1
|
Sanz MÁ, Montoro J, Balaguer-Roselló A, Chorão P, Villalba M, Gómez I, Solves P, Santiago M, Asensi P, Lamas B, Bataller A, Granados P, Eiris J, Martinez D, Lloret P, Louro A, Rebollar P, Perla A, de la Rubia J, Sanz J. Longitudinal outcome over four decades of allogeneic stem cell transplantation: a single center experience. Bone Marrow Transplant 2024; 59:1376-1386. [PMID: 38918495 DOI: 10.1038/s41409-024-02319-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/09/2024] [Accepted: 05/22/2024] [Indexed: 06/27/2024]
Abstract
This 45-year study (1978-2022) at a single institution evaluated HSCT outcomes and complications, emphasizing recent advances, with to provide insights into HSCT's evolving field and ongoing efforts to enhance patient outcomes. Involving 1707 patients, the study revealed an initial phase (1978-1987) with a limited activity that yielded modest outcomes, a nearly three-decade span (1988-2016) with a substantial increase in transplant activity, emphasizing umbilical cord blood transplantation (UCBT) for patients lacking a suitable matched sibling donor. In addition to a gradual increase in recipient age, significant improvement in outcomes emerged in the recent period (2017-2022), marked by UCBT replacement with haploidentical transplants, introduction of PTCY-based GVHD prophylaxis for all type of transplants, and increased use of conditioning regimens with thiotepa, busulfan, and fludarabine. In this period, reductions in GVHD, non-relapse mortality, and relapse rates significantly contributed to improved overall survival, event-free survival, and GVHD-free/relapse-free survival. The study identified specific factors, including GVHD prophylaxis and donor selection changes, associated with these positive trends. This four-decade study provides a unique perspective on allogeneic HSCT, showcasing the dynamic evolution of transplantation practices and their impact on outcomes, offering valuable insights for personalized treatment approaches and emphasizing continual innovation in this critical therapeutic modality.
Collapse
Affiliation(s)
- Miguel Ángel Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
- Department of Medicine, University of Valencia, València, Spain
| | - Juan Montoro
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
- School of Medicine and Dentistry, Catholic University of Valencia, València, Spain
| | - Aitana Balaguer-Roselló
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
| | - Pedro Chorão
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Marta Villalba
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Inés Gómez
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
| | - Pilar Solves
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
| | - Marta Santiago
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
| | - Pedro Asensi
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Brais Lamas
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Ana Bataller
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Pablo Granados
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Juan Eiris
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - David Martinez
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Pilar Lloret
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Alberto Louro
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Paula Rebollar
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Aurora Perla
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Javier de la Rubia
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
- School of Medicine and Dentistry, Catholic University of Valencia, València, Spain
| | - Jaime Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain.
- Department of Medicine, University of Valencia, València, Spain.
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain.
| |
Collapse
|
2
|
Yang H, Xun Y, Shen Y, Wang H, Tao Y, Wang H, Zhang X, Liu R, Yu H, Wei L, Yan J, Zhu X, You H. A simplified and robust risk stratification model for stem cell transplantation in pediatric acute myeloid leukemia. Cell Rep Med 2024:101762. [PMID: 39366384 DOI: 10.1016/j.xcrm.2024.101762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 06/20/2024] [Accepted: 09/11/2024] [Indexed: 10/06/2024]
Abstract
The efficacy of stem cell transplantation (SCT) in pediatric acute myeloid leukemia (pAML) remains unsatisfactory due to the limitations of existing prognostic models in predicting efficacy and selecting suitable candidates. This study aims to develop a cytomolecular risk stratification-independent prognostic model for SCT in pAML patients at CR1 stage. The pAML SCT model, based on age, KMT2A rearrangement (KMT2A-r), and minimal residual disease at end of course 1 (MRD1), effectively classifies patients into low-, intermediate-, and high-risk groups. We validate the effectiveness in an internal validation cohort and in four external validation cohorts, consisting of different graft sources and donors. Moreover, by incorporating the FMS-like tyrosine kinase 3/internal tandem duplication (FLT3/ITD) allelic ratio, the pAML SCT model is refined, enhancing its ability to effectively select suitable candidates. We develop a simple and robust risk stratification model for pAML patients undergoing SCT, to aid in risk stratification and inform pretransplant decision-making at CR1 stage.
Collapse
Affiliation(s)
- Hua Yang
- Laboratory for Excellence in Systems Biomedicine of Pediatric Oncology, Department of Pediatric Hematology and Oncology, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China; Department of Basic Medicine, School of Medicine, Foshan University, Foshan, Guangdong Province, China
| | - Yang Xun
- Laboratory for Excellence in Systems Biomedicine of Pediatric Oncology, Department of Pediatric Hematology and Oncology, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China; Department of Basic Medicine, School of Medicine, Foshan University, Foshan, Guangdong Province, China
| | - Yali Shen
- Laboratory for Excellence in Systems Biomedicine of Pediatric Oncology, Department of Pediatric Hematology and Oncology, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Hongtao Wang
- Department of Hematology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yu Tao
- Laboratory for Excellence in Systems Biomedicine of Pediatric Oncology, Department of Pediatric Hematology and Oncology, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Huihan Wang
- Department of Hematology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xinyue Zhang
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Rongqiu Liu
- Laboratory for Excellence in Systems Biomedicine of Pediatric Oncology, Department of Pediatric Hematology and Oncology, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Huarong Yu
- College of Basic Medicine, Chongqing Medical University, Chongqing, China
| | - Li Wei
- NHC Key Laboratory of Birth Defects and Reproductive Health, Chongqing Population and Family Planning Science and Technology Research Institute, Chongqing, China.
| | - Jinsong Yan
- Department of Hematology, Liaoning Medical Center for Hematopoietic Stem Cell Transplantation, Dalian Key Laboratory of Hematology, Liaoning Key Laboratory of Hematopoietic Stem Cell Transplantation and Translational Medicine, Diamond Bay Institute of Hematology, The Second Hospital of Dalian Medical University, Dalian, China.
| | - Xiaoyu Zhu
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China.
| | - Hua You
- Laboratory for Excellence in Systems Biomedicine of Pediatric Oncology, Department of Pediatric Hematology and Oncology, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.
| |
Collapse
|
3
|
Sapienza G, Castronovo M, Tringali S, Bono R, Rotolo C, Mulè A, Calafiore V, Patti C, Agueli C, Randazzo V, Santoro A, Matranga D, Castagna L. Sorafenib maintenance after allogeneic stem cell transplantation in patients with FLT3+ AML receiving midostaurin during induction and consolidation: a retrospective analysis. Front Oncol 2024; 14:1441254. [PMID: 39364317 PMCID: PMC11446915 DOI: 10.3389/fonc.2024.1441254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 08/27/2024] [Indexed: 10/05/2024] Open
Abstract
Introduction Acute myeloid leukemia (AML) relapse is the main cause of death after allogeneic stem cell transplant (allo-SCT). In AML FLT3+, it was shown that Sorafenib used as maintenance therapy after allo-SCT, significantly reduces the risk of relapse and death. Methods We analyzed 29 adult patients with FLT3m AML and underwent allogeneic stem cell transplant from 2019 to 2023. All patients received midostaurin plus conventional CT during induction and consolidation. After transplantation, Sorafenib maintenance was administered in all patients independently from MRD status at transplantation. Results Sorafenib maintenance was applied in 18 patients out 29 patients (62%). Median time to start sorafenib was 100 days (range 37-225) and median duration of treatment was 775 days (range 140-1064). For the whole population (n=29), 2-year OS, LFS, and CIR was 76%, 68% and 28%, respectively. The median time to relapse was 137 days (range 49-246). For patients treated with sorafenib (n=18), the 2-year OS, LFS, and CIR were 94%, 84% and 11%, respectively. For the whole population, the 100-day NRM was 0% and 1-year NRM was 3%. Death was caused by transplant-associated thrombotic microangiopathy in 1 patient. For patients who were administered with Sorafenib, the 1-y NRM was 5%. Death was caused by transplant associated transplant-associated thrombotic microangiopathy. Discussion This retrospective study suggests that sorafenib maintenance seem to be effective even in patients pre-treated with midostaurin.
