients older than 60 years, the results are even worse. Therefore, new therapeutic approaches are desperately needed. One promising approach in high-risk leukemia to prevent relapse is the induction of the immune system simultaneously or after reduction of the initial tumor burden. Different immunotherapeutic approaches such as allogenic stem cell transplantation or donor lymphocyte infusions are already standard therapies, but other options for AML treatment are in the pipeline. Moreover, the therapeutic landscape in AML is rapidly changing, and in the last years, a number of immunogenic targets structures eligible for specific therapy, risk assessment or evaluation of disease course were determined. For example, leukemia-associated antigens (LAA) showed to be critical as biomarkers of disease state and survival, as well as markers of minimal residual disease (MRD). Yet many mechanisms and properties are still insufficiently understood, which also represents a great potential for this form of therapy. Therefore, targeted therapy as immunotherapy could turn into an efficient tool to clear residual disease, improve the outcome of AML patients and reduce the relapse risk. In this review, established but also emerging immunotherapeutic approaches for AML patients will be discussed.
Collapse
|
23
|
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.
Collapse
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.
| |
Collapse
|
24
|
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: 65] [Impact Index Per Article: 32.5] [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.
Collapse
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.
| |
Collapse
|
25
|
Kantarcı EN, Eşkazan AE. Gilteritinib in the management of acute myeloid leukemia: Current evidence and future directions. Leuk Res 2022; 114:106808. [DOI: 10.1016/j.leukres.2022.106808] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/29/2022] [Accepted: 02/07/2022] [Indexed: 12/22/2022]
|
26
|
Solana-Altabella A, Ballesta-López O, Megías-Vericat JE, Martínez-Cuadrón D, Montesinos P. Emerging FLT3 inhibitors for the treatment of acute myeloid leukemia. Expert Opin Emerg Drugs 2022; 27:1-18. [DOI: 10.1080/14728214.2021.2009800] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Antonio Solana-Altabella
- Servicio de Farmacia, Área del Medicamento. Hospital Universitari i Politècnic La Fe. Av. Fernando Abril Martorell, Valencia– Spain
- Instituto de Investigación Sanitaria La Fe (IISLAFE). Av. Fernando Abril Martorell, Valencia–Spain
| | - Octavio Ballesta-López
- Servicio de Farmacia, Área del Medicamento. Hospital Universitari i Politècnic La Fe. Av. Fernando Abril Martorell, Valencia– Spain
- Instituto de Investigación Sanitaria La Fe (IISLAFE). Av. Fernando Abril Martorell, Valencia–Spain
| | - Juan Eduardo Megías-Vericat
- Servicio de Farmacia, Área del Medicamento. Hospital Universitari i Politècnic La Fe. Av. Fernando Abril Martorell, Valencia– Spain
| | - David Martínez-Cuadrón
- Servicio de Farmacia, Área del Medicamento. Hospital Universitari i Politècnic La Fe. Av. Fernando Abril Martorell, Valencia– Spain
- Instituto de Investigación Sanitaria La Fe (IISLAFE). Av. Fernando Abril Martorell, Valencia–Spain
| | - Pau Montesinos
- Instituto de Investigación Sanitaria La Fe (IISLAFE). Av. Fernando Abril Martorell, Valencia–Spain
- Servicio de Hematología y Hemoterapia. Hospital Universitari i Politècnic La Fe. Av. Fernando Abril Martorell, Valencia-Spain
| |
Collapse
|
27
|
Jahn N, Jahn E, Saadati M, Bullinger L, Larson RA, Ottone T, Amadori S, Prior TW, Brandwein JM, Appelbaum FR, Medeiros BC, Tallman MS, Ehninger G, Heuser M, Ganser A, Pallaud C, Gathmann I, Krzykalla J, Benner A, Bloomfield CD, Thiede C, Stone RM, Döhner H, Döhner K. Genomic landscape of patients with FLT3-mutated acute myeloid leukemia (AML) treated within the CALGB 10603/RATIFY trial. Leukemia 2022; 36:2218-2227. [PMID: 35922444 PMCID: PMC9417991 DOI: 10.1038/s41375-022-01650-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 06/22/2022] [Accepted: 07/04/2022] [Indexed: 02/02/2023]
Abstract
The aim of this study was to characterize the mutational landscape of patients with FLT3-mutated acute myeloid leukemia (AML) treated within the randomized CALGB 10603/RATIFY trial evaluating intensive chemotherapy plus the multi-kinase inhibitor midostaurin versus placebo. We performed sequencing of 262 genes in 475 patients: mutations occurring concurrently with the FLT3-mutation were most frequent in NPM1 (61%), DNMT3A (39%), WT1 (21%), TET2 (12%), NRAS (11%), RUNX1 (11%), PTPN11 (10%), and ASXL1 (8%) genes. To assess effects of clinical and genetic features and their possible interactions, we fitted random survival forests and interpreted the resulting variable importance. Highest prognostic impact was found for WT1 and NPM1 mutations, followed by white blood cell count, FLT3 mutation type (internal tandem duplications vs. tyrosine kinase domain mutations), treatment (midostaurin vs. placebo), ASXL1 mutation, and ECOG performance status. When evaluating two-fold variable combinations the most striking effects were found for WT1:NPM1 (with NPM1 mutation abrogating the negative effect of WT1 mutation), and for WT1:treatment (with midostaurin exerting a beneficial effect in WT1-mutated AML). This targeted gene sequencing study provides important, novel insights into the genomic background of FLT3-mutated AML including the prognostic impact of co-mutations, specific gene-gene interactions, and possible treatment effects of midostaurin.
