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Johansson KB, Zimmerman MS, Dmytrenko IV, Gao F, Link DC. Idasanutlin and navitoclax induce synergistic apoptotic cell death in T-cell acute lymphoblastic leukemia. Leukemia 2023; 37:2356-2366. [PMID: 37838759 PMCID: PMC10681904 DOI: 10.1038/s41375-023-02057-x] [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: 01/18/2023] [Revised: 09/24/2023] [Accepted: 10/04/2023] [Indexed: 10/16/2023]
Abstract
T-cell acute lymphoblastic leukemia (T-ALL) is an aggressive hematologic malignancy in which activating mutations in the Notch pathway are thought to contribute to transformation, in part, by activating c-Myc. Increased c-Myc expression induces oncogenic stress that can trigger apoptosis through the MDM2-p53 tumor suppressor pathway. Since the great majority of T-ALL cases carry inactivating mutations upstream in this pathway but maintain wildtype MDM2 and TP53, we hypothesized that T-ALL would be selectively sensitive to MDM2 inhibition. Treatment with idasanutlin, an MDM2 inhibitor, induced only modest apoptosis in T-ALL cells but upregulated the pro-apoptotic BH3 domain genes BAX and BBC3, prompting us to evaluate the combination of idasanutlin with BH3 mimetics. Combination treatment with idasanutlin and navitoclax, a potent Bcl-2/Bcl-xL inhibitor, induces more consistent and potent synergistic killing of T-ALL PDX lines in vitro than venetoclax, a Bcl-2 specific inhibitor. Moreover, a marked synergic response to combination treatment with idasanutlin and navitoclax was seen in vivo in all four T-ALL xenografts tested, with a significant increase in overall survival in the combination treatment group. Collectively, these preclinical data show that the combination of idasanutlin and navitoclax is highly active in T-ALL and may merit consideration in the clinical setting.
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Affiliation(s)
- Kimberly B Johansson
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Medical Scientist Training Program, Washington University School of Medicine, St. Louis, MO, USA
| | - Megan S Zimmerman
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Iryna V Dmytrenko
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Feng Gao
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel C Link
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA.
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2
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Sexauer AN, Alexe G, Gustafsson K, Zanetakos E, Milosevic J, Ayres M, Gandhi V, Pikman Y, Stegmaier K, Sykes DB. DHODH: a promising target in the treatment of T-cell acute lymphoblastic leukemia. Blood Adv 2023; 7:6685-6701. [PMID: 37648673 PMCID: PMC10641474 DOI: 10.1182/bloodadvances.2023010337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/17/2023] [Accepted: 08/09/2023] [Indexed: 09/01/2023] Open
Abstract
Patients with relapsed or refractory T-cell acute lymphoblastic leukemia (T-ALL) have a poor prognosis with few therapeutic options. With the goal of identifying novel therapeutic targets, we used data from the Dependency Map project to identify dihydroorotate dehydrogenase (DHODH) as one of the top metabolic dependencies in T-ALL. DHODH catalyzes the fourth step of de novo pyrimidine nucleotide synthesis. Small molecule inhibition of DHODH rapidly leads to the depletion of intracellular pyrimidine pools and forces cells to rely on extracellular salvage. In the absence of sufficient salvage, this intracellular nucleotide starvation results in the inhibition of DNA and RNA synthesis, cell cycle arrest, and, ultimately, death. T lymphoblasts appear to be specifically and exquisitely sensitive to nucleotide starvation after DHODH inhibition. We have confirmed this sensitivity in vitro and in vivo in 3 murine models of T-ALL. We identified that certain subsets of T-ALL seem to have an increased reliance on oxidative phosphorylation when treated with DHODH inhibitors. Through a series of metabolic assays, we show that leukemia cells, in the setting of nucleotide starvation, undergo changes in their mitochondrial membrane potential and may be more highly dependent on alternative fuel sources. The effect on normal T-cell development in young mice was also examined to show that DHODH inhibition does not permanently damage the developing thymus. These changes suggest a new metabolic vulnerability that may distinguish these cells from normal T cells and other normal hematopoietic cells and offer an exploitable therapeutic opportunity. The availability of clinical-grade DHODH inhibitors currently in human clinical trials suggests a potential for rapidly advancing this work into the clinic.
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Affiliation(s)
- Amy N. Sexauer
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology/Oncology, Boston Children’s Hospital, Boston, MA
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, MA
| | - Gabriela Alexe
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Broad Institute of MIT and Harvard, Cambridge, MA
- Harvard Medical School, Boston, MA
| | - Karin Gustafsson
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Stem Cell Institute, Cambridge, MA
- Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, MA
| | - Elizabeth Zanetakos
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, MA
| | - Jelena Milosevic
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, MA
| | - Mary Ayres
- Department of Experimental Therapeutics, MD Anderson Cancer Center, Houston, TX
| | - Varsha Gandhi
- Department of Experimental Therapeutics, MD Anderson Cancer Center, Houston, TX
| | - Yana Pikman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology/Oncology, Boston Children’s Hospital, Boston, MA
| | - Kimberly Stegmaier
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology/Oncology, Boston Children’s Hospital, Boston, MA
- Broad Institute of MIT and Harvard, Cambridge, MA
| | - David B. Sykes
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Stem Cell Institute, Cambridge, MA
- Massachusetts General Hospital Cancer Center, Boston, MA
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3
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Liu KX, Poux N, Shin KY, Moore N, Chen YH, Margossian S, Whangbo JS, Duncan CN, Lehmann LE, Marcus KJ. Comparison of Pulmonary Toxicity after Total Body Irradiation- and Busulfan-Based Myeloablative Conditioning for Allogeneic Hematopoietic Stem Cell Transplantation in Pediatric Patients. Transplant Cell Ther 2022; 28:502.e1-502.e12. [PMID: 35623615 PMCID: PMC11075968 DOI: 10.1016/j.jtct.2022.05.028] [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: 11/09/2021] [Revised: 05/14/2022] [Accepted: 05/16/2022] [Indexed: 11/22/2022]
Abstract
Pulmonary toxicity after allogeneic hematopoietic stem cell transplantation (allo-HSCT) for childhood leukemia and myelodysplastic syndrome (MDS), along with the impact of different myeloablative conditioning regimens, remain incompletely described. Here we compared the acute and long-term incidence of pulmonary toxicity (PT) after total body irradiation (TBI)- and busulfan-based myeloablative conditioning. We conducted this retrospective cohort study of 311 consecutive pediatric patients with leukemia or MDS who underwent allo-HSCT at Dana-Farber Cancer Institute/Boston Children's Hospital between 2008 and 2018. PT was graded using Common Terminology Criteria for Adverse Events version 5.0. The primary objective was to compare the cumulative incidence of grade ≥3 and grade 5 PT after TBI-based and busulfan-based myeloablative conditioning using Gray's test. Secondary objectives were to determine factors associated with PT and overall survival (OS) using competing risk analysis and Cox regression analyses, respectively. There was no significant difference between the TBI-conditioned group (n = 227) and the busulfan-conditioned group (n = 84) in the incidence of grade ≥3 PT (29.2% versus 34.7% at 2 years; P = .26) or grade 5 pulmonary toxicity (6.2% versus 6.1% at 2 years; P = .47). Age (hazard ratio [HR], 1.70, 95% confidence interval [CI], 1.11 to 2.59; P = .01), grade ≥2 PT prior to allo-HSCT or preexisting pulmonary conditions (HR, 1.84, 95% CI, 1.24 to 2.72; P < .01), acute graft-versus-host disease (GVHD) (HR, 2.50; 95% CI, 1.51 to 4.14; P < .01), and chronic GVHD (HR, 2.61; 95% CI, 1.26 to 5.42; P = .01) were associated with grade ≥3 PT on multivariable analysis. Grade ≥3 PT was associated with worse OS (81.1% versus 61.5% at 2 years; P < .01). In pediatric allo-HSCT recipients, rates of PT were similar in recipients of TBI-based and recipients of busulfan-based myeloablative conditioning regimens. Age, the presence of PT or preexisting pulmonary conditions prior to transplantation, and the development of either acute or chronic GVHD were associated with grade ≥3 PT post-transplantation. Furthermore, the occurrence of grade 3-4 PT post-transplantation was associated with inferior OS.
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Affiliation(s)
- Kevin X Liu
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Kee-Young Shin
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Yu-Hui Chen
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Steven Margossian
- Pediatric Stem Cell Transplant, Division of Pediatric Oncology, Boston Children's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jennifer S Whangbo
- Division of Hematology/Oncology, Stem Cell Transplant Program, Boston Children's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Christine N Duncan
- Pediatric Stem Cell Transplant, Division of Pediatric Oncology, Boston Children's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Leslie E Lehmann
- Pediatric Stem Cell Transplant, Division of Pediatric Oncology, Boston Children's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Karen J Marcus
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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4
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Wang XJ, Wang YH, Ong MJC, Gkitzia C, Soh SY, Hwang WYK. Cost-Effectiveness and Budget Impact Analyses of Tisagenlecleucel in Pediatric and Young Adult Patients with Relapsed or Refractory B-Cell Acute Lymphoblastic Leukemia from the Singapore Healthcare System Perspective. CLINICOECONOMICS AND OUTCOMES RESEARCH 2022; 14:333-355. [PMID: 35535300 PMCID: PMC9078873 DOI: 10.2147/ceor.s355557] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/07/2022] [Indexed: 12/29/2022] Open
Abstract
Purpose Children and young adults with relapsed or refractory (r/r) acute lymphoblastic leukemia (ALL) have poor survival due to ineffective therapy options. The newly approved chimeric antigen receptor T-cell (CAR-T) therapy, tisagenlecleucel, has demonstrated improved survival but at a high up-front cost. The study aims to evaluate the cost-effectiveness and budget impact of tisagenlecleucel versus salvage chemotherapy regimen (SCR) or blinatumomab (BLN) for the treatment of pediatric and young adult patients with relapsed/refractory B-cell ALL from the Singapore healthcare system perspective. Patients and Methods A three-health state partitioned survival model was constructed to analyze the cost-effectiveness of tisagenlecleucel vs SCR/BLN with/without allogenic hematopoietic stem cell transplantation (allo-HSCT) over a lifetime period. Clinical efficacy for tisagenlecleucel, SCR and BLN were based on pooled data from ELIANA, ENSIGN and B2101J trials, the study by von Stackelberg et al 2011, and MT103-205 respectively. Medical costs from pre-treatment until terminal care, including treatment, side effects, follow-up, subsequent allo-HSCT and relapse, were considered. Incremental cost-effectiveness ratios (ICERs) were estimated as the incremental costs per quality-adjusted life-year (QALY) gain. Additionally, the financial impact of tisagenlecleucel introduction in Singapore was estimated, comparing the present treatment scenario (without tisagenlecleucel) with a future scenario (with tisagenlecleucel), over 5 years. Results In the base-case analysis, tisagenlecleucel treatment demonstrated cost-effectiveness with an ICER of S$45,840 (US$34,762) per QALY (vs SCR) and S$51,978 (US$39,315) per QALY (vs BLN). The estimated budget ranges from S$477,857 (US$361,438) to S$1.4 million (US$1.05 million) annually for the initial 5 years. Conclusion Tisagenlecleucel is likely to be a cost-effective treatment option with limited budget implications while treating r/r ALL patients who have failed at least 2 lines of prior therapies.
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Affiliation(s)
- Xiao Jun Wang
- Novartis Singapore Pte Ltd, Singapore
- Correspondence: Xiao Jun Wang, Novartis Singapore Pte Ltd, 20 Pasir Panjang Road, #10-25/28 Mapletree Business City (West Tower), 117439, Singapore, Tel +65 67226010, Email
| | - Yi-Ho Wang
- Novartis Asia Pacific Pharmaceuticals Pte Ltd, Singapore
| | | | | | | | - William Ying Khee Hwang
- National Cancer Centre Singapore, Singapore
- Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
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5
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Boettcher M, Joechner A, Li Z, Yang SF, Schlegel P. Development of CAR T Cell Therapy in Children-A Comprehensive Overview. J Clin Med 2022; 11:jcm11082158. [PMID: 35456250 PMCID: PMC9024694 DOI: 10.3390/jcm11082158] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 01/27/2023] Open
Abstract
CAR T cell therapy has revolutionized immunotherapy in the last decade with the successful establishment of chimeric antigen receptor (CAR)-expressing cellular therapies as an alternative treatment in relapsed and refractory CD19-positive leukemias and lymphomas. There are fundamental reasons why CAR T cell therapy has been approved by the Food and Drug administration and the European Medicines Agency for pediatric and young adult patients first. Commonly, novel therapies are developed for adult patients and then adapted for pediatric use, due to regulatory and commercial reasons. Both strategic and biological factors have supported the success of CAR T cell therapy in children. Since there is an urgent need for more potent and specific therapies in childhood malignancies, efforts should also include the development of CAR therapeutics and expand applicability by introducing new technologies. Basic aspects, the evolution and the drawbacks of childhood CAR T cell therapy are discussed as along with the latest clinically relevant information.