Collapse
Affiliation(s)
- Giuseppe Sapienza
- Bone Marrow Transplantation (BMT) Unit, AOR Villa Sofia-Vincenzo Cervello, Palermo, Italy
| | - Marta Castronovo
- Bone Marrow Transplantation (BMT) Unit, AOR Villa Sofia-Vincenzo Cervello, Palermo, Italy
| | - Stefania Tringali
- Bone Marrow Transplantation (BMT) Unit, AOR Villa Sofia-Vincenzo Cervello, Palermo, Italy
| | - Roberto Bono
- Bone Marrow Transplantation (BMT) Unit, AOR Villa Sofia-Vincenzo Cervello, Palermo, Italy
| | - Cristina Rotolo
- Bone Marrow Transplantation (BMT) Unit, AOR Villa Sofia-Vincenzo Cervello, Palermo, Italy
| | - Antonino Mulè
- Onco-Hematology Unit, AOR Villa Sofia-Vincenzo Cervello, Palermo, Italy
| | - Valeria Calafiore
- Onco-Hematology Unit, AOR Villa Sofia-Vincenzo Cervello, Palermo, Italy
| | - Caterina Patti
- Onco-Hematology Unit, AOR Villa Sofia-Vincenzo Cervello, Palermo, Italy
| | - Cecilia Agueli
- Onco-Hematology and Cell Manipulation Laboratory Unit, AOR Villa Sofia-Vincenzo Cervello, Palermo, Italy
| | - Valentina Randazzo
- Onco-Hematology and Cell Manipulation Laboratory Unit, AOR Villa Sofia-Vincenzo Cervello, Palermo, Italy
| | - Alessandra Santoro
- Onco-Hematology and Cell Manipulation Laboratory Unit, AOR Villa Sofia-Vincenzo Cervello, Palermo, Italy
| | - Domenica Matranga
- Department of Health Promotion, Mother and Childcare, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Luca Castagna
- Bone Marrow Transplantation (BMT) Unit, AOR Villa Sofia-Vincenzo Cervello, Palermo, Italy
| |
Collapse
|
4
|
Chang Y, Li X, Zhou Y, Yang X, Zhao W, Fang H, Hou X. Simultaneous inhibition of FLT3 and HDAC by novel 6-ethylpyrazine-2-Carboxamide derivatives provides therapeutic advantages in acute myelocytic leukemia. Eur J Med Chem 2024; 279:116847. [PMID: 39265252 DOI: 10.1016/j.ejmech.2024.116847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2024] [Revised: 09/03/2024] [Accepted: 09/03/2024] [Indexed: 09/14/2024]
Abstract
Synergetic inhibition of FMS-like tyrosine kinase 3 (FLT3) and histone deacetylase (HDAC) by small molecule chimera presents a promising therapeutic approach for acute myeloid leukemia (AML) with FLT3 mutations. In this study, we first observed that the combined use of FLT3 inhibitor gilteritinib and HDAC inhibitor vorinostat increased the survival rate of leukemia xenograft mouse model. Then, we employed a pharmacophore fusion strategy to develop a novel series of FLT3/HDAC dual inhibitors. Among them, compound 25h demonstrated superior inhibitory activity against both FLT3 and HDAC. In particular, compound 25h exhibited enhanced anti-proliferation activity against MOLM-13 cells in comparison to gilteritinib, vorinostat, and their combination, while maintaining reduced cytotoxicity towards normal cells. Mechanistically, the heightened anti-tumor effect of compound 25h was attributed to its more potent regulation of intracellular pathways, notably phosphorylation of ERK, compared to single drug and combination treatments. Furthermore, compound 25h demonstrated superior anti-tumor efficacy in the MOLM-13 xenograft model compared to combination therapy, along with reduced in vivo toxicity. To conclude, we have identified a novel FLT3/HDAC dual inhibitor that could serve as a potential candidate for the treatment of AML.
Collapse
Affiliation(s)
- Yingjie Chang
- Department of Medicinal Chemistry, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, 44 Wenhuaxi Road, 250012, Jinan, Shandong, PR China
| | - Xue Li
- Department of Medicinal Chemistry, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, 44 Wenhuaxi Road, 250012, Jinan, Shandong, PR China
| | - Yue Zhou
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, 44 Wenhuaxi Road, 250012, Jinan, Shandong, PR China
| | - Xinying Yang
- Department of Medicinal Chemistry, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, 44 Wenhuaxi Road, 250012, Jinan, Shandong, PR China
| | - Wei Zhao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, 44 Wenhuaxi Road, 250012, Jinan, Shandong, PR China.
| | - Hao Fang
- Department of Medicinal Chemistry, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, 44 Wenhuaxi Road, 250012, Jinan, Shandong, PR China.
| | - Xuben Hou
- Department of Medicinal Chemistry, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, 44 Wenhuaxi Road, 250012, Jinan, Shandong, PR China.
| |
Collapse
|
5
|
Coiteux V, Abellan I, Ahmad I, Boisnard A, Busquet C, Ceballos P, Coman T, Godin S, Hermet É, Marcais A, Mamez AC, Quessar A, Souchet L, Magro L, Simon N. [Preventing relapse of acute leukemias and myelodysplastic syndromes in post-allograft transplantation: Prophylactic and preemptive strategies (SFGM-TC)]. Bull Cancer 2024:S0007-4551(24)00277-7. [PMID: 39242256 DOI: 10.1016/j.bulcan.2024.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 05/31/2024] [Accepted: 06/20/2024] [Indexed: 09/09/2024]
Abstract
Disease relapse remains the first cause of mortality of hematological malignancies after allogeneic hematopoietic stem cell transplantation (allo-HCT) for acute myeloid and lymphoid leukemia (AML and ALL) and for myelodysplastic syndroms (MDS). More and more patients are eligible for allo-HCT over the years and for many of them, only reduced intensity conditioning is possible, which is associated with a higher risk of relapse. Knowledge and biotechnology allow us to better identify diseases at very high risk of relapse and to measure residual disease before allo-HCT. Planning post-transplant maintenance treatment as part of a prophylaxis strategy is now feasible. Monitoring biomarkers of residual disease and post-transplant chimerism after allo-HCT allows a preemptive strategy. Within the frame of the 14th annual workshops of the Francophone Society for Bone Marrow Transplantation and Cell Therapy, the working group reviewed the literature and discussed novel strategies and therapies used to prevent relapse post-allo-HCT. Innovative drugs have been developed recently. Their toxicity profile allows their use post-allo-HCT, albeit with precaution. We reviewed the use of FLT3 inhibitors for AML, BCR::ABL inhibitors for Philadelphia chromosome for ALL, hypomethylating agents and Bcl-2 inhibitors for AML and MDS. The indications of immunomodulation and infusion of donor lymphocytes have been reviewed. Finally, we outlined methods of follow-up and support for patients receiving these prophylactic treatments.
Collapse
Affiliation(s)
- Valérie Coiteux
- CHU de Lille, service des maladies du sang, unité de greffe de moelle osseuse et thérapie cellulaire, Lille, France.
| | - Isabelle Abellan
- CHU de Montpellier, service d'onco-hématologie pédiatrique, Montpellier, France
| | - Imran Ahmad
- Hôpital Maisonneuve-Rosemont, université de Montréal, institut universitaire d'hématologie-oncologie et de thérapie cellulaire, Montréal, Québec, Canada
| | - Anne Boisnard
- AP-HP, hôpital Necker-Enfants malades, hématologie adultes, Paris, France
| | - Clémence Busquet
- CHU de Limoges, service d'hématologie clinique et thérapie cellulaire, Limoges, France
| | - Patrice Ceballos
- CHU de Montpellier, service d'hématologie clinique, Montpellier, France
| | - Tereza Coman
- CNRS ERL8254 Imagine Institute, Inserm U1163, Paris, France; Institut Gustave-Roussy, département d'hématologie, Villejuif, France
| | - Sandrine Godin
- CHU de Lille, service d'hématologie pédiatrique, Lille, France
| | - Éric Hermet
- CHU de Clermont-Ferrand, hématologie clinique, Clermont-Ferrand, France
| | - Ambroise Marcais
- AP-HP, hôpital Necke-Enfants malades, hématologie adultes, Paris, France; Université Paris Cité, institut Necker, CNRS, Inserm UMR 1151, Paris, France
| | - Anne-Claire Mamez
- Hôpitaux universitaires de Genève, université de Genève, faculté de médecine, département d'hématologie, Genève, Suisse
| | - Asmaa Quessar
- CHU d'Ibn-Rochd, service d'hématologie clinique et d'oncologie pédiatrique, Casablanca, Maroc
| | - Laetitia Souchet
- AP-HP, Sorbonne université, Pitié-Salpétrière, service d'hématologie clinique, Paris, France
| | - Léonardo Magro
- CHU de Lille, service des maladies du sang, unité de greffe de moelle osseuse et thérapie cellulaire, Lille, France
| | - Nicolas Simon
- CHU de Lille, institut de pharmacie, 59000 Lille, France; Université Lille, ULR 7365, GRITA - groupe de recherche sur les formes injectables et les technologies associées, 59000 Lille, France
| |
Collapse
|
6
|
Capria S, Trisolini SM, Torrieri L, Amabile E, Marsili G, Piciocchi A, Barberi W, Iori AP, Diverio D, Carmini D, Breccia M, Martelli M, Minotti C. Real-Life Management of FLT3-Mutated AML: Single-Centre Experience over 24 Years. Cancers (Basel) 2024; 16:2864. [PMID: 39199635 PMCID: PMC11352495 DOI: 10.3390/cancers16162864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 08/10/2024] [Accepted: 08/15/2024] [Indexed: 09/01/2024] Open
Abstract
We analyzed 140 patients with a median age of 51 years; 21% had WBC ≥ 100 × 109/L, and 52% had an NPM1 co-mutation. Until 2018, 101 patients received chemotherapy; thereafter, 39 received 3+7+midostaurin. The overall CR rate was 64%, higher in NPM1 mutant patients (73%). Univariate analysis showed that NPM1 mutation (p = 0.032) and WBC < 100 × 109/L (p = 0.013) positively influenced the response, with a trend for FLT3i administration (p = 0.052). Multivariate analysis confirmed WBC count as an independent prognostic factor (p = 0.017). In CR1, 41/90 patients underwent allogeneic and 18 autologous transplantation. The median EFS was 1.1 vs. 1.6 years in autografted and allografted patients, respectively (p = 0.9). The one-year non-relapse mortality was 0.00% for autologous and 28% for allogeneic transplants (p = 0.007); CIR at 1 and 3 years was higher in autologous transplants (39% vs. 15% and 57% vs. 21%, p = 0.004). The median survival was not reached in the FLT3i group. Overall, 69 patients received stem cell transplantation (18 autologous, 51 allogeneic). Post-transplant FLT3i was resumed in eight patients, all alive after a median of 65 months. Allogeneic transplantation is crucial in FLT3-mutated AML, but the next challenge will be to identify which patients can benefit from transplants in CR1 and in which to intensify post-transplant therapy.