Collapse
Affiliation(s)
- Nikolaus Jahn
- grid.410712.10000 0004 0473 882XDepartment of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Ekaterina Jahn
- grid.410712.10000 0004 0473 882XDepartment of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | | | - Lars Bullinger
- grid.6363.00000 0001 2218 4662Department of Hematology, Oncology and Tumor Immunology, Charité University, Berlin, Germany
| | - Richard A. Larson
- grid.170205.10000 0004 1936 7822Department of Medicine and Comprehensive Cancer Center, University of Chicago, Chicago, IL USA
| | - Tiziana Ottone
- grid.6530.00000 0001 2300 0941Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy ,grid.414603.4Santa Lucia Foundation, Neuro-Oncohematology, I.R.C.C.S., Rome, Italy
| | - Sergio Amadori
- grid.6530.00000 0001 2300 0941Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
| | - Thomas W. Prior
- grid.67105.350000 0001 2164 3847Case Western Reserve University, Cleveland, OH USA
| | - Joseph M. Brandwein
- grid.17089.370000 0001 2190 316XDepartment of Medicine, University of Alberta, Edmonton, AB Canada
| | - Frederick R. Appelbaum
- grid.270240.30000 0001 2180 1622Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA USA
| | - Bruno C. Medeiros
- grid.168010.e0000000419368956Division of Hematology, Stanford Comprehensive Cancer Center, Stanford University, Stanford, CA USA
| | - Martin S. Tallman
- grid.51462.340000 0001 2171 9952Division of Hematologic Malignancies, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY USA
| | - Gerhard Ehninger
- grid.412282.f0000 0001 1091 2917Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus der TU Dresden, Dresden, Germany
| | - Michael Heuser
- grid.10423.340000 0000 9529 9877Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Arnold Ganser
- grid.10423.340000 0000 9529 9877Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Celine Pallaud
- grid.419481.10000 0001 1515 9979Novartis Pharmaceuticals, Basel, Switzerland
| | - Insa Gathmann
- grid.419481.10000 0001 1515 9979Novartis Pharmaceuticals, Basel, Switzerland
| | - Julia Krzykalla
- grid.7497.d0000 0004 0492 0584Division of Biostatistics, German Cancer Research Center Heidelberg, Heidelberg, Germany
| | - Axel Benner
- grid.7497.d0000 0004 0492 0584Division of Biostatistics, German Cancer Research Center Heidelberg, Heidelberg, Germany
| | - Clara D. Bloomfield
- grid.261331.40000 0001 2285 7943The Ohio State University Comprehensive Cancer Center, Columbus, OH USA
| | - Christian Thiede
- grid.412282.f0000 0001 1091 2917Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus der TU Dresden, Dresden, Germany
| | - Richard M. Stone
- grid.65499.370000 0001 2106 9910Department of Medical Oncology, Dana-Farber/Partners CancerCare, Boston, MA USA
| | - Hartmut Döhner
- grid.410712.10000 0004 0473 882XDepartment of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Konstanze Döhner
- grid.410712.10000 0004 0473 882XDepartment of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| |
Collapse
|
28
|
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: 23] [Impact Index Per Article: 7.7] [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.
Collapse
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.)