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Affiliation(s)
- Michael Boettcher
- Department of Pediatric Surgery, University Medical Centre Mannheim, University of Heidelberg, 69117 Heidelberg, Germany;
| | - Alexander Joechner
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney 2006, Australia;
- Cellular Cancer Therapeutics Unit, Children’s Medical Research Institute, Sydney 2145, Australia; (Z.L.); (S.F.Y.)
| | - Ziduo Li
- Cellular Cancer Therapeutics Unit, Children’s Medical Research Institute, Sydney 2145, Australia; (Z.L.); (S.F.Y.)
| | - Sile Fiona Yang
- Cellular Cancer Therapeutics Unit, Children’s Medical Research Institute, Sydney 2145, Australia; (Z.L.); (S.F.Y.)
| | - Patrick Schlegel
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney 2006, Australia;
- Cellular Cancer Therapeutics Unit, Children’s Medical Research Institute, Sydney 2145, Australia; (Z.L.); (S.F.Y.)
- Department of Pediatric Hematology and Oncology, Westmead Children’s Hospital, Sydney 2145, Australia
- Correspondence:
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6
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Ribera JM, Morgades M, Genescà E, Chapchap EC, Montesinos P, Acuña-Cruz E, Gil C, García-Cadenas I, Barba P, González-Campos J, Queipo de Llano MP, Torrent A, Ribera J, Granada I, Bernal T, Díaz-Beyá M, Amigo ML, Coll R, Tormo M, Vall-Llovera F, Gómez-Centurión I, Sánchez-Sánchez MJ, Soria B, Cladera A, Artola MT, Garcia-Guiñon A, Giménez-Conca A, Amador ML, Martínez-Sánchez P, Algarra JL, Vidal MJ, Alonso N, Maluquer C, Llorente L, García-Boyero R, Ciudad J, Feliu E, Orfao A. Outcomes and prognostic factors of adults with refractory or relapsed T-cell acute lymphoblastic leukemia included in measurable residual disease-oriented trials. Hematol Oncol 2021; 39:529-538. [PMID: 34405901 DOI: 10.1002/hon.2910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/21/2021] [Accepted: 08/01/2021] [Indexed: 11/06/2022]
Abstract
Despite high complete remission (CR) rates with frontline therapy, relapses are frequent in adults with T-cell acute lymphoblastic leukemia (T-ALL) with limited salvage options. We analyzed the outcomes and prognostic factors for CR to salvage therapy and overall survival (OS) of patients with R/R T-ALL included in two prospective measurable residual disease-oriented trials. Seventy-five patients (70 relapsed, 5 refractory) were identified. Relapses occurred in bone marrow, isolated or combined in 50 patients, and in the central nervous system (CNS; isolated or combined) in 20. Second CR was attained in 30/75 patients (40%). Treatment with FLAG-Ida and isolated CNS relapse were independently associated with a higher CR rate after first salvage therapy. The median OS was 6.2 (95% confidence interval [CI], 3.9-8.6) months, with a 4-year OS probability of 18% (95% CI, 9%-27%). No differences in survival were observed according to the treatment with hematopoietic stem cell transplantation in patients in CR after first salvage therapy. Multivariable analysis showed a ≥12-month interval between first CR and relapse, CR after first salvage therapy and isolated CNS relapse as favorable prognostic factors for OS with hazard ratios (HR) (95% CI) of 1.931 (1.109-3.362), 2.958 (1.640-5.334), and 2.976 (1.157-7.655), respectively. This study confirms the poor outcomes of adults with R/R T-ALL among whom FLAG-Ida was the best of the rescue therapies evaluated. Late relapse, CR after first rescue therapy and isolated CNS relapse showed prognostic impact on survival. More effective rescue therapies are needed in adults with R/R T-ALL.
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Affiliation(s)
- Josep-Maria Ribera
- Hematology Department, Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mireia Morgades
- Hematology Department, Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eulàlia Genescà
- Hematology Department, Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Pau Montesinos
- Hematology Department, Hospital Universitari i Politènic La Fe, Valencia, Spain
| | - Evelyn Acuña-Cruz
- Hematology Department, Hospital Universitari i Politènic La Fe, Valencia, Spain
| | - Cristina Gil
- Hematology Department, Hospital General de Alicante, Alicante, Spain
| | | | - Pere Barba
- Hematology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | | | - Anna Torrent
- Hematology Department, Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jordi Ribera
- Hematology Department, Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Isabel Granada
- Hematology Department, Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Teresa Bernal
- Hematology Department, Hospital Central de Asturias, ISPA, IUOPA, Oviedo, Spain
| | | | - María-Luz Amigo
- Hematology Department, Hospital Morales Meseguer, Murcia, Spain
| | - Rosa Coll
- Hematology Department, Institut Català d'Oncologia, Hospital Josep Trueta, Girona, Spain
| | - Mar Tormo
- Hematology and Oncology Department, Instituto de investigación INCLIVA, Hospital Clínico Universitario, Valencia, Spain
| | - Ferran Vall-Llovera
- Hematology Department, Hospital Universitari Mútua de Terrasa, Terrassa, Spain
| | | | | | - Beatriz Soria
- Hematology Department, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - Antonia Cladera
- Hematology Department, Hospital Son Llàtzer, Palma de Mallorca, Spain
| | | | | | | | | | | | | | | | - Natalia Alonso
- Hematology Department, Hospital Universitario Santiago de Compostela, Santiago, Spain
| | - Clara Maluquer
- Hematology Department, Institut Catala d'Oncologia-Hospital Duran y Reynals, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Laura Llorente
- Hematology Department, Hospital HM Sanchinarro, Madrid, Spain
| | | | - Juana Ciudad
- Hematology Department, Centro de Investigación del Cáncer, IBSAL, IBMCC, CIBERONC, Hospital Universitario, Universidad de Salamanca-CSIC, Salamanca, Spain
| | - Evarist Feliu
- Hematology Department, Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alberto Orfao
- Hematology Department, Centro de Investigación del Cáncer, IBSAL, IBMCC, CIBERONC, Hospital Universitario, Universidad de Salamanca-CSIC, Salamanca, Spain
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7
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Wang A, Song Z, Zheng G, Nicolazzi C, Fromm JR, Shehu E, Srinivasan S, Chen X, Zhu C, Blondel MC, Adrian FJ. Evaluation of Preclinical Activity of Isatuximab in Patients with Acute Lymphoblastic Leukemia. Mol Cancer Ther 2021; 20:1916-1925. [PMID: 34376579 DOI: 10.1158/1535-7163.mct-21-0058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 06/12/2021] [Accepted: 07/30/2021] [Indexed: 11/16/2022]
Abstract
This study reports the pharmacologic effects of isatuximab, a CD38 mAb, on T- and B-cell acute lymphoblastic leukemia (ALL). We analyzed CD38 expression in 50-T-ALL and 50 B-ALL clinical samples, and 16 T-ALL and 11 B-ALL cell lines. We primarily focused on in vitro assessments of isatuximab-mediated antibody-dependent cellular cytotoxicity (ADCC) and antibody-dependent cellular phagocytosis (ADCP). In vivo assessment of isatuximab activity was performed in several ALL xenograft models, including disseminated and subcutaneous tumor models in female C.B-17 severe combined immunodeficiency mice. Our study reveals that most patients (90%-100%) carried CD38+ blasts independent of disease burden. The median CD38 receptor density on abnormal lymphoblasts is 41,026 copies/cell on T-ALL and 28,137 copies/cell on B-ALL, respectively. In patients with T-ALL, there is a significant increase of CD38 expression in abnormal blasts compared with normal T cells. High-level CD38 receptor density (RD) is critical to trigger effective isatuximab-mediated ADCC against target ALL cells. In addition, a correlation between CD38 RD and isatuximab-mediated ADCP is demonstrated. In the disseminated CD38+, T-ALL, and B-ALL xenograft models, isatuximab is able to induce robust antitumor activity, even at low doses. This study shows that isatuximab has significant in vitro and in vivo activity against ALL cells with robust ADCC and ADCP effects that are associated with CD38 expression levels in both T-ALL and B-ALL.
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Affiliation(s)
- Anlai Wang
- Sanofi Immuno-Oncology, Cambridge, Massachusetts
| | - Zhili Song
- Sanofi Immuno-Oncology, Cambridge, Massachusetts
| | - Gang Zheng
- Sanofi Immuno-Oncology, Cambridge, Massachusetts
| | | | - Jonathan R Fromm
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Elvis Shehu
- Sanofi Immuno-Oncology, Cambridge, Massachusetts
| | | | - Xueyan Chen
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Chen Zhu
- Sanofi Immuno-Oncology, Cambridge, Massachusetts.
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8
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Targeting serine hydroxymethyltransferases 1 and 2 for T-cell acute lymphoblastic leukemia therapy. Leukemia 2021; 36:348-360. [PMID: 34341479 PMCID: PMC8807390 DOI: 10.1038/s41375-021-01361-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 07/08/2021] [Accepted: 07/20/2021] [Indexed: 12/15/2022]
Abstract
Despite progress in the treatment of acute lymphoblastic leukemia (ALL), T-cell ALL (T-ALL) has limited treatment options, particularly in the setting of relapsed/refractory disease. Using an unbiased genome-scale CRISPR-Cas9 screen we sought to identify pathway dependencies for T-ALL which could be harnessed for therapy development. Disruption of the one-carbon folate, purine and pyrimidine pathways scored as the top metabolic pathways required for T-ALL proliferation. We used a recently developed inhibitor of SHMT1 and SHMT2, RZ-2994, to characterize the effect of inhibiting these enzymes of the one-carbon folate pathway in T-ALL and found that T-ALL cell lines were differentially sensitive to RZ-2994, with the drug inducing a S/G2 cell cycle arrest. The effects of SHMT1/2 inhibition were rescued by formate supplementation. Loss of both SHMT1 and SHMT2 was necessary for impaired growth and cell cycle arrest, with suppression of both SHMT1 and SHMT2 inhibiting leukemia progression in vivo. RZ-2994 also decreased leukemia burden in vivo and remained effective in the setting of methotrexate resistance in vitro. This study highlights the significance of the one-carbon folate pathway in T-ALL and supports further development of SHMT inhibitors for treatment of T-ALL and other cancers.
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9
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Pocock R, Farah N, Richardson SE, Mansour MR. Current and emerging therapeutic approaches for T-cell acute lymphoblastic leukaemia. Br J Haematol 2021; 194:28-43. [PMID: 33942287 DOI: 10.1111/bjh.17310] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
T-cell ALL (T-ALL) is an aggressive malignancy of T-cell progenitors. Although survival outcomes in T-ALL have greatly improved over the past 50 years, relapsed and refractory cases remain extremely challenging to treat and those who cannot tolerate intensive treatment continue to have poor outcomes. Furthermore, T-ALL has proven a more challenging immunotherapeutic target than B-ALL. In this review we explore our expanding knowledge of the basic biology of T-ALL and how this is paving the way for repurposing established treatments and the development of novel therapeutic approaches.