Collapse
Affiliation(s)
- Saveria Capria
- Hematology AOU Policlinico Umberto I, 00161 Rome, Italy; (S.M.T.); (W.B.); (A.P.I.); (D.D.); (D.C.); (C.M.)
| | - Silvia Maria Trisolini
- Hematology AOU Policlinico Umberto I, 00161 Rome, Italy; (S.M.T.); (W.B.); (A.P.I.); (D.D.); (D.C.); (C.M.)
| | - Lorenzo Torrieri
- Hematology, Department of Translational and Precision Medicine, “Sapienza” University, 00185 Rome, Italy; (L.T.); (E.A.); (M.B.); (M.M.)
| | - Elena Amabile
- Hematology, Department of Translational and Precision Medicine, “Sapienza” University, 00185 Rome, Italy; (L.T.); (E.A.); (M.B.); (M.M.)
| | | | | | - Walter Barberi
- Hematology AOU Policlinico Umberto I, 00161 Rome, Italy; (S.M.T.); (W.B.); (A.P.I.); (D.D.); (D.C.); (C.M.)
| | - Anna Paola Iori
- Hematology AOU Policlinico Umberto I, 00161 Rome, Italy; (S.M.T.); (W.B.); (A.P.I.); (D.D.); (D.C.); (C.M.)
| | - Daniela Diverio
- Hematology AOU Policlinico Umberto I, 00161 Rome, Italy; (S.M.T.); (W.B.); (A.P.I.); (D.D.); (D.C.); (C.M.)
| | - Daniela Carmini
- Hematology AOU Policlinico Umberto I, 00161 Rome, Italy; (S.M.T.); (W.B.); (A.P.I.); (D.D.); (D.C.); (C.M.)
| | - Massimo Breccia
- Hematology, Department of Translational and Precision Medicine, “Sapienza” University, 00185 Rome, Italy; (L.T.); (E.A.); (M.B.); (M.M.)
| | - Maurizio Martelli
- Hematology, Department of Translational and Precision Medicine, “Sapienza” University, 00185 Rome, Italy; (L.T.); (E.A.); (M.B.); (M.M.)
| | - Clara Minotti
- Hematology AOU Policlinico Umberto I, 00161 Rome, Italy; (S.M.T.); (W.B.); (A.P.I.); (D.D.); (D.C.); (C.M.)
| |
Collapse
|
7
|
Lap CJ, Abrahim MS, Nassereddine S. Perspectives and challenges of small molecule inhibitor therapy for FLT3-mutated acute myeloid leukemia. Ann Hematol 2024; 103:2215-2229. [PMID: 37975931 DOI: 10.1007/s00277-023-05545-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
Acute myeloid leukemia (AML) is a heterogeneous clonal disease characterized overall by an aggressive clinical course. The underlying genetic abnormalities present in leukemic cells contribute significantly to the AML phenotype. Mutations in FMS-like tyrosine kinase 3 (FLT3) are one of the most common genetic abnormalities identified in AML, and the presence of these mutations strongly influences disease presentation and negatively impacts prognosis. Since mutations in FLT3 were identified in AML, they have been recognized as a valid therapeutic target resulting in decades of research to develop effective small molecule inhibitor treatment that could improve outcome for these patients. Despite the approval of several FLT3 inhibitors over the last couple of years, the treatment of patients with FLT3-mutated AML remains challenging and many questions still need to be addressed. This review will provide an up-to-date overview of our current understanding of FLT3-mutated AML and discuss what the current status is of the available FLT3 inhibitors for the day-to-day management of this aggressive disease.
Collapse
Affiliation(s)
- Coen J Lap
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Marwa Sh Abrahim
- The George Washington Cancer Center, George Washington University, Washington, DC, USA
| | - Samah Nassereddine
- The George Washington Cancer Center, George Washington University, Washington, DC, USA.
| |
Collapse
|
8
|
Renard C, Corbel A, Paillard C, Pochon C, Schneider P, Simon N, Buchbinder N, Fahd M, Yakoub-Agha I, Calvo C. [Preventive and therapeutic strategies for relapse after hematopoietic stem cell transplant for pediatric AML (SFGM-TC)]. Bull Cancer 2024:S0007-4551(24)00109-7. [PMID: 38926053 DOI: 10.1016/j.bulcan.2024.02.006] [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: 07/18/2023] [Revised: 01/24/2024] [Accepted: 02/03/2024] [Indexed: 06/28/2024]
Abstract
Treatment of pediatric high-risk acute myeloid leukemia (AML), defined either on molecular or cytogenetic features, relies on bone marrow transplant after cytologic remission. However, relapse remains the first post-transplant cause of mortality. In this 13th session of practice harmonization of the francophone society of bone marrow transplantation and cellular therapy (SFGM-TC), our group worked on recommendations regarding the management of post-transplant relapse in AML pediatric patients based on international literature, national survey and expert opinion. Overall, immunomodulation strategy relying on both measurable residual disease (MRD) and chimerism evaluation should be used for high-risk AML. In very high-risk (VHR) AML with a 5-year overall survival ≤30 %, a post-transplant maintenance should be proposed using either hypomethylating agents, combined with DLI whenever possible, or FLT3 tyrosine kinase inhibitors if this target is present on leukemia cells. In the pre-emptive or early relapse settings (< 6 months post-transplant), treatments combining DLI, Azacytidine and Venetoclax should be considered. Access to phase I/II trails for targeted therapies (menin, IDH or JAK inhibitors) should be discussed in each patient according to the underlying molecular abnormalities of the disease.