| |
Collapse
|
29
|
Srinivasan S, Kumar S, Vijayasekharan K, Agrawal AK. Prevalence and Clinical Outcome of FMS-Like Tyrosine Kinase Mutations Among Patients With Core Binding Factor-Acute Myeloid Leukemia: Systematic Review and Meta-Analysis. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 22:e221-e232. [PMID: 34750085 DOI: 10.1016/j.clml.2021.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 09/29/2021] [Accepted: 09/29/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Core binding factor acute myeloid leukemia (CBF-AML) belongs to favorable risk group in AML. However, approximately 50% of patients with CBF-AML remain incurable and their outcomes are also determined by the various co-occurring mutations. Though, FMS-like tyrosine kinase-3(FLT3) mutation in AML is associated with poor survival, the prevalence and prognostic significance of FLT3 mutations among CBF-AML is unknown. PATIENTS AND METHODS We performed a systematic review and meta-analysis to assess the prevalence of FLT3 mutations (ITD and TKD) among patients with CBF-AML. The pooled prevalence of FLT3 mutations was estimated for patients with CBF-AML, t(8;21) and Inv(16). Pooled odds ratio was calculated to compare the prevalence of various FLT3 mutations within the 2 subsets of CBF-AML. A random effects model was adopted for analysis when heterogenicity existed (Pheterogenicity< 0.05 or I2 > 50%). Otherwise, a fixed effects model was used. RESULTS The pooled prevalence of any FLT3 mutations among patients with CBF-AML was available from 18 studies and was 13% (95% CI: 10%-16%; I2 = 79%). Comparison of prevalence of FLT3 mutations between the 2 subgroups of CBF-AML showed that patients with t(8;21) had a higher prevalence of FLT3-ITD [pooled odds ratio(OR): 2.23 (95% CI:1.41-3.53, P < .01)] and lower prevalence of FLT3-TKD [pooled OR: 0.29 (95% CI:0.19-0.44; P < .01)] compared to patients with Inv(16). Additionally, we have discussed the prognostic significance of FLT3 mutations in CBF-AML patients. CONCLUSION The prevalence of FLT3-TKD mutation was commoner among Inv(16) AML while FLT3-ITD mutation was commoner among t(8;21) AML. Uniform reporting of outcomes is essential to understand the prognostic significance of FLT3 mutations among CBF-AML.
Collapse
Affiliation(s)
- Shyam Srinivasan
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Shathish Kumar
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | | | - Amit Kumar Agrawal
- Department of Medical Oncology, All India Institute of Medical Sciences, Raipur, India
| |
Collapse
|
30
|
Döhner H, Wei AH, Löwenberg B. Towards precision medicine for AML. Nat Rev Clin Oncol 2021; 18:577-590. [PMID: 34006997 DOI: 10.1038/s41571-021-00509-w] [Citation(s) in RCA: 130] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 02/08/2023]
Abstract
With rapid advances in sequencing technologies, tremendous progress has been made in understanding the molecular pathogenesis of acute myeloid leukaemia (AML), thus revealing enormous genetic and clonal heterogeneity, and paving the way for precision medicine approaches. The successful development of precision medicine for patients with AML has been exemplified by the introduction of targeted FLT3, IDH1/IDH2 and BCL-2 inhibitors. When used as single agents, these inhibitors display moderate antileukaemic activity. However, augmented clinical activity has been demonstrated when they are administered in combination with drugs with broader mechanisms of action targeting epigenetic and/or other oncogenic signalling pathways or with conventional cytotoxic agents. The development of immunotherapies has been hampered by the expression of antigens that are expressed by both leukaemic and non-malignant haematopoietic progenitor cells; nonetheless, a diverse range of immunotherapies are now entering clinical development. This myriad of emerging agents also creates challenges, such as how to safely combine agents with different mechanisms of action, the need to circumvent primary and secondary resistance, and new challenges in future clinical trial design. In this Review, we discuss the current state of precision medicine for AML, including both the potential to improve patient outcomes and the related challenges.
Collapse
Affiliation(s)
- Hartmut Döhner
- Department of Internal Medicine III, University of Ulm, Ulm, Germany.
| | - Andrew H Wei
- Department of Clinical Hematology, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Bob Löwenberg
- Department of Hematology, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| |
Collapse
|
31
|
Larson RA, Mandrekar SJ, Huebner LJ, Sanford BL, Laumann K, Geyer S, Bloomfield CD, Thiede C, Prior TW, Döhner K, Marcucci G, Voso MT, Klisovic RB, Galinsky I, Wei AH, Sierra J, Sanz MA, Brandwein JM, de Witte T, Niederwieser D, Appelbaum FR, Medeiros BC, Tallman MS, Krauter J, Schlenk RF, Ganser A, Serve H, Ehninger G, Amadori S, Gathmann I, Döhner H, Stone RM. Midostaurin reduces relapse in FLT3-mutant acute myeloid leukemia: the Alliance CALGB 10603/RATIFY trial. Leukemia 2021; 35:2539-2551. [PMID: 33654204 PMCID: PMC8591906 DOI: 10.1038/s41375-021-01179-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 01/13/2021] [Accepted: 02/01/2021] [Indexed: 01/31/2023]
Abstract
The prospective randomized, placebo-controlled CALGB 10603/RATIFY trial (Alliance) demonstrated a statistically significant overall survival benefit from the addition of midostaurin to standard frontline chemotherapy in a genotypically-defined subgroup of 717 patients with FLT3-mutant acute myeloid leukemia (AML). The risk of death was reduced by 22% on the midostaurin-containing arm. In this post hoc analysis, we analyzed the cumulative incidence of relapse (CIR) on this study and also evaluated the impact of 12 4-week cycles of maintenance therapy. CIR analyses treated relapses and AML deaths as events, deaths from other causes as competing risks, and survivors in remission were censored. CIR was improved on the midostaurin arm (HR = 0.71 (95% CI, 0.54-0.93); p = 0.01), both overall and within European LeukemiaNet 2017 risk classification subsets when post-transplant events were considered in the analysis as events. However, when transplantation was considered as a competing risk, there was overall no significant difference between the risks of relapse on the two randomized arms. Patients still in remission after consolidation with high-dose cytarabine entered the maintenance phase, continuing with either midostaurin or placebo. Analyses were inconclusive in quantifying the impact of the maintenance phase on the overall outcome. In summary, midostaurin reduces the CIR.