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Affiliation(s)
- Rachael Pocock
- Department of Haematology, UCL Cancer Institute, University College London, London, UK
| | - Nadine Farah
- Department of Haematology, UCL Cancer Institute, University College London, London, UK
| | - Simon E Richardson
- Wellcome-MRC Cambridge Stem Cell Institute, University of Cambridge, Cambridge, UK
- Department of Haematology, University of Cambridge, Jeffrey Cheah Biomedical Centre, Cambridge, UK
| | - Marc R Mansour
- Department of Haematology, UCL Cancer Institute, University College London, London, UK
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10
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Fuster JL, Bautista F, González B, Fernández JM, Rives S, Dapena JL. Blinatumomab to improve the outcome of children with relapsed B-cell acute lymphoblastic leukemia. Clin Transl Oncol 2021; 23:1963-1966. [PMID: 33742341 DOI: 10.1007/s12094-021-02590-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/08/2021] [Indexed: 11/26/2022]
Affiliation(s)
- J L Fuster
- Pediatric Oncology and Hematology Department, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Ctra. Madrid-Cartagena s/n, El Palmar, 30120, Murcia, Spain.
| | - F Bautista
- Pediatric Oncology, Hematology and Stem Cell Transplantation Department, Hospital Niño Jesús, Madrid, Spain
| | - B González
- Pediatric Oncology and Hematology Department, Hospital Universitario La Paz, Madrid, Spain
| | - J M Fernández
- Pediatric Oncology and Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - S Rives
- Pediatric Hematology and Oncology Department, Hospital San Joan de Déu, Institut de Recerca San Joan de Déu, Barcelona, Spain
| | - J L Dapena
- Pediatric Hematology and Oncology Department, Hospital San Joan de Déu, Institut de Recerca San Joan de Déu, Barcelona, Spain
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11
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Lew G, Chen Y, Lu X, Rheingold SR, Whitlock JA, Devidas M, Hastings CA, Winick NJ, Carroll WL, Wood BL, Borowitz MJ, Pulsipher MA, Hunger SP. Outcomes after late bone marrow and very early central nervous system relapse of childhood B-acute lymphoblastic leukemia: a report from the Children's Oncology Group phase III study AALL0433. Haematologica 2021; 106:46-55. [PMID: 32001530 PMCID: PMC7776266 DOI: 10.3324/haematol.2019.237230] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 01/24/2020] [Indexed: 12/18/2022] Open
Abstract
Outcomes after relapse of childhood B-acute lymphoblastic leukemia (B-ALL) are poor, and optimal therapy is unclear. The children’s Oncology Group study AALL0433 evaluated a new platform for relapsed ALL. Between March 2007 and October 2013 AALL0433 enrolled 275 participants with late bone marrow or very early isolated central nervous system (iCNS) relapse of childhood B-ALL. Patients were randomized to receive standard versus intensive vincristine dosing; this randomization was closed due to excess peripheral neuropathy in 2010. Patients with matched sibling donors received allogeneic hematopoietic cell transplantation (HCT) after the first three blocks of therapy. The prognostic value of minimal residual disease (MRD) was also evaluated in this study. The 3-year event free and overall survival (EFS/OS) for the 271 eligible patients were 63.6±3.0% and 72.3±2.8% respectively. MRD at the end of Induction-1 was highly predictive of outcome, with 3-year EFS/OS of 84.9±4.0% and 93.8±2.7% for patients with MRD <0.1%, versus 53.7±7.8% and 60.6± 7.8% for patients with MRD ≥0.1% (P<0.0001). Patients who received HCT versus chemotherapy alone had an improved 3-year disease-free survival (77.5±6.2% vs. 66.9 + 4.5%, P=0.03) but not OS (81.5±5.8% for HCT vs. 85.8±3.4% for chemotherapy, P=0.46). Patients with early iCNS relapse fared poorly, with a 3-year EFS/OS of 41.4±9.2% and 51.7±9.3%, respectively. Infectious toxicities of the chemotherapy platform were significant. The AALL0433 chemotherapy platform is efficacious for late bone marrow relapse of B-ALL, but with significant toxicities. The MRD threshold of 0.1% at the end of Induction-1 was highly predictive of the outcome. The optimal role for HCT for this patient population remains uncertain. This trial is registered at clinicaltrials.gov (NCT# 00381680).
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Affiliation(s)
- Glen Lew
- Emory University / Children's Healthcare of Atlanta
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12
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Wakase S, Teshima T, Zhang J, Ma Q, Watanabe Y, Yang H, Qi CZ, Chai X, Xie Y, Wu EQ, Igarashi A. Cost-Effectiveness Analysis of Tisagenlecleucel for the Treatment of Pediatric and Young Adult Patients with Relapsed or Refractory B Cell Acute Lymphoblastic Leukemia in Japan. Transplant Cell Ther 2020; 27:241.e1-241.e11. [PMID: 33781519 DOI: 10.1016/j.jtct.2020.12.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
Until recently, treatment options were relatively limited for children and young adults with relapsed or refractory (r/r) acute lymphoblastic leukemia (ALL). Tisagenlecleucel is a chimeric antigen receptor T cell (CAR-T) immunotherapy with promising efficacy and manageable safety that was approved in Japan in 2019 for the treatment of CD19-positive r/r B cell ALL (B-ALL). However, there is no publication assessing the cost-effectiveness of CAR-T in Japan. The objective of this study was to assess the cost-effectiveness of a tisagenlecleucel treatment strategy compared to a blinatumomab treatment strategy and a clofarabine combination treatment strategy (i.e., clofarabine + cyclophosphamide + etoposide) in Japan for pediatric and young adult patients up to 25 years of age with r/r B-ALL. A partitioned survival model with a lifetime horizon and monthly cycle was constructed from a Japanese public healthcare payer's perspective. Patients were distributed across the following partitioned health states: event-free survival (EFS), progressive disease, and death, which were informed by the EFS and overall survival (OS) data of respective clinical trials before year 5. For the tisagenlecleucel arm, a decision-tree structure was used to partition patients based on the infusion status; those who discontinued prior to receiving infusion were assigned efficacy and cost inputs of blinatumomab and those who received infusion were assigned efficacy and costs inputs based on tisagenlecleucel-infused patients. As trial data for blinatumomab and clofarabine ended before year 5, matching-adjusted indirect comparisons were used to extrapolate OS between the end of trial observation and up to year 5. All surviving patients followed the mortality risk of long-term ALL survivors without additional risk of disease relapse after year 5, regardless of initial treatment strategies. The model accounted for pretreatment costs, treatment costs, adverse event costs, follow-up costs, subsequent allogeneic hematopoietic stem cell transplantation costs, and terminal care costs. Incremental cost-effectiveness ratios (ICERs) per life-years (LYs) gained and ICERs per quality-adjusted life-years (QALYs) gained were evaluated using a 2% discount rate, and a threshold of ¥7.5 million was used to assess cost-effectiveness. Deterministic and probabilistic sensitivity analyses were performed. The total LYs (discounted) for tisagenlecleucel, blinatumomab, and clofarabine combination treatment strategies were 13.3, 4.0, and 2.7 years, respectively; the corresponding QALYs were 11.6, 3.1, and 2.1 years, respectively. The ICERs per QALY gained for tisagenlecleucel were ¥2,035,071 versus blinatumomab and ¥2,644,702 versus clofarabine combination therapy. Extensive sensitivity analyses supported the findings. Tisagenlecleucel is a cost-effective treatment strategy for pediatric and young adult patients with r/r B-ALL from a Japanese public healthcare payer's perspective.
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Affiliation(s)
| | - Takanori Teshima
- Department of Hematology, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Jie Zhang
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Qiufei Ma
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | | | | | | | | | - Eric Q Wu
- Analysis Group, Inc., Boston, Massachusetts
| | - Ataru Igarashi
- Yokohama City University School of Medicine, Yokohama, Japan; Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
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13
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Thielen FW, van Dongen‐Leunis A, Arons AMM, Ladestein JR, Hoogerbrugge PM, Uyl‐de Groot CA. Cost-effectiveness of Anti-CD19 chimeric antigen receptor T-Cell therapy in pediatric relapsed/refractory B-cell acute lymphoblastic leukemia. A societal view. Eur J Haematol 2020; 105:203-215. [PMID: 32289184 PMCID: PMC7497258 DOI: 10.1111/ejh.13427] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION In several studies, the chimeric antigen receptor T-cell therapy tisagenlecleucel demonstrated encouraging rates of remission and lasting survival benefits in pediatric patients with relapsed/refractory (r/r) acute lymphoblastic leukemia (ALL). We assessed the cost-effectiveness of tisagenlecleucel (list price: 320 000 EUR) among these patients when compared to clofarabine monotherapy (Clo-M), clofarabine combination therapy (Clo-C), and blinatumomab (Blina) from both a healthcare and a societal perspective. We also assessed future medical and future non-medical consumption costs. METHODS A three-state partitioned survival model was used to simulate a cohort of pediatric patients (12 years of age) through different disease states until the end of life (lifetime horizon). Relevant outcomes were life years, quality-adjusted life years (QALYs), healthcare costs, societal costs, and the incremental cost-effectiveness ratio (ICER). Uncertainty was explored through deterministic and probabilistic sensitivity analyses as well as through several scenario analyzes. RESULTS Total discounted costs for tisagenlecleucel were 552 679 EUR from a societal perspective, which was much higher than the total discounted costs from a healthcare perspective (ie, 409 563 EUR). Total discounted societal costs for the comparator regimens ranged between 160 803 EUR for Clo-M and 267 259 EUR for Blina. Highest QALYs were estimated for tisagenlecleucel (11.26), followed by Blina (2.25), Clo-C (1.70) and Clo-M (0.74). Discounted societal ICERs of tisagenlecleucel ranged between 31 682 EUR/QALY for Blina and 37 531 EUR/QALY for Clo-C and were considered cost-effective with a willingness-to-pay (WTP) threshold of 80 000 EUR/QALY. None of the scenarios exceeded this threshold, and more than 98% of the iterations in the probabilistic sensitivity analysis were cost-effective. DISCUSSION At the current price and WTP threshold, tisagenlecleucel is cost-effective from both a healthcare and a societal perspective. Nevertheless, long-term effectiveness data are needed to validate the several assumptions that were necessary for this model.
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Affiliation(s)
- Frederick W. Thielen
- Erasmus School of Health Policy & Management/Institute for Medical Technology AssessmentErasmus UniversityRotterdamThe Netherlands
| | - Annemieke van Dongen‐Leunis
- Erasmus School of Health Policy & Management/Institute for Medical Technology AssessmentErasmus UniversityRotterdamThe Netherlands
| | | | | | | | - Carin A. Uyl‐de Groot
- Erasmus School of Health Policy & Management/Institute for Medical Technology AssessmentErasmus UniversityRotterdamThe Netherlands
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14
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FPGS relapse-specific mutations in relapsed childhood acute lymphoblastic leukemia. Sci Rep 2020; 10:12074. [PMID: 32694622 PMCID: PMC7374087 DOI: 10.1038/s41598-020-69059-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/06/2020] [Indexed: 11/29/2022] Open
Abstract
Although the cure rate for childhood acute lymphoblastic leukemia (ALL) has exceeded 80% with contemporary therapy, relapsed ALL remains a leading cause of cancer-related death in children. Relapse-specific mutations can be identified by comprehensive genome sequencing and might have clinical significance. Applying whole-exome sequencing to eight triplicate samples, we identified in one patient relapse-specific mutations in the folylpolyglutamate synthetase (FPGS) gene, whose product catalyzes the addition of multiple glutamate residues (polyglutamation) to methotrexate upon their entry into the cells. To determine the prevalence of mutations of the FPGS mutations, and those of two important genes in the thiopurine pathway, NT5C2 and PRPS1, we studied 299 diagnostic and 73 relapsed samples in 372 patients. Three more FPGS mutants were identified in two patients, NT5C2 mutations in six patients, and PRPS1 mutants in two patients. One patient had both NT5C2 and PRPS1 mutants. None of these alterations were detected at diagnosis with a sequencing depth of 1000X, suggesting that treatment pressure led to increased prevalence of mutations during therapy. Functional characterization of the FPGS mutants showed that they directly resulted in decreased enzymatic activity, leading to significant reduction in methotrexate polyglutamation, and therefore likely contributed to drug resistance and relapse in these cases. Thus, besides genomic alterations in thiopurine metabolizing enzymes, the relapse-specific mutations of FPGS represent another critical mechanism of acquired antimetabolite drug resistance in relapsed childhood ALL.
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15
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Colunga-Pedraza JE, González-Llano O, González-Martinez CE, Gómez-Almaguer D, Yáñez-Reyes JM, Jiménez-Antolinez V, Colunga-Pedraza PR. Outpatient low toxic regimen with bortezomib in relapsed/refractory acute lymphoblastic leukemia in pediatrics and AYA patients: Single-center Mexican experience. Pediatr Blood Cancer 2020; 67:e28241. [PMID: 32159276 DOI: 10.1002/pbc.28241] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 01/28/2020] [Accepted: 02/04/2020] [Indexed: 02/03/2023]
Abstract
Relapsed or refractory acute lymphoblastic leukemia represents a major challenge in low- and middle-income countries where new therapies are not easily accessible. Combinations of cost-effective drugs should be considered as a bridge for hematopoietic stem cell transplantation. We retrospectively analyzed pediatric and adolescent and young adult patients who received reinduction with a protocol based on l-asparaginase, doxorubicin, vincristine, dexamethasone, and bortezomib (BZ). Fifteen patients were included. Total complete response (CR) was achieved by nine of 15 patients (60%); five patients achieved CR with negative minimal residual disease, two achieved complete morphological response (CR), and two complete morphological response without platelet recovery. Eleven patients (73%) were not hospitalized and 10 (66%) did not require any blood component transfusions. There were no cases of serious toxicity or mortality. Nine patients (60%) underwent transplant. Five-year overall survival was 40%. This BZ-based protocol is effective and safe when administered as an outpatient regimen and feasible in a low resource setting.