Collapse
Affiliation(s)
- Cécile Renard
- Service d'hématologie pédiatrique, Institut d'hématologie et d'oncologie pédiatrique, Hospices Civils de Lyon, 1, place Professeur Joseph Renaut, 69008 Lyon, France.
| | - Alizee Corbel
- Service d'hémato-cancérologie pédiatrique, CHU de Rennes, 16, boulevard de Bulgarie, 35200 Rennes, France
| | - Catherine Paillard
- Service d'onco-hématologie pédiatrique, Hôpital de Hautepierre CHRU de Strasbourg, avenue Molière, 67200 Strasbourg, France
| | - Cécile Pochon
- service d'onco-hématologie pédiatrique, hôpital de Brabois CHRU de Nancy, rue du Morvan, 54511 Vandoeuvre-les-Nancy, France
| | - Pascale Schneider
- service d'hémato-oncologie pédiatrique, hôpital Charles-Nicolle CHU de Rouen, 1, rue De Germont, 76038 Rouen, France
| | - Nicolas Simon
- Université Lille, EA 7365-GRITA-groupe de recherche sur les formes injectables et les technologies associées, CHU Lille, Institut de Pharmacie, 59000 Lille, France
| | - Nimrod Buchbinder
- service d'hémato-oncologie pédiatrique, hôpital Charles-Nicolle CHU de Rouen, 1, rue De Germont, 76038 Rouen, France
| | - Mony Fahd
- Service d'hématologie et immunologie pédiatrique, hôpital Robert Debré, AP-HP, 48, boulevard Sérurier, 75019 Paris, France
| | | | - Charlotte Calvo
- Service d'hématologie et immunologie pédiatrique, hôpital Robert Debré, AP-HP, 48, boulevard Sérurier, 75019 Paris, France
| |
Collapse
|
9
|
Diral E, Furnari G, Bruno A, Greco R, Clerici D, Marktel S, Farina F, Mastaglio S, Vago L, Piemontese S, Peccatori J, Corti C, Bernardi M, Ciceri F, Lupo-Stanghellini MT. Sorafenib maintenance in FLT3-ITD mutated AML after allogeneic HCT: a real-world, single-center experience. Front Oncol 2024; 14:1391743. [PMID: 38978738 PMCID: PMC11228150 DOI: 10.3389/fonc.2024.1391743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/21/2024] [Indexed: 07/10/2024] Open
Abstract
Despite allogeneic hematopoietic stem cell transplant (allo-HCT) and the development of novel FLT3 inhibitors in both induction (midostaurin) and in the relapsed/refractory setting (gilteritinib), FLT3-ITD mutated leukemia (FLT3-ITD+ AML) still represents a challenge for modern hematology. Sorafenib is, to this date, the only inhibitor that demonstrated efficacy in improving both progression-free and overall survival as post-HCT maintenance therapy, even if its use in this setting has not been approved so far by regulatory agencies. The aim of our study was to evaluate the feasibility, safety, and efficacy of sorafenib maintenance in preventing early relapse in FLT3-ITD+ AML after HCT in a single-center experience. We analyzed 26 consecutive patients who received post-HCT 2-year maintenance with sorafenib at our center between 2017 and 2023. The median time from HCT to sorafenib start was 130 days, and the median dosage was 200 mg per day. Two (8%) and three (12%) patients discontinued maintenance due to toxicity and disease relapse, respectively. Eight (31%) patients terminated the 2-year maintenance and stopped sorafenib, while 13 patients are still under treatment. Overall, 21/26 patients (81%) are alive and in stable complete remission as outlined by a 2-year disease-free survival of 83.61%. No major long-term toxicity was reported at the last follow-up. Our real-world experience supports the use of sorafenib as a feasible and effective therapeutic option in post-HCT maintenance for FLT3-ITD+ AML.
Collapse
Affiliation(s)
- Elisa Diral
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulia Furnari
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Bruno
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Raffaella Greco
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Daniela Clerici
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sarah Marktel
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Farina
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sara Mastaglio
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Vago
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Simona Piemontese
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Jacopo Peccatori
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Consuelo Corti
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Bernardi
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | | |
Collapse
|
10
|
Bruzzese A, Vigna E, Martino EA, Labanca C, Mendicino F, Lucia E, Olivito V, Stanzione G, Zimbo A, Lugli E, Neri A, Morabito F, Gentile M. The potential of triplet combination therapies for patients with FLT3-ITD -mutated acute myeloid leukemia. Expert Rev Hematol 2024; 17:241-253. [PMID: 38748404 DOI: 10.1080/17474086.2024.2356258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 05/13/2024] [Indexed: 05/21/2024]
Abstract
INTRODUCTION Acute myeloid leukemia (AML) encompasses a heterogeneous group of aggressive myeloid malignancies, where FMS-like tyrosine kinase 3 (FLT3) mutations are prevalent, accounting for approximately 25-30% of adult patients. The presence of this mutation is related to a dismal prognosis and high relapse rates. In the lasts years many FLT3 inhibitors have been developed. AREAS COVERED This review provides a comprehensive overview of FLT3mut AML, summarizing the state of art of current treatment and available data about combination strategies including an FLT3 inhibitor. EXPERT OPINION In addition, the review discusses the emergence of drug resistance and the need for a nuanced approaches in treating patients who are ineligible for or resistant to intensive chemotherapy. Specifically, it explores the historical context of FLT3 inhibitors (FLT3Is) and their impact on treatment outcomes, emphasizing the pivotal role of midostaurin, as well as gilteritinib and quizartinib, and providing detailed insights into ongoing trials exploring the safety and efficacy of novel triplet combinations involving FLT3Is in different AML settings.
Collapse
Affiliation(s)
| | - Ernesto Vigna
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | | | | | | | - Eugenio Lucia
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | | | - Gaia Stanzione
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
- Division of Hematology, Azienda Policlinico-S. Marco, University of Catania, Catania, Italy
| | - Annamaria Zimbo
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
- UOC Laboratorio Analisi Cliniche, Biomolecolari e Genetica, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | - Elisabetta Lugli
- Ematologia Azienda USL-IRCSS Reggio Emilia, Emilia-Romagna, Italy
| | - Antonino Neri
- Scientific Directorate IRCCS of Reggio Emilia, Emilia-Romagna, Reggio Emilia, Italy
| | | | - Massimo Gentile
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
- Department of Pharmacy, Health and Nutritional Science, University of Calabria, Rende, Italy
| |
Collapse
|
11
|
Zhao Y, Zhang X, Ding X, Wang Y, Li Z, Zhao R, Cheng HE, Sun Y. Efficacy and safety of FLT3 inhibitors in monotherapy of hematological and solid malignancies: a systemic analysis of clinical trials. Front Pharmacol 2024; 15:1294668. [PMID: 38828446 PMCID: PMC11140126 DOI: 10.3389/fphar.2024.1294668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 04/29/2024] [Indexed: 06/05/2024] Open
Abstract
Introduction: FLT3 mutations are closely associated with the occurrence of hematological and solid malignancies, especially with acute myeloid leukemia. Currently, several FLT3 inhibitors are in clinical trials, and some have been applied in clinic. However, the safety, efficacy and pharmacodynamics of these FLT3 inhibitors have not been systemically analyzed before. Methods: We searched and reviewed clinical trial reports on the monotherapy of 13 FLT3 inhibitors, including sorafenib, lestaurtinib, midostaurin, gilteritinib, quizartinib, sunitinib, crenolanib, tandutinib, cabozantinib, pexidartinib, pacritinib, famitinib, and TAK-659 in patients with hematological and solid malignancies before May 31, 2023. Results: Our results showed the most common adverse events (AEs) were gastrointestinal adverse reactions, including diarrhea, hand-foot syndrome and nausea, while the most common hematological AEs were febrile neutropenia, anemia, and thrombocytopenia. Based on the published data, the mean overall survival (OS) and the mean progression-free survival (PFS) were 9.639 and 5.905 months, respectively. The incidence of overall response rate (ORR), complete remission (CR), partial response (PR), and stable disease (SD) for all these FLT3 inhibitors was 29.0%, 8.7%, 16.0%, and 42.3%, respectively. The ORRs of FLT3 inhibitors in hematologic malignancies and solid tumors were 40.8% and 18.8%, respectively, indicating FLT3 inhibitors were more effective for hematologic malignancies than for solid tumors. In addition, time to maximum plasma concentration (Tmax) in these FLT3 inhibitors ranged from 0.7-12.0 hours, but the elimination half-life (T1/2) range was highly variable, from 6.8 to 151.8 h. Discussion: FLT3 inhibitors monotherapy has shown significant anti-tumor effect in clinic, and the effectiveness may be further improved through combination medication.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Hai-En Cheng
- School of Medical Laboratory, Shandong Second Medical University, Weifang, China
| | - Yanli Sun
- School of Medical Laboratory, Shandong Second Medical University, Weifang, China
| |
Collapse
|
12
|
Tarlock K, Gerbing RB, Ries RE, Smith JL, Leonti A, Huang BJ, Kirkey D, Robinson L, Peplinksi JH, Lange B, Cooper TM, Gamis AS, Kolb EA, Aplenc R, Pollard JA, Alonzo TA, Meshinchi S. Prognostic impact of cooccurring mutations in FLT3-ITD pediatric acute myeloid leukemia. Blood Adv 2024; 8:2094-2103. [PMID: 38295280 PMCID: PMC11063409 DOI: 10.1182/bloodadvances.2023011980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/28/2023] [Accepted: 01/11/2024] [Indexed: 02/02/2024] Open
Abstract
ABSTRACT We sought to define the cooccurring mutational profile of FLT3-ITD-positive (ITDpos) acute myeloid leukemia (AML) in pediatric and young adult patients and to define the prognostic impact of cooperating mutations. We identified 464 patients with FLT3-ITD mutations treated on Children's Oncology Group trials with available sequencing and outcome data. Overall survival, event-free survival (EFS), and relapse risk were determined according to the presence of cooccurring risk stratifying mutations. Among the cohort, 79% of patients had cooccurring alterations across 239 different genes that were altered through mutations or fusions. Evaluation of the prognostic impact of the cooccurring mutations demonstrated that patients with ITDpos AML experienced significantly different outcomes according to the cooccurring mutational profile. Patients with ITDpos AML harboring a cooccurring favorable-risk mutation of NPM1, CEBPA, t(8;21), or inv(16) experienced a 5-year EFS of 64%, which was significantly superior to of 22.2% for patients with ITDpos AML and poor-risk mutations of WT1, UBTF, or NUP98::NSD1 as well to 40.9% for those who lacked either favorable-risk or poor-risk mutation (ITDpos intermediate; P < .001 for both). Multivariable analysis demonstrated that cooccurring mutations had significant prognostic impact, whereas allelic ratio had no impact. Therapy intensification, specifically consolidation transplant in remission, resulted in significant improvements in survival for ITDpos AML. However, patients with ITDpos/NUP98::NSD1 continued to have poor outcomes with intensified therapy, including sorafenib. Cooccurring mutational profile in ITDpos AML has significant prognostic impacts and is critical to determining risk stratification and therapeutic allocation. These clinical trials were registered at www.clinicaltrials.gov as NCT00002798, NCT00070174, NCT00372593, and NCT01371981.