Collapse
Affiliation(s)
- Richard A Larson
- Department of Medicine and Comprehensive Cancer Center, University of Chicago, Chicago, IL, USA.
| | - Sumithra J Mandrekar
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, USA
| | - Lucas J Huebner
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, USA
| | - Ben L Sanford
- Alliance Statistics and Data Center, Duke University, Durham, NC, USA
| | - Kristina Laumann
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, USA
| | - Susan Geyer
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, USA
| | - Clara D Bloomfield
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Christian Thiede
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus der TU Dresden, Dresden, Germany
| | - Thomas W Prior
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Konstanze Döhner
- Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | - Guido Marcucci
- City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
| | | | - Ilene Galinsky
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Andrew H Wei
- Department of Clinical Haematology, The Alfred Hospital and Monash University, Melbourne, Australia
| | - Jorge Sierra
- Hematology Department, Hospital de la Santa Creu i Sant Pau, IIB Sant Pau and Jose Carreras Leukemia Research Institute, Autonomous University of Barcelona, Barcelona, Spain
| | - Miguel A Sanz
- Department of Hematology, Hospital Universitario y Politécnico La Fe and Department of Medicine, University of Valencia, Valencia, Spain
| | | | - Theo de Witte
- Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - Frederick R Appelbaum
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Bruno C Medeiros
- Division of Hematology, Stanford Comprehensive Cancer Center, Stanford University, Stanford, CA, USA
| | - Martin S Tallman
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jürgen Krauter
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Richard F Schlenk
- Department of Internal Medicine III, University of Ulm, Ulm, Germany
- NCT Trial Center, National Center of Tumor Diseases, Heidelberg University Hospital and German Cancer Research Center, Heidelberg, Germany
| | - Arnold Ganser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Hubert Serve
- Department of Medicine II, Hematology/Oncology, Goethe University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Gerhard Ehninger
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus der TU Dresden, Dresden, Germany
| | - Sergio Amadori
- Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
| | | | - Hartmut Döhner
- Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | - Richard M Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| |
Collapse
|
32
|
Saikia TK. How I Treat Adult Acute Myeloid Leukemia. Indian J Med Paediatr Oncol 2021. [DOI: 10.1055/s-0041-1732825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Tapan K. Saikia
- Department of Medical Oncology, Prince Aly Khan Hospital, Mumbai, Maharashtra, India Medical ,Oncology Prince Aly Khan Hospital, Mumbai, Maharashtra, India
| |
Collapse
|
33
|
Diagnostic and therapeutic pitfalls in NPM1-mutated AML: notes from the field. Leukemia 2021; 35:3113-3126. [PMID: 33879827 PMCID: PMC8056374 DOI: 10.1038/s41375-021-01222-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/21/2021] [Accepted: 03/09/2021] [Indexed: 02/02/2023]
Abstract
Mutations of Nucleophosmin (NPM1) are the most common genetic abnormalities in adult acute myeloid leukaemia (AML), accounting for about 30% of cases. NPM1-mutated AML has been recognized as distinct entity in the 2017 World Health Organization (WHO) classification of lympho-haematopoietic neoplasms. WHO criteria allow recognition of this leukaemia entity and its distinction from AML with myelodysplasia-related changes, AML with BCR-ABL1 rearrangement and AML with RUNX1 mutations. Nevertheless, controversial issues include the percentage of blasts required for the diagnosis of NPM1-mutated AML and whether cases of NPM1-mutated myelodysplasia and chronic myelomonocytic leukaemia do exist. Evaluation of NPM1 and FLT3 status represents a major pillar of the European LeukemiaNet (ELN) genetic-based risk stratification model. Moreover, NPM1 mutations are particularly suitable for assessing measurable residual disease (MRD) since they are frequent, stable at relapse and do not drive clonal haematopoiesis. Ideally, combining monitoring of MRD with the ELN prognostication model can help to guide therapeutic decisions. Here, we provide examples of instructive cases of NPM1-mutated AML, in order to provide criteria for the appropriate diagnosis and therapy of this frequent leukaemia entity.
Collapse
|