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Affiliation(s)
- Julia E Colunga-Pedraza
- Hematology Service, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Oscar González-Llano
- Hematology Service, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Carlos Eugenio González-Martinez
- Hematology Service, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - David Gómez-Almaguer
- Hematology Service, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - José Miguel Yáñez-Reyes
- Hematology Service, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Valentine Jiménez-Antolinez
- Hematology Service, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Perla R Colunga-Pedraza
- Hematology Service, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
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16
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Styczynski LM, Schappacher KA, Baccei ML. Early life vincristine fails to prime developing pain pathways. Neurosci Lett 2020; 720:134764. [PMID: 31958538 DOI: 10.1016/j.neulet.2020.134764] [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: 11/25/2019] [Revised: 01/13/2020] [Accepted: 01/16/2020] [Indexed: 10/25/2022]
Abstract
Early life administration of vincristine (VNC), commonly used to treat pediatric leukemia, evokes peripheral neuropathy and mechanical pain hypersensitivity in rats that lasts into adolescence. However, the degree to which VNC-evoked neuropathic pain persists throughout adulthood has yet to be examined. It also remains unclear if pediatric VNC exposure can 'prime' developing nociceptive pathways and thereby exacerbate chronic pain following subsequent trauma later in life. To address these issues, rats received five total doses of VNC (60 μg/kg; or vehicle) on postnatal days (P) 11, 13, 17, 19 and 21 followed by a hindpaw surgical incision during adulthood. In addition, in order to model the clinical scenario where cancer relapse necessitates another round of chemotherapy, separate groups of rats that had been treated with VNC (or vehicle) as neonates were subsequently administered VNC as adults (five injections at 100 μg/kg). Intraepidermal nerve fiber density and baseline mechanical pain sensitivity were similar between the neonatal VNC and vehicle-treated littermate controls at 13-15 weeks of age, suggesting that the peripheral neuropathy, and resulting chronic pain, had resolved by adulthood. Importantly, there was no significant overall effect of early life VNC on the severity of post-operative pain following adult incision. Similarly, prior VNC exposure did not significantly influence the degree of mechanical pain hypersensitivity produced by adult VNC treatment. Collectively, these findings suggest that early life VNC administration does not increase the susceptibility to develop chronic pain as adults.
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Affiliation(s)
- Lauren M Styczynski
- Medical Sciences Program, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, USA; Pain Research Center, Department of Anesthesiology, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, USA
| | - Katie A Schappacher
- Department of Pharmacology and Systems Physiology, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati OH 45267, USA; Pain Research Center, Department of Anesthesiology, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, USA
| | - Mark L Baccei
- Pain Research Center, Department of Anesthesiology, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, USA.
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17
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Moriyama T, Liu S, Li J, Meyer J, Zhao X, Yang W, Shao Y, Heath R, Hnízda A, Carroll WL, Yang JJ. Mechanisms of NT5C2-Mediated Thiopurine Resistance in Acute Lymphoblastic Leukemia. Mol Cancer Ther 2019; 18:1887-1895. [PMID: 31358663 DOI: 10.1158/1535-7163.mct-18-1112] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/15/2019] [Accepted: 07/23/2019] [Indexed: 02/02/2023]
Abstract
Relapse remains a formidable challenge for acute lymphoblastic leukemia (ALL). Recently, recurrent mutations in NT5C2 were identified as a common genomic lesion unique in relapsed ALL and were linked to acquired thiopurine resistance. However, molecular mechanisms by which NT5C2 regulates thiopurine cytotoxicity were incompletely understood. To this end, we sought to comprehensively characterize the biochemical and cellular effects of NT5C2 mutations. Compared with wild-type NT5C2, mutant proteins showed elevated 5'-nucleotidase activity with a stark preference of thiopurine metabolites over endogenous purine nucleotides, suggesting neomorphic effects specific to thiopurine metabolism. Expression of mutant NT5C2 mutations also significantly reduced thiopurine uptake in vitro with concomitant increase in efflux of 6-mercaptopurine (MP) metabolites, plausibly via indirect effects on drug transporter pathways. Finally, intracellular metabolomic profiling revealed significant shifts in nucleotide homeostasis induced by mutant NT5C2 at baseline; MP treatment also resulted in global changes in metabolomic profiles with completely divergent effects in cells with mutant versus wild-type NT5C2. Collectively, our data indicated that NT5C2 mutations alter thiopurine metabolism and cellular disposition, but also influence endogenous nucleotide homeostasis and thiopurine-induced metabolomic response. These complex mechanisms contributed to NT5C2-mediated drug resistance in ALL and pointed to potential opportunities for therapeutic targeting in relapsed ALL.
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Affiliation(s)
- Takaya Moriyama
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee.
| | - Shuguang Liu
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jing Li
- Department of Oncology, Pharmacology Core, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, Michigan
| | - Julia Meyer
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, California
| | - Xujie Zhao
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Wentao Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Youming Shao
- Protein Production Center, St. Jude Children's Hospital, Memphis, Tennessee
| | - Richard Heath
- Protein Production Center, St. Jude Children's Hospital, Memphis, Tennessee
| | - Aleš Hnízda
- Institute of Organic Chemistry and Biochemistry, Academy of Sciences of the Czech Republic, Prague, Czech Republic
| | - William L Carroll
- New York University Cancer Institute, New York University Langone Medical Center, New York, New York.,Department of Pathology, New York University Langone Medical Center, New York, New York.,Department of Pediatrics, New York University Langone Medical Center, New York, New York
| | - Jun J Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee. .,Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
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18
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Trucco M, Barredo JC, Goldberg J, Leclerc GM, Hale GA, Gill J, Setty B, Smith T, Lush R, Lee JK, Reed DR. A phase I window, dose escalating and safety trial of metformin in combination with induction chemotherapy in relapsed refractory acute lymphoblastic leukemia: Metformin with induction chemotherapy of vincristine, dexamethasone, PEG-asparaginase, and doxorubicin. Pediatr Blood Cancer 2018; 65:e27224. [PMID: 29856514 DOI: 10.1002/pbc.27224] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 04/09/2018] [Accepted: 04/11/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Acute lymphoblastic leukemia (ALL) remains a major cause of death in children. AMP-activated protein kinase (AMPK) affects the unfolded protein response (UPR), leading to increased vulnerability to endoplasmic reticulum (ER) stress in ALL cells. In vitro, metformin causes ALL cell death via AMPK-mediated inhibition of the UPR. It was evaluated whether ER stress could be induced in relapsed ALL through a phase I study investigating the safety and feasibility of metformin in combination with relapse induction chemotherapy. PROCEDURE Metformin was administered twice daily for 28 days in addition to vincristine, dexamethasone, PEG-asparaginase and doxorubicin (VXLD). Dose escalation of metformin was evaluated using a 3+3 design. Pharmacokinetics (PK), pharmacodynamic (PD) evaluation of the AMPK and ER stress/UPR pathways, and treatment response were assessed. RESULTS Fourteen patients were enrolled; all were evaluable for toxicity. The recommended phase 2 dose (RP2D) was Dose level 2, 1,000 mg/m2 /day. A single dose-limiting toxicity (DLT), hypoglycemia with acidosis, was observed at the RP2D and two DLTs, diarrhea and acidosis, were observed at Dose Level 3. Nine patients were evaluable for response as defined by the protocol, receiving at least 85% of planned metformin doses. Five complete remissions, one partial response, and one stable disease were observed. PD evaluation showed induction of ER stress, activation of AMPK, and inhibition of the UPR. CONCLUSIONS The VXLD with metformin was tolerable with a RP2D for metformin of 1,000 mg/m2 /day and yielded responses in a heavily pretreated population. ER stress was induced and toxicities attributable to metformin occurred in all dose levels.
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Affiliation(s)
- Matteo Trucco
- University of Miami Sylvester Comprehensive Cancer Center, Miami, FL.,UM Department of Pediatrics, Miami, FL
| | - Julio C Barredo
- University of Miami Sylvester Comprehensive Cancer Center, Miami, FL.,UM Department of Pediatrics, Miami, FL.,UM Department of Medicine, Miami, FL.,UM Department of Biochemistry and Molecular Biology, Miami, FL
| | | | - Gilles M Leclerc
- University of Miami Sylvester Comprehensive Cancer Center, Miami, FL.,UM Department of Pediatrics, Miami, FL
| | - Gregory A Hale
- Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | | | | | - Tiffany Smith
- Chemical Biology and Molecular Medicine Program, Moffitt Cancer Center, Tampa, FL
| | - Richard Lush
- Chemical Biology and Molecular Medicine Program, Moffitt Cancer Center, Tampa, FL
| | - Jae K Lee
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL
| | - Damon R Reed
- Johns Hopkins All Children's Hospital, St. Petersburg, FL.,Chemical Biology and Molecular Medicine Program, Moffitt Cancer Center, Tampa, FL.,Adolescent and Young Adult Program, Moffitt Cancer Center, Tampa, FL
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19
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Bride KL, Vincent TL, Im SY, Aplenc R, Barrett DM, Carroll WL, Carson R, Dai Y, Devidas M, Dunsmore KP, Fuller T, Glisovic-Aplenc T, Horton TM, Hunger SP, Loh ML, Maude SL, Raetz EA, Winter SS, Grupp SA, Hermiston ML, Wood BL, Teachey DT. Preclinical efficacy of daratumumab in T-cell acute lymphoblastic leukemia. Blood 2018; 131:995-999. [PMID: 29305553 PMCID: PMC5833263 DOI: 10.1182/blood-2017-07-794214] [Citation(s) in RCA: 148] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 12/11/2017] [Indexed: 12/27/2022] Open
Abstract
As a consequence of acquired or intrinsic disease resistance, the prognosis for patients with relapsed or refractory T-cell acute lymphoblastic leukemia (T-ALL) is dismal. Novel, less toxic drugs are clearly needed. One of the most promising emerging therapeutic strategies for cancer treatment is targeted immunotherapy. Immune therapies have improved outcomes for patients with other hematologic malignancies including B-cell ALL; however no immune therapy has been successfully developed for T-ALL. We hypothesize targeting CD38 will be effective against T-ALL. We demonstrate that blasts from patients with T-ALL have robust surface CD38 surface expression and that this expression remains stable after exposure to multiagent chemotherapy. CD38 is expressed at very low levels on normal lymphoid and myeloid cells and on a few tissues of nonhematopoietic origin, suggesting that CD38 may be an ideal target. Daratumumab is a human immunoglobulin G1κ monoclonal antibody that binds CD38, and has been demonstrated to be safe and effective in patients with refractory multiple myeloma. We tested daratumumab in a large panel of T-ALL patient-derived xenografts (PDX) and found striking efficacy in 14 of 15 different PDX. These data suggest that daratumumab is a promising novel therapy for pediatric T-ALL patients.