Collapse
Affiliation(s)
- Katherine Tarlock
- Division of Hematology/Oncology, Seattle Children’s Hospital, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | | | - Rhonda E. Ries
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Jenny L. Smith
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Amanda Leonti
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Benjamin J. Huang
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Danielle Kirkey
- Division of Hematology/Oncology, Seattle Children’s Hospital, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Leila Robinson
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Jack H. Peplinksi
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Beverly Lange
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Todd M. Cooper
- Division of Hematology/Oncology, Seattle Children’s Hospital, Seattle, WA
| | - Alan S. Gamis
- Divisions of Hematology/Oncology, Children’s Mercy Hospital and Clinics, Kansas City, MO
| | - E. Anders Kolb
- Nemours Center for Cancer and Blood Disorders, Alfred I. DuPont Hospital for Children, Wilmington, DE
| | - Richard Aplenc
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jessica A. Pollard
- Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Todd A. Alonzo
- Children’s Oncology Group, Monrovia, CA
- University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Soheil Meshinchi
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| |
Collapse
|
13
|
Sun Q, Chen W, Wang A, Yang Z, Chen G, Zhu Z. Treatment of a Patient with Acute Promyelocytic Leukemia with Multiple Isolated Relapses in the Central Nervous System: A Case Report and Mini-Review of the Literature. Case Rep Hematol 2024; 2024:5593775. [PMID: 38737168 PMCID: PMC11087148 DOI: 10.1155/2024/5593775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 05/14/2024] Open
Abstract
The efficacy of therapeutics for acute promyelocytic leukemia (APL) has exhibited an increase in recent years. Only a few patients experience relapse, including extramedullary relapse, and in patients with extramedullary relapse, the central nervous system (CNS) is the most common site. To date, there is no expert consensus or clinical guidelines available for CNS relapse, at least to the best of our knowledge. The optimal therapeutic strategy and management options for these patients remain unclear. The present study reports the treatment of a patient with APL with multiple isolated relapses in the CNS. In addition, through a mini-review of the literature, the present study provides a summary of various reports of this disease and discusses possible treatment options for these patients.
Collapse
Affiliation(s)
- Qixin Sun
- Departments of Geriatric Hematology and Oncology, Guangzhou First People's Hospital, Guangzhou, Guangdong 510180, China
| | - Wenyi Chen
- Departments of Medical Records, Guangzhou First People's Hospital, Guangzhou, Guangdong 510180, China
| | - Ahui Wang
- Departments of Clinical Laboratory, Guangzhou First People's Hospital, Guangzhou, Guangdong 510180, China
| | - Zili Yang
- Departments of Geriatric Critical Care Medicine, Guangzhou First People's Hospital, Guangzhou, Guangdong 510180, China
| | - Guiping Chen
- Departments of Geriatric Hematology and Oncology, Guangzhou First People's Hospital, Guangzhou, Guangdong 510180, China
| | - Zhigang Zhu
- Departments of Geriatric Hematology and Oncology, Guangzhou First People's Hospital, Guangzhou, Guangdong 510180, China
| |
Collapse
|
14
|
Schmälter AK, Ngoya M, Galimard JE, Bazarbachi A, Finke J, Kröger N, Bornhäuser M, Stelljes M, Stölzel F, Tischer J, Schroeder T, Dreger P, Blau IW, Savani B, Giebel S, Esteve J, Nagler A, Schmid C, Ciceri F, Mohty M. Continuously improving outcome over time after second allogeneic stem cell transplantation in relapsed acute myeloid leukemia: an EBMT registry analysis of 1540 patients. Blood Cancer J 2024; 14:76. [PMID: 38697960 PMCID: PMC11066014 DOI: 10.1038/s41408-024-01060-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 05/05/2024] Open
Abstract
Second allogeneic stem cell transplantation (alloSCT2) is among the most effective treatments for acute myeloid leukemia (AML) relapse after first alloSCT (alloSCT1). Long-term EBMT registry data were used to provide large scale, up-to-date outcome results and to identify factors for improved outcome. Among 1540 recipients of alloSCT2, increasing age, better disease control and performance status before alloSCT2, more use of alternative donors and higher conditioning intensity represented important trends over time. Between the first (2000-2004) and last (2015-2019) period, two-year overall and leukemia-free survival (OS/LFS) increased considerably (OS: 22.5-35%, LFS: 14.5-24.5%). Cumulative relapse incidence (RI) decreased from 64% to 50.7%, whereas graft-versus-host disease and non-relapse mortality (NRM) remained unchanged. In multivariable analysis, later period of alloSCT2 was associated with improved OS/LFS (HR = 0.47/0.53) and reduced RI (HR = 0.44). Beyond, remission duration, disease stage and patient performance score were factors for OS, LFS, RI, and NRM. Myeloablative conditioning for alloSCT2 decreased RI without increasing NRM, leading to improved OS/LFS. Haploidentical or unrelated donors and older age were associated with higher NRM and inferior OS. In summary, outcome after alloSCT2 has continuously improved over the last two decades despite increasing patient age. The identified factors provide clues for the optimized implementation of alloSCT2.
Collapse
Affiliation(s)
- Ann-Kristin Schmälter
- Department of Hematology and Oncology, Augsburg University Hospital and Medical Faculty, Bavarian Cancer Research Center (BZKF) and Comprehensive Cancer Center Augsburg, Augsburg, Germany
| | - Maud Ngoya
- EBMT Paris Study Unit, Department of Hematology and Cell Therapy, Hôpital Saint-Antoine, Paris, France
| | - Jacques-Emmanuel Galimard
- EBMT Paris Study Unit, Department of Hematology and Cell Therapy, Hôpital Saint-Antoine, Paris, France
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut, Medical Center, Beirut, Libanon
| | - Jürgen Finke
- University of Freiburg, Department of Medicine, Hematology, Oncology, Freiburg, Germany
| | - Nicolaus Kröger
- University Medical Center Hamburg-Eppendorf, Department of Stem Cell Transplantation, Hamburg, Germany
| | - Martin Bornhäuser
- University Hospital Dresden, TU Dresden, Medizinische Klinik und Poliklinik I, Dresden, Germany
| | - Matthias Stelljes
- University of Muenster, Department of Hematology and Oncology, Muenster, Germany
| | - Friedrich Stölzel
- University Hospital Schleswig-Holstein, Kiel, Department of Stem Cell Transplantation and Cellular Immunotherapies, Kiel University, Kiel, Germany
| | - Johanna Tischer
- University Hospital of Munich, Campus Grosshadern, Department of Internal Medicine III, Munich, Germany
| | - Thomas Schroeder
- University Hospital Essen, Department of Hematology and Stem Cell Transplantation, Essen, Germany
| | - Peter Dreger
- University of Heidelberg, Medizinische Klinik und Poliklinik V, Heidelberg, Germany
| | - Igor-Wolfgang Blau
- Medizinische Klinik Hämatologie, Onkologie und Tumorimmunologie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Bipin Savani
- Department of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tenn, USA
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Hematology-Oncology, Maria Sklodowska-Curie Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Jordi Esteve
- Hematology Department, Hospital Clinic Barcelona, Barcelona, Spain
| | - Arnon Nagler
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel
| | - Christoph Schmid
- Department of Hematology and Oncology, Augsburg University Hospital and Medical Faculty, Bavarian Cancer Research Center (BZKF) and Comprehensive Cancer Center Augsburg, Augsburg, Germany.
| | - Fabio Ciceri
- Unit of Hematology and BMT, IRCCS Ospedale San Raffaele, University Vita-Salute San Raffaele, Milano, Italy
| | - Mohamad Mohty
- EBMT Paris Study Unit, Department of Hematology and Cell Therapy, Hôpital Saint-Antoine, Paris, France
| |
Collapse
|
15
|
Bazarbachi A, Labopin M, Moukalled N, Kröger N, Rautenberg C, Schetelig J, Finke J, Blau IW, Blaise D, Stelljes M, Eder M, Platzbecker U, Dreger P, Bethge W, Tischer J, Burns D, Sengeloev H, Brissot E, Giebel S, Nagler A, Ciceri F, Mohty M. Improvements in Posttransplant Outcomes Over Two Decades in Older Patients with Acute Myeloid Leukemia in the EBMT ALWP Study. Clin Cancer Res 2024; 30:1778-1787. [PMID: 38514469 DOI: 10.1158/1078-0432.ccr-23-3673] [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: 11/24/2023] [Revised: 01/12/2024] [Accepted: 02/22/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE Acute myeloid leukemia (AML) is a disease of older patients. Progress in allogeneic hematopoietic cell transplantation (allo-HCT) allowed the delivery of allo-HCT to older patients. We assessed changes over time in transplant characteristics and outcomes in patients with AML ages 65 years and above. PATIENTS AND METHODS We identified 7,215 patients with AML (median age 68 years, range 65-80) allografted between 2000 and 2021 in first complete remission (CR1; 64%), second or subsequent remission (CR2+; 14%), or active disease (22%). RESULTS Median follow-up was 40 months. The 3-year cumulative relapse incidence (RI) gradually and significantly decreased from 37% to 31%, then to 30% (P = 0.001) over the three time periods (2000-2009; 2010-2014; 2015-2021), whereas nonrelapse mortality (NRM) decreased from 31% and 31% to 27% (P = 0.003). The 3-year leukemia-free survival (LFS) and overall survival (OS) gradually and significantly improved from 32% to 38%, and then to 44% (P = 0.001) and from 37% to 42%, and then to 49% (P = 0.001), respectively. In multivariate analysis, significant improvement in the RI, LFS, and OS were noted after 2015, whereas NRM was not significantly affected. This improvement was observed regardless of disease status at transplant. CONCLUSIONS In older patients with AML, we observed an impressive improvement over time in posttransplant outcomes, mostly attributed to decreased RI rather than decreased NRM, and regardless of disease status at transplant. These large-scale, real-world data can serve as a benchmark for future studies in this setting and indicate that the opportunity for transplant for the elderly should be mandatory and no longer an option.
Collapse
Affiliation(s)
- Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Myriam Labopin
- EBMT Statistical Unit, Sorbonne University, Saint-Antoine Hospital, AP-HP, INSERM UMRs 938, Paris
| | - Nour Moukalled
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | | | - Christina Rautenberg
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Johannes Schetelig
- Medical Department I, TU Dresden & DKMS Clinical Trials Unit, Dresden, Germany
| | | | - Igor Wolfgang Blau
- Medizinische Klinik m. S. Hämatologie, Onkologie und Tumorimmunologie, Berlin
| | - Didier Blaise
- Transplantation and Cellular Immunotherapy Program, Department of Hematology, Instititut Paoli Calmettes, MSC Lab, Aix Marseille University, Marseille, France
| | - Matthias Stelljes
- Department of Medicine A, Hematology, Oncology, and Pneumology University Hospital Münster, Germany
| | | | | | | | - Wolfgang Bethge
- University Hospital Tübingen, Department of Hematology & Oncology, Tübingen, Germany
| | - Johanna Tischer
- Department of Medicine III, LMU University Hospital, LMU Munich, Germany
| | - David Burns
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | | | - Eolia Brissot
- Sorbonne University, Saint-Antoine Hospital, AP-HP, INSERM UMRs 938, Paris
| | - Sebastian Giebel
- Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Fabio Ciceri
- IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milano, Italy
| | - Mohamad Mohty
- Sorbonne University, Saint-Antoine Hospital, AP-HP, INSERM UMRs 938, Paris
| |
Collapse
|
16
|
Abaza Y, McMahon C, Garcia JS. Advancements and Challenges in the Treatment of AML. Am Soc Clin Oncol Educ Book 2024; 44:e438662. [PMID: 38662975 DOI: 10.1200/edbk_438662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
The therapeutic arsenal for the management of AML has expanded significantly in recent years. Before 2017, newly diagnosed AML was treated with either standard cytarabine- and anthracycline-based induction chemotherapy (for all fit patients) or a single-agent hypomethylating agent (in unfit patients or those 75 years and older). While assessing patient fitness remains important, characterizing the disease biology has become critical to select the optimal initial therapy for each patient with more options available. FLT3 inhibitors, gemtuzumab ozogamicin, and CPX-351 have been shown to improve outcomes for specific subsets of patients. Venetoclax (VEN) with a hypomethylating agent (HMA) is the standard-of-care frontline regimen for most older patients, except perhaps for those with an IDH1 mutation where ivosidenib with azacitidine may also be considered. On the basis of the success seen with HMA/VEN in older patients, there is now increasing interest in incorporating VEN into frontline regimens in younger patients, with promising data from multiple early phase studies. This article focuses on recent updates and ongoing challenges in the management of AML, with a particular focus on the ongoing challenge of secondary AML and considerations regarding the selection of initial therapy in younger patients. An overview of common side effects and toxicities associated with targeted therapies is also presented here, along with recommended strategies to mitigate these risks.
Collapse
Affiliation(s)
- Yasmin Abaza
- Division of Hematology and Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Christine McMahon
- Division of Hematology, University of Colorado School of Medicine, Aurora, CO
| | | |
Collapse
|
17
|
Schiller GJ, Kustanovich V. Considerations regarding maintenance therapy for acute myeloid leukemia in remission. Expert Rev Anticancer Ther 2024; 24:15-20. [PMID: 38230741 DOI: 10.1080/14737140.2024.2306164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 01/12/2024] [Indexed: 01/18/2024]
Abstract
INTRODUCTION For most adult patients with acute myeloid leukemia, relapse is characteristic of the disease. When allotransplant in first complete remission is administered as consolidative therapy, relapse is still common, affecting 20-40% of recipients. Maintenance of remission with low-dose treatments may hold promise in preventing relapse. AREAS COVERED Improvements in the detection of clinical and biological variants of disease allow the practitioner to identify which patients, based on disease features, may benefit from therapy directed at residual clonal elements that might contribute to relapse. Along with improvements in methods of detecting residual disease, novel agents are under investigation as a platform in order to maintain remission and may contribute to prolonged survival. In this manuscript, we review literature available through PubMed regarding the use of maintenance therapy, described as post-remission or post-transplant treatment intended to delay or prevent relapse. EXPERT OPINION Although results of randomized studies are limited, a role for maintenance therapy, particularly directed at molecular targets, in distinct settings of post-remission management is recommended. We also advise that randomized studies of immune therapy along with opportunities for further evaluation of risk-agnostic interventions be a focus of cooperative groups.
Collapse
Affiliation(s)
- Gary J Schiller
- Hematological Malignancy/Stem Cell Transplant Program, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Vlad Kustanovich
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| |
Collapse
|
18
|
Kennedy VE, Smith CC. FLT3 targeting in the modern era: from clonal selection to combination therapies. Int J Hematol 2023:10.1007/s12185-023-03681-0. [PMID: 38112995 DOI: 10.1007/s12185-023-03681-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 10/14/2023] [Accepted: 11/14/2023] [Indexed: 12/21/2023]
Abstract
Fms-like tyrosine kinase 3 (FLT3) is the most frequently mutated gene in acute myeloid leukemia (AML). Modern targeting of FLT3 with inhibitors has improved clinical outcomes and FLT3 inhibitors have been incorporated into the treatment of AML in all phases of the disease, including the upfront, relapsed/refractory and maintenance settings. This review will discuss the current understanding of FLT3 biology, the clinical use of FLT3 inhibitors, resistance mechanisms and emerging combination treatment strategies.
Collapse
Affiliation(s)
- Vanessa E Kennedy
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, 505 Parnassus Ave, Box 1270, San Francisco, CA, 94143, USA
| | - Catherine C Smith
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, 505 Parnassus Ave, Box 1270, San Francisco, CA, 94143, USA.