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Affiliation(s)
- Karen L Bride
- Division of Oncology, Department of Pediatrics, Center for Childhood Cancer Research, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Tiffaney L Vincent
- Division of Oncology, Department of Pediatrics, Center for Childhood Cancer Research, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Soo-Yeon Im
- Division of Oncology, Department of Pediatrics, Center for Childhood Cancer Research, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Richard Aplenc
- Division of Oncology, Department of Pediatrics, Center for Childhood Cancer Research, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David M Barrett
- Division of Oncology, Department of Pediatrics, Center for Childhood Cancer Research, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - William L Carroll
- Laura and Isaac Perlmutter Cancer Center at NYU Langone, New York University, New York, NY
| | | | - Yunfeng Dai
- Department of Biostatistics, University of Florida, Gainesville, FL
| | | | | | - Tori Fuller
- Division of Oncology, Department of Pediatrics, Center for Childhood Cancer Research, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Tina Glisovic-Aplenc
- Division of Oncology, Department of Pediatrics, Center for Childhood Cancer Research, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Terzah M Horton
- Baylor College of Medicine Dan L. Duncan Comprehensive Cancer Center, Houston, TX
| | - Stephen P Hunger
- Division of Oncology, Department of Pediatrics, Center for Childhood Cancer Research, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mignon L Loh
- Division of Hematology/Oncology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA
| | - Shannon L Maude
- Division of Oncology, Department of Pediatrics, Center for Childhood Cancer Research, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth A Raetz
- Department of Pediatrics and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Stuart S Winter
- Children's Minnesota Cancer and Blood Disorders, Minneapolis, MN; and
| | - Stephan A Grupp
- Division of Oncology, Department of Pediatrics, Center for Childhood Cancer Research, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michelle L Hermiston
- Division of Hematology/Oncology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA
| | | | - David T Teachey
- Division of Oncology, Department of Pediatrics, Center for Childhood Cancer Research, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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21
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Pierro J, Hogan LE, Bhatla T, Carroll WL. New targeted therapies for relapsed pediatric acute lymphoblastic leukemia. Expert Rev Anticancer Ther 2017. [PMID: 28649891 DOI: 10.1080/14737140.2017.1347507] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The improvement in outcomes for children with acute lymphoblastic leukemia (ALL) is one of the greatest success stories of modern oncology however the prognosis for patients who relapse remains dismal. Recent discoveries by high resolution genomic technologies have characterized the biology of relapsed leukemia, most notably pathways leading to the drug resistant phenotype. These observations open the possibility of targeting such pathways to prevent and/or treat relapse. Likewise, early experiences with new immunotherapeutic approaches have shown great promise. Areas covered: We performed a literature search on PubMed and recent meeting abstracts using the keywords below. We focused on the biology and clonal evolution of relapsed disease highlighting potential new targets of therapy. We further summarized the results of early trials of the three most prominent immunotherapy agents currently under investigation. Expert commentary: Discovery of targetable pathways that lead to drug resistance and recent breakthroughs in immunotherapy show great promise towards treating this aggressive disease. The best way to treat relapse, however, is to prevent it which makes incorporation of these new approaches into frontline therapy the best approach. Challenges remain to balance efficacy with toxicity and to prevent the emergence of resistant subclones which is why combining these newer agents with conventional chemotherapy will likely become standard of care.
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Affiliation(s)
- Joanna Pierro
- a Division of Pediatric Hematology Oncology, Department of Pediatrics , Perlmutter Cancer Center, NYU Langone Medical Center , New York , NY , USA
| | - Laura E Hogan
- b Division of Pediatric Hematology/Oncology, Department of Pediatrics , Stony Brook Children's , Stony Brook , NY , USA
| | - Teena Bhatla
- a Division of Pediatric Hematology Oncology, Department of Pediatrics , Perlmutter Cancer Center, NYU Langone Medical Center , New York , NY , USA
| | - William L Carroll
- a Division of Pediatric Hematology Oncology, Department of Pediatrics , Perlmutter Cancer Center, NYU Langone Medical Center , New York , NY , USA
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Iguchi A, Cho Y, Sugiyama M, Terashita Y, Ariga T, Hosoya Y, Hirabayashi S, Manabe A, Hara K, Aiba T, Shiokawa T, Tada H, Sato N. Bortezomib combined with standard induction chemotherapy in Japanese children with refractory acute lymphoblastic leukemia. Int J Hematol 2017; 106:291-298. [PMID: 28401497 DOI: 10.1007/s12185-017-2235-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 03/31/2017] [Accepted: 04/04/2017] [Indexed: 01/02/2023]
Abstract
Bortezomib has been shown to be effective and well-tolerated in patients with refractory acute lymphoblastic leukemia (ALL) in the Therapeutic Advances in Childhood Leukemia trial. However, the safety and efficacy of bortezomib have not been evaluated in Japanese pediatric patients. Here, we report the results of a clinical trial designed to evaluate the safety of bortezomib combined with induction chemotherapy in Japanese children with refractory ALL. A total of six patients with B-precursor ALL were enrolled in this study. Four-dose bortezomib (1.3 mg/m2/dose) combined with two standard induction chemotherapies was used. Prolonged pancytopenia (grade 4) was observed in all patients. Four of the six patients developed severe infectious complications. Peripheral neuropathy (grade 2) occurred in five patients. The individual plasma bortezomib concentration-time profiles were not related to toxicity and efficacy. Five patients were evaluable for response, and four patients achieved complete response (CR) or CR without platelet recovery (80%). In conclusion, four-dose bortezomib (1.3 mg/m2/dose) combined with standard re-induction chemotherapy was associated with a high risk of infectious complications induced by prolonged neutropenia, although high efficacy has been achieved for Japanese pediatric patients with refractory ALL. Attention must be given to severe infectious complications when performing re-induction chemotherapy including bortezomib.
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Affiliation(s)
- Akihiro Iguchi
- Department of Pediatrics, Hokkaido University Hospital, N14W5 Kita-ku, Sapporo, 060-8638, Japan.
| | - Yuko Cho
- Department of Pediatrics, Hokkaido University Hospital, N14W5 Kita-ku, Sapporo, 060-8638, Japan
| | - Minako Sugiyama
- Department of Pediatrics, Hokkaido University Hospital, N14W5 Kita-ku, Sapporo, 060-8638, Japan
| | - Yukayo Terashita
- Department of Pediatrics, Hokkaido University Hospital, N14W5 Kita-ku, Sapporo, 060-8638, Japan
| | - Tadashi Ariga
- Department of Pediatrics, Hokkaido University Hospital, N14W5 Kita-ku, Sapporo, 060-8638, Japan
| | - Yosuke Hosoya
- Department of Pediatrics, St. Luke's International Hospital, Tokyo, Japan
| | | | - Atsushi Manabe
- Department of Pediatrics, St. Luke's International Hospital, Tokyo, Japan
| | - Keisuke Hara
- Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Tetsuya Aiba
- Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Tsugumi Shiokawa
- Department of Instrumental Analysis Advanced Science Research Center, Okayama University, Okayama, Japan
| | - Hiroko Tada
- Department of Instrumental Analysis Advanced Science Research Center, Okayama University, Okayama, Japan
| | - Norihiro Sato
- Department of Clinical Research & Medical Innovation Center, Hokkaido University Hospital, Sapporo, Japan
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Koh KN, Im HJ, Kim H, Kang HJ, Park KD, Shin HY, Ahn HS, Lee JW, Yoo KH, Sung KW, Koo HH, Lim YT, Park JE, Park BK, Park HJ, Seo JJ. Outcome of Reinduction Chemotherapy with a Modified Dose of Idarubicin for Children with Marrow-Relapsed Acute Lymphoblastic Leukemia: Results of the Childhood Acute Lymphoblastic Leukemia (CALL)-0603 Study. J Korean Med Sci 2017; 32:642-649. [PMID: 28244291 PMCID: PMC5334163 DOI: 10.3346/jkms.2017.32.4.642] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 01/07/2017] [Indexed: 01/06/2023] Open
Abstract
This multicenter, prospective trial was conducted to develop an effective and safe reinduction regimen for marrow-relapsed pediatric acute lymphoblastic leukemia (ALL) by modifying the dose of idarubicin. Between 2006 and 2009, the trial accrued 44 patients, 1 to 21 years old with first marrow-relapsed ALL. The reinduction regimen comprised prednisolone, vincristine, L-asparaginase, and idarubicin (10 mg/m²/week). The idarubicin dose was adjusted according to the degree of myelosuppression. The second complete remission (CR2) rate was 72.7%, obtained by 54.2% of patients with early relapse < 24 months after initial diagnosis and 95.0% of those with late relapse (P = 0.002). Five patients entered remission with extended treatment, resulting in a final CR2 rate of 84.1%. The CR2 rate was not significantly different according to the idarubicin dose. The induction death rate was 2.3% (1/44). The 5-year event-free and overall survival rates were 22.2% ± 6.4% and 27.3% ± 6.7% for all patients, 4.2% ± 4.1% and 8.3% ± 5.6% for early relapsers, and 43.8% ± 11.4% and 50.0% ± 11.2% for late relapsers, respectively. Early relapse and slow response to reinduction chemotherapy were predictors of poor outcomes. In conclusion, a modified dose of idarubicin was effectively incorporated into the reinduction regimen for late marrow-relapsed ALL with a low toxic death rate. However, the CR2 rate for early relapsers was suboptimal, and the second remission was not durable in most patients.
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Affiliation(s)
- Kyung Nam Koh
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Ho Joon Im
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Hyery Kim
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Hyoung Jin Kang
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul, Korea
| | - Kyung Duk Park
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul, Korea
| | - Hee Young Shin
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul, Korea
| | - Hyo Seop Ahn
- Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ji Won Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keon Hee Yoo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki Woong Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Hoe Koo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Tak Lim
- Department of Pediatrics, Pusan National University College of Medicine, Busan, Korea
| | - Jun Eun Park
- Department of Pediatrics, Ajou University College of Medicine, Suwon, Korea
| | - Byung Kiu Park
- Center for Pediatric Cancer, National Cancer Center, Goyang, Korea
| | - Hyeon Jin Park
- Center for Pediatric Cancer, National Cancer Center, Goyang, Korea
| | - Jong Jin Seo
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea.
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Ceppi F, Duval M, Leclerc JM, Laverdiere C, Delva YL, Cellot S, Teira P, Bittencourt H. Improvement of the Outcome of Relapsed or Refractory Acute Lymphoblastic Leukemia in Children Using a Risk-Based Treatment Strategy. PLoS One 2016; 11:e0160310. [PMID: 27632202 PMCID: PMC5025146 DOI: 10.1371/journal.pone.0160310] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 07/18/2016] [Indexed: 11/18/2022] Open
Abstract
Relapsed/refractory acute lymphoblastic leukemia (ALL) is a leading cause of death by cancer in children. Our institution has switched relapse treatment strategy to improve survival. We reviewed records of first relapse/refractory childhood ALL between 1996 and 2012. Based on length of first remission, relapse site and immunophenotype, patients were classified into two groups: standard-risk relapse (SRR) and high-risk relapse and refractory (HRRR). Before 2007, all patients were uniformly treated with the same induction as at presentation, followed by hematopoietic stem cell transplantation (HSCT). Since 2007, treatment was given according to risk of failure: SRR were mostly treated with chemotherapy; HRRR patients underwent HSCT after intensive chemotherapy, aiming reduction of pre-transplant disease burden. Sixty-four patients were included. Thirty (47%) were SRR and 34 (53%) HRRR, including 11 with refractory ALL. Five-years overall survival (OS) and event-free survival (EFS) were similar for SRR, but were significantly higher with new risk-based strategy for HRRR: 56% versus 17% (P = 0.03) for OS, and 56% vs 11% for EFS (P = 0.008), respectively. In multivariate analysis, treatment strategy was significantly associated with survival. In conclusion, change for a risk-based strategy in our institution increased survival of high-risk patients to levels similar of those of standard-risk patients.
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Affiliation(s)
- Francesco Ceppi
- Hemato-Oncology Division, Charles Bruneau Cancer Research Center, CHU Ste-Justine, Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Michel Duval
- Hemato-Oncology Division, Charles Bruneau Cancer Research Center, CHU Ste-Justine, Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Jean-Marie Leclerc
- Hemato-Oncology Division, Charles Bruneau Cancer Research Center, CHU Ste-Justine, Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Caroline Laverdiere
- Hemato-Oncology Division, Charles Bruneau Cancer Research Center, CHU Ste-Justine, Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Yves-Line Delva
- Hemato-Oncology Division, Charles Bruneau Cancer Research Center, CHU Ste-Justine, Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Sonia Cellot
- Hemato-Oncology Division, Charles Bruneau Cancer Research Center, CHU Ste-Justine, Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Pierre Teira
- Hemato-Oncology Division, Charles Bruneau Cancer Research Center, CHU Ste-Justine, Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Henrique Bittencourt
- Hemato-Oncology Division, Charles Bruneau Cancer Research Center, CHU Ste-Justine, Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
- * E-mail:
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Bortezomib, Dexamethasone, Mitoxantrone, and Vinorelbine (BDMV): An Active Reinduction Regimen for Children With Relapsed Acute Lymphoblastic Leukemia and Asparaginase Intolerance. J Pediatr Hematol Oncol 2016; 38:345-9. [PMID: 27352191 PMCID: PMC7451259 DOI: 10.1097/mph.0000000000000560] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Children with relapsed acute lymphoblastic leukemia (ALL) typically receive vincristine-prednisone-L-asparaginase-doxorubicin reinduction chemotherapy similar to contemporary induction regimens. However, up to 20% of patients are unable to receive vincristine-prednisone-L-asparaginase-doxorubicin secondary to asparaginase intolerance. We report our experience with a promising reinduction regimen for children with relapsed ALL who are unable to receive asparaginase. PATIENTS AND METHODS This is a single institution, retrospective review of the safety and activity of bortezomib, dexamethasone, mitoxantrone, and vinorelbine (BDMV) in patients with relapsed ALL. Complete remission and adverse events after reinduction were study endpoints. Patients treated with BDMV between 2012 and 2015 were identified. Response and adverse events (AEs) were assessed by review of medical records. Standard response criteria were used and AEs were graded based on NCI CTCAEv4.0. RESULTS Seven of 10 patients achieved complete remission after 1 cycle of BDMV, with 4 achieving minimal residual disease negativity. The most common ≥grade 3 nonhematological toxicities were infection (91%), gastrointestinal (45%), metabolic (45%), and cardiovascular (9%). CONCLUSIONS BDMV is an active reinduction regimen for children with relapsed ALL who cannot receive asparaginase. The toxicity profile is as expected for this patient population. Further prospective clinical trials are warranted to evaluate the safety and efficacy of BDMV.