- Helen Diller Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA.
| |
Collapse
|
19
|
Bazarbachi A, Labopin M, Gedde-Dahl T, Remenyi P, Forcade E, Kröger N, Socié G, Craddock C, Bourhis JH, Versluis J, Yakoub-Agha I, Salmenniemi U, El-Cheikh J, Bug G, Esteve J, Nagler A, Ciceri F, Mohty M. Improved Posttransplant Outcomes in Recent Years for AML Patients with FLT3-ITD and Wild-type NPM1: A Report from the EBMT Acute Leukemia Working Party. Clin Cancer Res 2023; 29:4441-4448. [PMID: 37603683 DOI: 10.1158/1078-0432.ccr-23-0954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/17/2023] [Accepted: 08/14/2023] [Indexed: 08/23/2023]
Abstract
PURPOSE Allogeneic hematopoietic cell transplantation (allo-HCT) is recommended in first complete remission (CR1) in patients with acute myeloid leukemia (AML) harboring FMS-like tyrosine kinase 3-internal tandem duplication (FLT3-ITD). We assessed changes over time in transplant characteristics and outcomes in patients with AML age 60 years and younger with a FLT3-ITD. EXPERIMENTAL DESIGN We identified 1,827 adult patients with AML (median age 49 years, range 18-60) with FLT3-ITD and intermediate karyotype, allografted between 2012 and 2021 in CR1. RESULTS NPM1 was mutated in 72% of patients. We compared changes over time in 688 patients transplanted between 2012 and 2016, and 1,139 patients transplanted between 2017 and 2021. For patients with wild-type NPM1, the 2-year leukemia-free survival (LFS) and overall survival (OS) significantly improved over time from 54% to 64% (HR = 0.67; P = 0.011) and from 63% to 71% (HR = 0.66; P = 0.021), respectively. Allo-HCT in recent years significantly reduced the cumulative incidence of relapse (CIR). For patients with NPM1 mutation, no significant changes over time were noted. CONCLUSIONS In patients with AML with FLT3-ITD and wild-type NPM1, we noticed a significant decrease over time in the CIR and improvement of LFS and OS, likely reflecting the efficacy of FLT-3 inhibitors, including when used as posttransplant maintenance, in this high-risk setting. On the contrary, no significant change over time was noticed in outcomes of patients harboring a FLT3 and NPM1 mutation.
Collapse
Affiliation(s)
- Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Myriam Labopin
- EBMT Statistical Unit, Sorbonne University, Saint-Antoine Hospital, AP-HP, INSERM UMRs 938, Paris, France
| | - Tobias Gedde-Dahl
- Oslo University Hospital, Rikshospitalet, Clinic for Cancer Medicine, Department of Hematology, Section for Stem Cell Transplantation, Oslo, Norway
| | - Peter Remenyi
- Dél-pesti Centrumkórház-Országos Hematológiai és Infektológiai Intézet, Department of Haematology and Stem Cell Transplant, Albert, Budapest, Hungary
| | - Edouard Forcade
- Service d'Hématologie Clinique et Thérapie Cellulaire, CHU Bordeaux, Bordeaux, France
| | - Nicolaus Kröger
- Department for Stem Cell Transplantation, University Medical Center Hamburg, Hamburg, Germany
| | - Gerard Socié
- Hopital St. Louis, Department of Hematology-BMT, Paris, France
| | - Charles Craddock
- University Hospital Birmingham NHS Trust, Queen Elizabeth Medical Centre, Edgbaston, Department of Haematology, Birmingham, England
| | - Jean Henri Bourhis
- Gustave Roussy Cancer Campus, BMT Service, Department of Hematology, Villejuif, France
| | - Jurjen Versluis
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Hematology, Rotterdam, the Netherlands
| | | | - Urpu Salmenniemi
- HUCH Comprehensive Cancer Center, Stem Cell Transplantation Unit, Helsinki, Finland
| | - Jean El-Cheikh
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Gesine Bug
- Goethe University Frankfurt, Department of Medicine 2, Hematology and Oncology, Frankfurt am Main, Germany
| | - Jordi Esteve
- Hospital Clínic of Barcelona, IDIBAPS, Barcelona, Spain
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - Fabio Ciceri
- University Vita-Salute, IRCCS Ospedale San Raffaele, Haematology and BMT, Milano, Italy
| | - Mohamad Mohty
- Sorbonne University, Saint-Antoine Hospital, AP-HP, INSERM UMRs 938, Paris, France
| |
Collapse
|
20
|
DeWolf S, Tallman MS, Rowe JM, Salman MY. What Influences the Decision to Proceed to Transplant for Patients With AML in First Remission? J Clin Oncol 2023; 41:4693-4703. [PMID: 37611216 PMCID: PMC10564290 DOI: 10.1200/jco.22.02868] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 05/12/2023] [Accepted: 06/14/2023] [Indexed: 08/25/2023] Open
Abstract
Although allogeneic hematopoietic cell transplantation (allo-HCT) remains the backbone of curative treatment for the majority of fit adults diagnosed with AML, there is indeed a subset of patients for whom long-term remission may be achieved without transplantation. Remarkable changes in our knowledge of AML biology in recent years has transformed the landscape of diagnosis, management, and treatment of AML. Specifically, markedly increased understanding of molecular characteristics of AML, the expanded application of minimal/measurable residual diseases testing, and an increased armamentarium of leukemia-directed therapeutic agents have created a new paradigm for the medical care of patients with AML. An attempt is herein made to decipher the decision to proceed to transplant for patients with AML in first complete remission on the basis of the current best available evidence. The focus is on factors affecting the biology and treatment of AML itself, rather than on variables related to allo-HCT, an area characterized by significant advancements that have reduced overall therapy-related complications. This review seeks to focus on areas of particular complexity, while simultaneously providing clarity on how our current knowledge and treatment strategies may, or may not, influence the decision to pursue allo-HCT in patients with AML.
Collapse
Affiliation(s)
- Susan DeWolf
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Martin S. Tallman
- Division of Hematology and Oncology Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jacob M. Rowe
- Rambam Health Care Campus and Technion, Israel Institute of Technology, Haifa, Israel
- Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel
| | | |
Collapse
|
21
|
Gerhartz B, Damodharan S, Puccetti DM, Boriosi JP, Hokanson JS, Capitini CM. Use of milrinone to support therapy-induced heart failure through hematopoietic stem cell transplantation in a pediatric patient with high-risk FLT3+ acute myeloid leukemia. Pediatr Blood Cancer 2023; 70:e30542. [PMID: 37485552 DOI: 10.1002/pbc.30542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 06/25/2023] [Indexed: 07/25/2023]
Affiliation(s)
- Brianna Gerhartz
- Department of Pediatrics, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Sudarshawn Damodharan
- Department of Pediatrics, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA
- Division of Pediatric Hematology, Oncology and Bone Marrow Transplant, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Diane M Puccetti
- Department of Pediatrics, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA
- Division of Pediatric Hematology, Oncology and Bone Marrow Transplant, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Juan P Boriosi
- Division of Pediatric Critical Care Medicine, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA
| | - John S Hokanson
- Division of Pediatric Cardiology, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Christian M Capitini
- Department of Pediatrics, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA
- Division of Pediatric Hematology, Oncology and Bone Marrow Transplant, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA
- Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin, USA
| |
Collapse
|
22
|
Cremer A, Enssle JC, Pfaff S, Kouidri K, Lang F, Brandts C, Zeiher A, Cremer S, Steffen B, Serve H, Bug G. Treatment with midostaurin and other FLT3 targeting inhibitors is associated with an increased risk of cardiovascular adverse events in patients who underwent allogeneic hematopoietic stem cell transplantation with FLT3-mutated AML. Ann Hematol 2023; 102:2903-2908. [PMID: 37552323 PMCID: PMC10492676 DOI: 10.1007/s00277-023-05396-y] [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: 04/12/2023] [Accepted: 07/29/2023] [Indexed: 08/09/2023]
Abstract
The addition of midostaurin to standard chemotherapy has improved survival in patients with FLT3-mutated AML. However, the impact of midostaurin and other FLT3 inhibitors (FLT3i) on cardiovascular adverse events (CAEs) has not been studied in patients who underwent allogeneic hematopoietic stem cell transplantation in a real-world setting. We reviewed 132 patients with AML who were treated with intensive induction therapy and consecutive allogeneic stem cell transplantation at our institution (42 FLT3-mutated AML and 90 with FLT3 wildtype). We identified treatment with midostaurin and/or FLT3i as an independent risk factor for CAEs not resulting in higher non-relapse mortality (NRM) or impaired overall survival (OS). Hence, close monitoring for CAEs is warranted for these patients.
Collapse
Affiliation(s)
- Anjali Cremer
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt Am Main, Germany.
- Frankfurt Cancer Institute (FCI), Frankfurt Am Main, Germany.