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Abstract
PURPOSE OF REVIEW As T cells engineered with chimeric antigen receptors (CARs) are entering advanced phases of clinical trial testing with promising results, the potential implications of use in an allogeneic environment are emerging as an important consideration. This review discusses the use of allogeneic CAR therapy, the potential effects of T-cell receptor (TCR) signaling on CAR T-cell efficacy, and the potential for TCR elimination to generate an off-the-shelf product. RECENT FINDINGS The majority of preclinical and clinical data regarding allogeneic T cells are focused on safety of their use given the potential for graft-versus-host disease (GVHD) mediated by the T-cell receptor expressed with the introduced CAR. Recent clinical trials using donor-derived CAR T cells are using either rigorous patient selection or T-cell selection (such as enrichment for virus-specific T cells). Although no GVHD has been reported, the efficacy of the allogeneic CAR treatment needs to be optimized. Several preclinical models limit allogeneic CAR-driven GVHD by utilizing memory T-cell selection, virus-specific T cells, gene-editing techniques, or suicide gene engineering. SUMMARY In the allogeneic environment, the potential effects of TCR signaling on the efficacy of CAR could affect the clinical responses with the use of donor-derived CAR T cells. Better understanding of the functionality of donor-derived T cells for therapy is essential for the development of universal effector cells for CAR therapy.
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Feasibility Study of a Novel Experimental Induction Protocol Combining B43-PAP (Anti-CD19) Immunotoxin With Standard Induction Chemotherapy in Children and Adolescents With Relapsed B-Lineage ALL: A Report From the Children's Oncology Group. J Immunother 2016; 38:299-305. [PMID: 26261894 DOI: 10.1097/cji.0000000000000088] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND B43-pokeweed antiviral protein (B43-PAP) is a high-affinity anti-CD19 immunotoxin that is capable of causing apoptotic death in B-lineage leukemic cells with a drug-resistant phenotype. B43-PAP exhibited in vivo antileukemic activity in preclinical studies as well as on a single-agent phase I clinical trial. This pediatric phase I/II study evaluated the toxicity profile and efficacy of B43-PAP immunotoxin in combination with standard induction chemotherapy in children and adolescents with relapsed CD19-positive B-lineage acute lymphoblastic leukemia (B-ALL). Pharmacokinetic profile and immunogenicity of B43-PAP were assessed. EXPERIMENTAL DESIGN B43-PAP in combination with standard 3 and 4-drug induction chemotherapy was administered on days 9-13 and 21-25 of a 28-day treatment course with vincristine, prednisone, L-asparaginase, daunomycin, and intrathecal methotrexate. Thirty patients with relapsed B-ALL were enrolled on study CCG-0957. RESULTS Grade III/IV nonhematologic dose-limiting toxicities were encountered in 4 patients evaluable for toxicity and included myalgias, motor dysfunction, pulmonary toxicity, and elevated liver transaminase. Dose-limiting toxicities occurred only with the 4-drug regimen. Fourteen patients achieved a complete remission at the end of induction among the 20 patients evaluable for response. CONCLUSIONS B43-PAP in combination with standard induction chemotherapy can be safely administered and exhibits clinical antileukemic activity against relapsed B-ALL.
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Radiation Sensitization of Leukemic Cells for Low Dose Total Body Irradiation. EBioMedicine 2015; 2:278-9. [PMID: 26137568 PMCID: PMC4485904 DOI: 10.1016/j.ebiom.2015.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 03/12/2015] [Accepted: 03/12/2015] [Indexed: 11/22/2022] Open
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Zhao J, Melancon M, Zhou M. Nanoparticle Formulation to Improve the Efficacy of Radiation Therapy Against Radiation-resistant Leukemia. EBioMedicine 2015; 2:486. [PMID: 26288809 PMCID: PMC4535157 DOI: 10.1016/j.ebiom.2015.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Accepted: 05/02/2015] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jun Zhao
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, United States
| | - Marites Melancon
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, United States
| | - Min Zhou
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, United States
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Uckun FM, Mitchell LG, Qazi S, Liu Y, Zheng N, Myers DE, Song Z, Ma H, Cheng J. Development of Polypeptide-based Nanoparticles for Non-viral Delivery of CD22 RNA Trans-splicing Molecule as a New Precision Medicine Candidate Against B-lineage ALL. EBioMedicine 2015; 2:649-59. [PMID: 26288837 PMCID: PMC4534679 DOI: 10.1016/j.ebiom.2015.04.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 04/23/2015] [Accepted: 04/27/2015] [Indexed: 11/29/2022] Open
Abstract
CD22ΔE12 has emerged as a driver lesion in the pathogenesis of pediatric B-lineage acute lymphoblastic leukemia (ALL) and a new molecular target for RNA therapeutics. Here we report a 43-gene CD22ΔE12 signature transcriptome that shows a striking representation in primary human leukemia cells from patients with relapsed BPL. Our data uniquely indicate that CD22ΔE12 is a candidate driver lesion responsible for the activation of MAPK and PI3-K pathways in aggressive forms of B-lineage ALL. We also show that the forced expression of a CD22 RNA trans-splicing molecule (RTM) markedly reduces the capacity of the leukemic stem cell fraction of CD22ΔE12+ B-lineage ALL cells to engraft and cause overt leukemia in NOD/SCID mice. We have successfully complexed our rationally designed lead CD22-RTM with PVBLG-8 to prepare a non-viral nanoscale formulation of CD22ΔE12-RTM with potent anti-cancer activity against CD22ΔE12+ B-lineage leukemia and lymphoma cells. CD22-RTM nanoparticles effectively delivered the CD22-RTM cargo into B-lineage ALL cells and exhibited significant anti-leukemic activity in vitro. The CD22ΔE12-driven transcriptome shows striking representation in relapsed B-lineage ALL CD22 RNA trans-splicing molecule (RTM) reduces the in vivo clonogenicity of leukemic stem cells Nanoformulations of CD22-RTM show therapeutic potential against B-lineage ALL and lymphomas
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Affiliation(s)
- Fatih M Uckun
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles (CHLA), Los Angeles, CA 90027, United States ; Division of Hematology-Oncology, Department of Pediatrics, University of Southern California Keck School of Medicine (USC KSOM), Los Angeles, CA 90027, United States ; Translational and Clinical Sciences Program, Norris Comprehensive Cancer Center, University of Southern California Keck School of Medicine (USC KSOM), Los Angeles, CA 90027, United States
| | | | - Sanjive Qazi
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles (CHLA), Los Angeles, CA 90027, United States ; Bioinformatics Program, Gustavus Adolphus College, 800 W College Avenue, St. Peter, MN 56082, United States
| | - Yang Liu
- Department of Materials Science and Engineering, University of Illinois at Urbana-Champaign (UIUC) Bioengineering Department, Urbana, IL 61801, United States
| | - Nan Zheng
- Department of Materials Science and Engineering, University of Illinois at Urbana-Champaign (UIUC) Bioengineering Department, Urbana, IL 61801, United States
| | - Dorothea E Myers
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles (CHLA), Los Angeles, CA 90027, United States
| | - Ziyuan Song
- Department of Materials Science and Engineering, University of Illinois at Urbana-Champaign (UIUC) Bioengineering Department, Urbana, IL 61801, United States
| | - Hong Ma
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles (CHLA), Los Angeles, CA 90027, United States
| | - Jianjun Cheng
- Department of Materials Science and Engineering, University of Illinois at Urbana-Champaign (UIUC) Bioengineering Department, Urbana, IL 61801, United States
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Myers DE, Yiv S, Qazi S, Ma H, Cely I, Shahidzadeh A, Arellano M, Finestone E, Gaynon PS, Termuhlen A, Cheng J, Uckun FM. CD19-antigen specific nanoscale liposomal formulation of a SYK P-site inhibitor causes apoptotic destruction of human B-precursor leukemia cells. Integr Biol (Camb) 2015; 6:766-80. [PMID: 24910947 DOI: 10.1039/c4ib00095a] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We report the anti-leukemic potency of a unique biotargeted nanoscale liposomal nanoparticle (LNP) formulation of the spleen tyrosine kinase (SYK) P-site inhibitor C61. C61-loaded LNP were decorated with a murine CD19-specific monoclonal antibody directed against radiation-resistant CD19-receptor positive aggressive B-precursor acute lymphoblastic leukemia (ALL) cells. The biotargeted C61-LNP were more potent than untargeted C61-LNP and consistently caused apoptosis in B-precursor ALL cells. The CD19-directed C61-LNP also destroyed B-precursor ALL xenograft cells and their leukemia-initiating in vivo clonogenic fraction. This unique nanostructural therapeutic modality targeting the SYK-dependent anti-apoptotic blast cell survival machinery shows promise for overcoming the clinical radiochemotherapy resistance of B-precursor ALL cells.
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Affiliation(s)
- Dorothea E Myers
- Developmental Therapeutics Program, Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles (CHLA), Los Angeles, CA 90027, USA.
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Uckun FM, Myers DE, Cheng J, Qazi S. Liposomal Nanoparticles of a Spleen Tyrosine Kinase P-Site Inhibitor Amplify the Potency of Low Dose Total Body Irradiation Against Aggressive B-Precursor Leukemia and Yield Superior Survival Outcomes in Mice. EBioMedicine 2015; 2:554-62. [PMID: 26285772 PMCID: PMC4535154 DOI: 10.1016/j.ebiom.2015.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 04/07/2015] [Accepted: 04/09/2015] [Indexed: 11/23/2022] Open
Abstract
This study was designed to improve the efficacy of radiation therapy against radiation-resistant leukemia. We report that the potency of low dose radiation therapy against B-precursor acute lymphoblastic leukemia (BPL) can be markedly enhanced by combining radiation with a liposomal nanoparticle (LNP) formulation of the SYK-P-site inhibitor C61 (“C61-LNP”). C61-LNP plus low dose total body irradiation (TBI) was substantially more effective than TBI alone or C61-LNP alone in improving the event-free survival outcome NOD/SCID mice challenged with an otherwise invariably fatal dose of human ALL xenograft cells derived from relapsed BPL patients. C61-LNP plus low dose TBI also yielded progression-free survival, tumor-free survival and overall survival outcomes in CD22ΔE12 × BCR–ABL double transgenic mice with advanced stage, radiation-resistant BPL with lymphomatous features that were significantly superior to those of mice treated with TBI alone or C61-LNP alone. Liposomal nanoparticles of C61 kill radiation-resistant leukemia cells Liposomal nanoparticles of C61 potentiate TBI against human leukemia cells Liposomal nanoparticles of C61 plus TBI improve the survival outcome of leukemic mice.
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Affiliation(s)
- Fatih M Uckun
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles (CHLA), Los Angeles, CA 90027, USA ; Department of Pediatrics, University of Southern California Keck School of Medicine (USC KSOM), Los Angeles, CA 90027, USA ; Norris Comprehensive Cancer Center, University of Southern California Keck School of Medicine (USC KSOM), Los Angeles, CA 90027, USA
| | - Dorothea E Myers
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles (CHLA), Los Angeles, CA 90027, USA
| | - Jianjun Cheng
- Department of Materials Science and Engineering, University of Illinois at Urbana-Champaign (UIUC), Urbana, IL 61801, USA
| | - Sanjive Qazi
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles (CHLA), Los Angeles, CA 90027, USA ; Bioinformatics Program, Gustavus Adolphus College, 800 W College Avenue, St. Peter, MN 56082, USA
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Uckun FM, Myers DE, Ma H, Rose R, Qazi S. Low Dose Total Body Irradiation Combined With Recombinant CD19-Ligand × Soluble TRAIL Fusion Protein is Highly Effective Against Radiation-Resistant B-Precursor Acute Lymphoblastic Leukemia in Mice. EBioMedicine 2015; 2:306-316. [PMID: 26097891 PMCID: PMC4469281 DOI: 10.1016/j.ebiom.2015.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
In high-risk remission B-precursor acute lymphoblastic leukemia (BPL) patients, relapse rates have remained high post-hematopoietic stem cell transplantation (HSCT) even after the use of very intensive total body irradiation (TBI)-based conditioning regimens, especially in patients with a high “minimal residual disease” (MRD) burden. New agents capable of killing radiation-resistant BPL cells and selectively augmenting their radiation sensitivity are therefore urgently needed. We report preclinical proof-of-principle that the potency of radiation therapy against BPL can be augmented by combining radiation with recombinant human CD19-Ligand × soluble TRAIL (“CD19L–sTRAIL”) fusion protein. CD19L–sTRAIL consistently killed radiation-resistant primary leukemia cells from BPL patients as well as BPL xenograft cells and their leukemia-initiating in vivo clonogenic fraction. Low dose total body irradiation (TBI) combined with CD19L–sTRAIL was highly effective against (1) xenografted CD19+ radiochemotherapy-resistant human BPL in NOD/SCID (NS) mice challenged with an otherwise invariably fatal dose of xenograft cells derived from relapsed BPL patients as well as (2) radiation-resistant advanced stage CD19+ murine BPL with lymphomatous features in CD22ΔE12xBCR-ABL double transgenic mice. We hypothesize that the incorporation of CD19L–sTRAIL into the pre-transplant TBI regimens of patients with very high-risk BPL will improve their survival outcome after HSCT. CD19L–sTRAIL plus low dose radiation kills leukemia-initiating cells. CD19L–sTRAIL plus low dose TBI is very well tolerated in mice. CD19L–sTRAIL plus low dose TBI is very effective in mouse models of BPL.
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Affiliation(s)
- Fatih M Uckun
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles (CHLA), Los Angeles, CA 90027 ; Division of Hematology-Oncology, Department of Pediatrics, University of Southern California Keck School of Medicine (USC KSOM), Los Angeles, CA 90027 ; Norris Comprehensive Cancer Center, University of Southern California Keck School of Medicine (USC KSOM), Los Angeles, CA 90027
| | - Dorothea E Myers
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles (CHLA), Los Angeles, CA 90027
| | - Hong Ma
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles (CHLA), Los Angeles, CA 90027
| | - Rebecca Rose
- Rose Pathology Services, LLC, St. Paul, MN 55104
| | - Sanjive Qazi
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles (CHLA), Los Angeles, CA 90027 ; Bioinformatics Program, Gustavus Adolphus College, 800 W College Avenue, St. Peter, MN 56082, USA
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Inagaki J, Fukano R, Noguchi M, Kurauchi K, Tanioka S, Okamura J. Hematopoietic stem cell transplantation following unsuccessful salvage treatment for relapsed acute lymphoblastic leukemia in children. Pediatr Blood Cancer 2015; 62:674-9. [PMID: 25546601 DOI: 10.1002/pbc.25353] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 10/22/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND For children who experience a re-induction failure or multiple recurrences following the first relapse of acute lymphoblastic leukemia (ALL), it is uncertain whether additional intensive chemotherapy aimed at hematopoietic stem cell transplantation (SCT) in complete remission (CR) or immediate SCT even in non-CR should be performed. This study aimed to investigate the impact of disease status at SCT on the outcomes of SCT for these children, whose prognosis is considered unquestionably poor even with SCT. PROCEDURE The medical records of 55 children with ALL who underwent SCT following the experience of re-induction failure (n = 25) or multiple relapses (n = 30) were retrospectively analyzed. RESULTS Twenty-one patients underwent SCT in CR (delayed CR2, CR3, and CR4) and 34 in non-CR (first or subsequent relapse). The probability of overall survival of patients with CR and with non-CR at SCT was 42.9% and 23.5% (P = 0.15), leukemia-free survival was 38.1% and 20.6% (P = 0.18), and the cumulative incidence of relapse at 2 years was 23.8% and 50%, respectively (P = 0.05). In multivariate analysis, non-CR at SCT was a significant risk factor for higher relapse incidence and male sex was a significant risk factor for lower survival. CONCLUSIONS Our results indicated that in case of tolerable patient condition, further re-induction chemotherapy might be reasonable so that SCT could be performed in CR, which might result in a low incidence of relapse after SCT. Novel approaches are required to induce CR for the treatment of children with relapsed/refractory ALL.
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Affiliation(s)
- Jiro Inagaki
- Department of Pediatrics, National Kyushu Cancer Center, Fukuoka, Japan
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Shalabi H, Angiolillo A, Fry TJ. Beyond CD19: Opportunities for Future Development of Targeted Immunotherapy in Pediatric Relapsed-Refractory Acute Leukemia. Front Pediatr 2015; 3:80. [PMID: 26484338 PMCID: PMC4589648 DOI: 10.3389/fped.2015.00080] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 09/18/2015] [Indexed: 12/30/2022] Open
Abstract
Chimeric antigen receptor (CAR) T cell therapy has been used as a targeted approach in cancer therapy. Relapsed and refractory acute leukemia in pediatrics has been difficult to treat with conventional therapy due to dose-limiting toxicities. With the recent success of CD 19 CAR in pediatric patients with B cell acute lymphoblastic leukemia (ALL), this mode of therapy has become a very attractive option for these patients with high-risk disease. In this review, we will discuss current treatment paradigms of pediatric acute leukemia and potential therapeutic targets for additional high-risk populations, including T cell ALL, AML, and infant ALL.
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Affiliation(s)
- Haneen Shalabi
- Center for Cancer and Blood Disorders, Children's National Medical Center , Washington, DC , USA
| | - Anne Angiolillo
- Center for Cancer and Blood Disorders, Children's National Medical Center , Washington, DC , USA
| | - Terry J Fry
- Hematologic Malignancies Section, Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health , Bethesda, MD , USA
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Abstract
Despite the significant advances in modern chemotherapy, it remains challenging to treat adult patients with acute lymphoblastic leukaemia (ALL). The relapse rate remains high, and the outcome at the time of relapse is dismal. Antibody-based therapies have demonstrated promising results in this patient group. Variable mechanisms have been applied to target surface antigens (CD20 [also termed MS4A1], CD22, CD52 and CD19) that are commonly expressed on malignant leukaemia cells. In this review, we will focus on the clinical application of such therapies in adult ALL, including the naked antibodies: Rituximab, Ofatumumab, Epratuzumab and Alemtuzumab; the immunotoxins: BL22 and Combotox; the immunoconjugates: inotuzumab and SAR 3419; as well as the Bi-specific T cell engaging (BiTE)-specific antibody, Blinatumomab.
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Affiliation(s)
- Jing Ai
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
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Kobayashi S, Ito M, Sano H, Mochizuki K, Akaihata M, Waragai T, Ohara Y, Hosoya M, Ohto H, Kikuta A. T-cell-replete haploidentical stem cell transplantation is highly efficacious for relapsed and refractory childhood acute leukaemia. Transfus Med 2014; 24:305-10. [PMID: 25224311 PMCID: PMC4240737 DOI: 10.1111/tme.12150] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 07/18/2014] [Accepted: 08/11/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND Despite improvements in first-line therapies, the outcomes of relapsed or refractory childhood acute leukaemia that has not achieved complete remission after relapse, has relapsed after stem cell transplantation (SCT), has primary induction failure and has relapsed with a very unfavourable cytogenetic risk profile, are dismal. OBJECTIVES AND METHODS We evaluated the feasibility and efficacy of T-cell-replete haploidentical peripheral blood stem cell transplantation (haplo-SCT) with low-dose anti-human thymocyte immunoglobulin (ATG), tacrolimus, methotrexate and prednisolone (PSL) in 14 paediatric patients with high-risk childhood acute leukaemia. RESULTS All patients achieved complete engraftment. The median time to reaching an absolute neutrophil count of more than 0.5 × 10(9) L(-1) was 14 days. Acute graft-vs-host disease (aGVHD) of grades II-IV and III-IV developed in 10 (71%) and 2 (14%) patients, respectively. Treatment-related mortality and relapse occurred in one (7%) patient and six (43%) patients, respectively. Eleven patients were alive and seven of them were disease-free with a median follow-up of 36 months (range: 30-159 months). The probability of event-free survival after 2 years was 50%. CONCLUSION These findings indicate that T-cell-replete haplo-SCT, with low-dose ATG and PSL, provides sustained remission with an acceptable risk of GVHD in paediatric patients with advanced haematologic malignancies.
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Buie LW, Moore J, van Deventer H. Successful Use of Octreotide as a Chemoprotectant for Prevention of PEG-Asparaginase-Induced Pancreatitis. Pharmacotherapy 2014; 34:e149-51. [DOI: 10.1002/phar.1460] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Larry W. Buie
- Department of Pharmacy; University of North Carolina Health Care; Chapel Hill North Carolina
- Eshelman School of Pharmacy; University of North Carolina; Chapel Hill North Carolina
| | - Joseph Moore
- Department of Pharmacy; University of North Carolina Health Care; Chapel Hill North Carolina
- Eshelman School of Pharmacy; University of North Carolina; Chapel Hill North Carolina
| | - Hank van Deventer
- Division of Hematology/Oncology; Department of Medicine; University of North Carolina Health Care; Chapel Hill North Carolina
- Lineberger Comprehensive Cancer Center; University of North Carolina; Chapel Hill North Carolina
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Fukano R, Nishimura M, Ito N, Nakashima K, Kodama Y, Okamura J, Inagaki J. Efficacy of prophylactic additional cranial irradiation and intrathecal chemotherapy for the prevention of CNS relapse after allogeneic hematopoietic SCT for childhood ALL. Pediatr Transplant 2014; 18:518-23. [PMID: 24815062 DOI: 10.1111/petr.12276] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2014] [Indexed: 11/30/2022]
Abstract
We evaluated the efficacy of CRT and IT chemotherapy, in addition to conditioning including TBI, for the prevention of CNS relapse, in allogeneic HSCT for childhood ALL. From January 1999 to December 2009, a total of 48 patients, without previous or presenting CNS involvement, underwent HSCT for ALL. All patients received myeloablative conditioning including TBI of 12 or 13.2 Gy and IT chemotherapy twice between days -10 and -2 prior to HSCT. Twenty-five patients received CRT prior to TBI (CRT+), and 23 patients did not (CRT-). CRT+ and CRT- patients had a seven-yr EFS rate of 40.0 ± 9.8% and 41.7 ± 10.6%, respectively (p = 0.8252). The seven-yr relapse rates for CRT+ and CRT- patients were 45.0 ± 11.2% and 38.4 ± 11.6%, respectively (p = 0.7460). CNS relapses were evident in 1 (4.0%) CRT+ patient and 1 (4.4%) CRT- patient (p = 1.000). There were no significant differences in EFS and the probability of CNS relapse between CRT+ and CRT- patients. These results demonstrate that CRT and IT chemotherapy, in addition to conditioning chemotherapy, may not be necessary in childhood ALL patients without previous or presenting CNS involvement.
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Affiliation(s)
- Reiji Fukano
- Department of Pediatrics, National Kyushu Cancer Center, Fukuoka, Japan
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Management of relapsed acute lymphoblastic leukemia in childhood with conventional and innovative approaches. Curr Opin Oncol 2014; 25:707-15. [PMID: 24076579 DOI: 10.1097/cco.0000000000000011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW To review and summarize the available evidence on factors predicting prognosis of children with relapsed acute lymphoblastic leukemia (ALL) and on the currently used treatment strategies, as well as on the most promising and innovative molecular or cellular therapies. RECENT FINDINGS Relapse still represents the most common cause of treatment failure, occurring in approximately 15-20% of childhood ALL. Risk-oriented standard salvage regimens are mostly based on combinations of the same agents incorporated in frontline therapies. Allogeneic hematopoietic stem cell transplantation (HSCT) is largely employed as postremission therapy, being superior to chemotherapy in high-risk patients. With conventional therapies including HSCT, 40-50% of children with relapsed ALL can be rescued. Thus, innovative approaches are needed to further improve the outcome of patients, especially when carrying poor prognostic factors. The last decade has witnessed the development of novel agents, including nucleoside analogues, anti-CD22 monoclonal antibodies and bi-specific, anti-CD3/CD19 antibodies, together with new formulations of existing chemotherapeutic agents and targeted molecules, such as tyrosine kinase inhibitors and FLT3 inhibitors. SUMMARY A significant proportion of children with relapsed ALL are salvaged by risk-oriented therapies. Novel agents should be integrated into combination regimens with the aim of further improving outcome of patients.
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Recent advances in acute lymphoblastic leukemia in children and adolescents: an expert panel discussion. Curr Opin Oncol 2014; 25 Suppl 3:S1-13; quiz S14-6. [PMID: 24305505 DOI: 10.1097/cco.0000000000000017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW Acute lymphoblastic leukemia (ALL) is the most common form of childhood leukemia, representing 75% to 80% of cases of acute leukemia among children. Dramatic improvements in the cure rates and survival outcomes for children with ALL have been seen over the past several decades; currently the 5-year survival rate for childhood ALL is more than 80%. These improvements have come about because of advances in the understanding of the molecular genetics and pathogenesis of the disease, incorporation of risk-adapted therapy, and the advent of new targeted agents. RECENT FINDINGS Scientific advances have provided new insights into leukemogenesis, drug resistance, and host pharmacogenomics, identified novel subtypes of leukemia, and suggested potential targets for therapy. At the same time novel monoclonal antibodies, small molecule inhibitors, chemotherapeutics, and cell-based treatment strategies have been developed and investigated. SUMMARY In this article, experts will discuss some of the current challenges and future directions in the treatment of pediatric ALL. The authors will offer expert guidance to practicing oncologists on how to best incorporate newer treatment approaches into the care of children and adolescents with ALL. The most important ongoing clinical trials in the area will also be reviewed.
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Uckun FM, Qazi S. Spleen tyrosine kinase as a molecular target for treatment of leukemias and lymphomas. Expert Rev Anticancer Ther 2014; 10:1407-18. [DOI: 10.1586/era.10.112] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Uckun FM, Qazi S. SYK as a New Therapeutic Target in B-Cell Precursor Acute Lymphoblastic Leukemia. ACTA ACUST UNITED AC 2014; 5:124-131. [PMID: 24851191 PMCID: PMC4026065 DOI: 10.4236/jct.2014.51015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The identification of SYK as a master regulator of apoptosis controlling the activation of the PI3-K/AKT, NFκB, and STAT3 pathways—three major anti-apoptotic signaling pathways in B-lineage leukemia/lymphoma cells—prompts the hypothesis that rationally designed inhibitors targeting SYK may overcome the resistance of malignant B-lineage lymphoid cells to apoptosis and thereby provide the foundation for more effective multi-modality treatment regimens for poor prognosis B-precursor acute lymphoblastic leukemia (BPL). In recent preclinical proof-of-concept studies, a liposomal nanoparticle (LNP) formulation of a SYK substrate-binding site inhibitor, known as C61, has been developed as a nanomedicine candidate against poor prognosis and relapsed BPL. This nanoscale formulation of C61 exhibited a uniquely favorable pharmacokinetics and safety profile in mice, induced apoptosis in radiation-resistant primary leukemic cells taken directly from BPL patients as well as in vivo clonogenic BPL xenograft cells, destroyed the leukemic stem cell fraction of BPL blasts, and exhibited potent in vivo anti-leukemic activity in xenograft models of aggressive BPL. Further development of C61-LNP may provide the foundation for new and effective treatment strategies against therapy-refractory BPL.
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Affiliation(s)
- Fatih M Uckun
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, USA ; Children's Center for Cancer and Blood Diseases, CHLA, Los Angeles, USA
| | - Sanjive Qazi
- Children's Center for Cancer and Blood Diseases, CHLA, Los Angeles, USA
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How to treat relapsed acute lymphoblastic leukemia: transplant vs. conventional chemotherapy. Indian J Pediatr 2013; 80:846-52. [PMID: 23625468 DOI: 10.1007/s12098-013-1036-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 04/03/2013] [Indexed: 10/26/2022]
Abstract
Management of relapsed acute lymphoblastic leukemia (ALL) is challenging and far from satisfactory. The treatment approaches are often varied and controversial. The duration of first remission, site of relapse, immunophenotypic and molecular characteristics of relapsed disease and response to therapy influence treatment outcome. There are three main therapeutic options i.e., chemotherapy alone, induction chemotherapy followed by HLA matched allogeneic transplant and palliation. These may be chosen based on the above mentioned factors. The response to therapy may be evaluated morphologically or by minimal residual disease (MRD). Persistence of MRD, as assessed by molecular techniques or through flowcytometry, clearly influences prognosis in children with relapsed ALL. It not only helps in identifying the subset of patients likely to benefit from allogeneic bone marrow transplant (ABMT) but also in determining the timing of transplant. Patients with non-T phenotype, with late relapsing disease and good response to re-induction therapy have been shown to do equally well with chemotherapy alone. On the other hand patients with early relapse and poor initial response are selected for ABMT. With the improvement in supportive care, better selection of HLA match donors and better immunosuppressive therapies, transplant related mortality has decreased considerably. Despite all of these overall salvage rates are still poor and novel agents are being tested in various trials to establish their role in relapsed ALL therapy.
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Abstract
With steadily improved cure rates for children with newly diagnosed acute lymphoblastic leukaemia (ALL), treating relapsed ALL has become increasingly challenging largely due to resistance to salvage therapy. Improved biological understanding of mechanisms of relapse and drug resistance, the identification of actionable molecular targets by studying leukaemic cell and host genetics, precise risk stratification with minimum residual disease measurement, and the development of new therapeutic drugs and approaches are needed to improve outcomes of relapsed patients. Molecularly targeted therapies and innovative immunotherapeutic approaches that include specialised monoclonal antibodies and cellular therapies hold promise of enhanced leukaemia cell killing with non-overlapping toxicities. Advances in preparative regimens, donor selection, and supportive care should improve the success of haemopoietic stem-cell transplantation for high-risk patients.
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Affiliation(s)
- Deepa Bhojwani
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN 38015, USA.
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Abstract
We report preclinical proof of principle for effective treatment of B-precursor acute lymphoblastic leukemia (ALL) by targeting the spleen tyrosine kinase (SYK)-dependent antiapoptotic blast cell survival machinery with a unique nanoscale pharmaceutical composition. This nanoscale liposomal formulation (NLF) contains the pentapeptide mimic 1,4-Bis (9-O dihydroquinidinyl) phthalazine/hydroquinidine 1,4-phathalazinediyl diether (C61) as the first and only selective inhibitor of the substrate binding P-site of SYK. The C61 NLF exhibited a very favorable pharmacokinetic and safety profile in mice, induced apoptosis in primary B-precursor ALL blast cells taken directly from patients as well as in vivo clonogenic ALL xenograft cells, destroyed the in vivo clonogenic fraction of ALL blast cells, and, at nontoxic dose levels, exhibited potent in vivo antileukemic activity against patient-derived ALL cells in xenograft models of aggressive B-precursor ALL. Our findings establish SYK as an attractive molecular target for therapy of B-precursor ALL. Further development of the C61 NLF may provide the foundation for therapeutic innovation against therapy-refractory B-precursor ALL.
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Abstract
Bruton’s tyrosine kinase (Btk) is intimately involved in multiple signal-transduction pathways regulating survival, activation, proliferation, and differentiation of B-lineage lymphoid cells. Btk is overexpressed and constitutively active in several B-lineage lymphoid malignancies. Btk has emerged as a new antiapoptotic molecular target for treatment of B-lineage leukemias and lymphomas. Preclinical and early clinical results indicate that Btk inhibitors may be useful in the treatment of leukemias and lymphomas.
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Affiliation(s)
- Osmond J D'Cruz
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, CA, USA
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Relapse-specific mutations in NT5C2 in childhood acute lymphoblastic leukemia. Nat Genet 2013; 45:290-4. [PMID: 23377183 PMCID: PMC3681285 DOI: 10.1038/ng.2558] [Citation(s) in RCA: 216] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 01/28/2013] [Indexed: 01/12/2023]
Abstract
Relapsed childhood acute lymphoblastic leukemia (ALL) carries a poor prognosis, despite intensive retreatment, owing to intrinsic drug resistance. The biological pathways that mediate resistance are unknown. Here, we report the transcriptome profiles of matched diagnosis and relapse bone marrow specimens from ten individuals with pediatric B-lymphoblastic leukemia using RNA sequencing. Transcriptome sequencing identified 20 newly acquired, novel nonsynonymous mutations not present at initial diagnosis, with 2 individuals harboring relapse-specific mutations in the same gene, NT5C2, encoding a 5'-nucleotidase. Full-exon sequencing of NT5C2 was completed in 61 further relapse specimens, identifying additional mutations in 5 cases. Enzymatic analysis of mutant proteins showed that base substitutions conferred increased enzymatic activity and resistance to treatment with nucleoside analog therapies. Clinically, all individuals who harbored NT5C2 mutations relapsed early, within 36 months of initial diagnosis (P = 0.03). These results suggest that mutations in NT5C2 are associated with the outgrowth of drug-resistant clones in ALL.
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Martin A, Morgan E, Hijiya N. Relapsed or refractory pediatric acute lymphoblastic leukemia: current and emerging treatments. Paediatr Drugs 2012; 14:377-87. [PMID: 22880941 DOI: 10.2165/11598430-000000000-00000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Relapsed acute lymphoblastic leukemia (ALL) represents a major cause of morbidity and mortality in pediatrics. With contemporary chemotherapy, >85% of patients with newly diagnosed ALL survive. Unfortunately, 20% of these patients will relapse and for these children, outcomes remain poor despite our best known chemotherapy protocols. Most of these children will achieve a second complete remission, but maintaining this remission remains difficult. Because relapsed ALL is such a significant cause of morbidity and mortality, it is the focus of much research interest. Efforts have been made and continue to focus on understanding the underlying biology that drives relapse. The role of hematopoietic stem cell transplantation in relapsed ALL remains unclear, but many clinicians still favor this for high-risk patients given the poor prognosis with current chemotherapy alone. It is important to use new drugs with little cross-resistance in the treatment of relapsed ALL. New classes of agents are currently being studied. We also discuss prognostic factors and the biology of relapsed ALL.
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Affiliation(s)
- Alissa Martin
- Division of HematologyOncologyStem Cell Transplant, Ann Robert H. Lurie Childrens Hospital of Chicago, Chicago, IL 60611, USA
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50
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Leung AWK, Vincent L, Chiang AKS, Lee ACW, Cheng FWT, Cheuk DKL, Luk CW, Ling SC, Li CK. Prognosis and outcome of relapsed acute lymphoblastic leukemia: a Hong Kong Pediatric Hematology and Oncology Study Group report. Pediatr Blood Cancer 2012; 59:454-60. [PMID: 22610685 DOI: 10.1002/pbc.24162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 03/14/2012] [Indexed: 02/05/2023]
Abstract
BACKGROUND In 2000, the Hong Kong Pediatric Hematology Oncology Study Group started a new relapsed acute lymphoblastic leukemia (ALL) treatment protocol based on modified ALL-REZ BFM 96 protocol aiming at improving the treatment outcome in Chinese children. PROCEDURE All patients in Hong Kong with first relapse of childhood ALL were included. Patients were stratified into four risk groups (S1, S2, S3, and S4) and the treatment consisted of intensive chemotherapy followed by allogeneic hematopoietic stem cell transplantation, if indicated. RESULTS Fifty-six patients were recruited and median age at diagnosis of ALL was 4.6 (range, 0.3-17) years. The median time from initial diagnosis to relapse was 2.5 (range, 0.3-9.1) years and follow-up time was 2.7 (range, 0-9.9) years. Forty-nine patients (87.5%) achieved second complete remission (CR2). CR2 rates for S1, S2, S3, and S4 groups were 100%, 93%, 90%, and 67%, respectively. Five-year overall survival (OS) was 50.5 ± 6.9% and event-free survival (EFS) was 41.5 ± 7.1%. There was no significant difference in survival among S1, S2, and S3 groups but S4 patients performed significantly worse with 5-year OS and EFS of 8% and 0%, respectively. CONCLUSION Children with relapsed ALL of S1-S3 risk groups could be successfully treated with intensified treatment protocol. The S4 high risk group needs more innovative approach to improve treatment outcome.
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Affiliation(s)
- Alex Wing Kwan Leung
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
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