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Frankfurt Am Main, Germany.
| | - Julius C Enssle
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt Am Main, Germany
- Frankfurt Cancer Institute (FCI), Frankfurt Am Main, Germany
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Frankfurt Am Main, Germany
| | - Saskia Pfaff
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt Am Main, Germany
| | - Khouloud Kouidri
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt Am Main, Germany
| | - Fabian Lang
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt Am Main, Germany
| | - Christian Brandts
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt Am Main, Germany
- Frankfurt Cancer Institute (FCI), Frankfurt Am Main, Germany
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Frankfurt Am Main, Germany
- University Cancer Center Frankfurt (UCT), University Hospital, Goethe University, Frankfurt, Germany
| | - Andreas Zeiher
- Department of Medicine, Cardiology, University Hospital Frankfurt, Goethe University, Frankfurt Am Main, Germany
| | - Sebastian Cremer
- Department of Medicine, Cardiology, University Hospital Frankfurt, Goethe University, Frankfurt Am Main, Germany
| | - Björn Steffen
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt Am Main, Germany
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Frankfurt Am Main, Germany
| | - Hubert Serve
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt Am Main, Germany
- Frankfurt Cancer Institute (FCI), Frankfurt Am Main, Germany
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Frankfurt Am Main, Germany
| | - Gesine Bug
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt Am Main, Germany
- Frankfurt Cancer Institute (FCI), Frankfurt Am Main, Germany
| |
Collapse
|
23
|
Shao R, Zhang Y, He J, Huang F, Fan Z, Yang K, Xu Y, Xu N, Luo Y, Deng L, Zhang X, Chen J, Han M, Li X, Yu S, Liu H, Liang X, Luo X, Shi P, Wang Z, Jiang L, Zhou X, Lin R, Chen Y, Tu S, Sun J, Wang Y, Liu Q, Xuan L. Impact of genetic patterns on sorafenib efficacy in patients with FLT3-ITD acute myeloid leukemia undergoing allogeneic hematopoietic stem cell transplantation: a multi-center, cohort study. Signal Transduct Target Ther 2023; 8:348. [PMID: 37704613 PMCID: PMC10499827 DOI: 10.1038/s41392-023-01614-1] [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: 02/13/2023] [Revised: 08/14/2023] [Accepted: 08/21/2023] [Indexed: 09/15/2023] Open
Abstract
Sorafenib therapy improves overall survival (OS) in patients with FLT3 internal tandem duplication (ITD) acute myeloid leukemia (AML) undergoing allogeneic hematopoietic stem cell transplantation. We explored the efficacy of sorafenib therapy in this population with different concomitant genetic patterns. In this multi-center, cohort study, we enrolled patients with FLT3-ITD AML undergoing allogenic hematopoietic cell transplantation. Patients with sorafenib maintenance post-transplantation for at least four weeks were allocated to the sorafenib group, and otherwise to the control group. Endpoints were OS, disease-free survival, and relapse for the whole cohort and OS for genetic pattern subgroups. Among 613 patients enrolled, 275 were in the sorafenib and 338 the control group. Median follow-up was 36.5 (interquartile range (IQR), 25.2-44.7) months post-transplantation. The 3-year OS post-transplantation was 79.6% (95% confidential interval (CI) 74.8%-84.6%) and 65.2% (95% CI 60.3%-70.6%) (Hazard ratio (HR) 0.50, 95% CI 0.37-0.69; P < 0.0001) in both groups. Sorafenib maintenance post-transplantation improved OS in the favorable (HR 0.33, 95% CI 0.14-0.77; P = 0.011) and adverse (HR 0.56, 95% CI 0.33-0.93; P = 0.026) ELN 2017 risk subgroups. Patients with mutated NPM1, DNMT3A, co-occurring NPM1/DNMT3A, "activated signaling" and "DNA methylation" genes benefited in OS from sorafenib maintenance, while those carrying CEBPA, "tumor suppressors" and "myeloid transcription factors" genes did not. Patients with FLT3-ITDhigh and FLT3-ITDlow AML both benefited in OS from sorafenib maintenance. Our results identify the response of genetic patterns to sorafenib maintenance, providing new viewpoints for the optimal use of sorafenib in FLT3-ITD AML in the transplantation setting.
Collapse
Affiliation(s)
- Ruoyang Shao
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Yu Zhang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Jinping He
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Zhiping Fan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Kaibo Yang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Yajing Xu
- Department of Hematology, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Na Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Yi Luo
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Lan Deng
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, 510280, China
- Department of Hematology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200125, China
| | - Xi Zhang
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Jia Chen
- The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Mingzhe Han
- Hematopoietic Stem Cell Transplantation Center, Institute of Hematology and Blood Diseases Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Tianjin, 300020, China
| | - Xudong Li
- Department of Hematology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Sijian Yu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Hui Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Xinquan Liang
- Department of Hematology, the First People's Hospital of Chenzhou, Chenzhou, 423099, China
| | - Xiaodan Luo
- Department of Hematology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
- Department of Hematology, the Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510799, China
| | - Pengcheng Shi
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Zhixiang Wang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Ling Jiang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Xuan Zhou
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Ren Lin
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Yan Chen
- Department of Hematology, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Sanfang Tu
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, 510280, China
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Yu Wang
- Department of Hematology, Peking University People's Hospital, Beijing, 100044, China.
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China.
- Guangdong Provincial Key Laboratory of Digital Medicine and Biomechanics, National Key Discipline of Human Anatomy, School of Basic Medical Sciences, Southern Medical University, Guangzhou, 510515, China.
| | - Li Xuan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China.
| |
Collapse
|
24
|
Czogała M, Czogała W, Pawińska-Wąsikowska K, Książek T, Bukowska-Strakova K, Sikorska-Fic B, Łaguna P, Fałkowska A, Drabko K, Muszyńska-Rosłan K, Krawczuk-Rybak M, Kozłowska M, Irga-Jaworska N, Zielezińska K, Urasiński T, Bartoszewicz N, Styczyński J, Skalska-Sadowska J, Wachowiak J, Rodziewicz-Konarska A, Kałwak K, Ciebiera M, Chaber R, Mizia-Malarz A, Chodała-Grzywacz A, Karolczyk G, Bobeff K, Młynarski W, Mycko K, Badowska W, Tomaszewska R, Szczepański T, Machnik K, Zamorska N, Balwierz W, Skoczeń S. Characteristics and Outcome of FLT3-ITD-Positive Pediatric Acute Myeloid Leukemia-Experience of Polish Pediatric Leukemia and Lymphoma Study Group from 2005 to 2022. Cancers (Basel) 2023; 15:4557. [PMID: 37760526 PMCID: PMC10526903 DOI: 10.3390/cancers15184557] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/30/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The FMS-like tyrosine kinase 3 (FLT3) gene mutated in 10-15% of pediatric acute myeloid leukemia (AML) is associated with an inferior outcome. The aim of the study was to analyze the outcome and characteristics of FLT3-ITD-positive pediatric AML. METHODS We retrospectively analyzed the nationwide pediatric AML database from between 2005 and 2022. FLT3-ITD was found in 54/497 (10.7%) patients with available analysis. Three consecutive treatment protocols were used (AML-BFM 2004 Interim, AML-BFM 2012 Registry, AML-BFM 2019 recommendations). RESULTS Probabilities of 5-year overall (OS), event-free (EFS) and relapse-free survival were significantly lower in the FLT3-ITD-positive patients compared to FLT3-ITD-negative (0.54 vs. 0.71, p = 0.041; 0.36 vs. 0.59, p = 0.0004; 0.47 vs. 0.70, p = 0.0029, accordingly). An improvement in the outcome was found in the analyzed period of time, with a trend of better survival in patients treated under the AML-BFM 2012 and AML-BFM 2019 protocols compared to the AML-BFM 2004 protocol (5-year EFS 0.52 vs. 0.27, p = 0.069). There was a trend of improved outcomes in patients treated with FLT3 inhibitors (n = 9, 2-year EFS 0.67 vs. 0.33, p = 0.053) and those who received stem cell transplantation (SCT) (n = 26; 5-year EFS 0.70 vs. 0.27, p = 0.059). The co-occurrence of the WT1 mutation had a dismal impact on the prognosis (5-year EFS 0.23 vs. 0.69, p = 0.002), while the NPM1 mutation improved survival (5-year OS 1.0 vs. 0.44, p = 0.036). CONCLUSIONS It seems that SCT and FLT3 inhibitors have a beneficial impact on the prognosis. Additional genetic alterations, like the WT1 and NPM1 mutations, significantly influence the outcome.
Collapse
Affiliation(s)
- Małgorzata Czogała
- Department of Pediatric Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, 30-663 Krakow, Poland; (W.C.); (K.P.-W.); (W.B.); (S.S.)
- Department of Pediatric Oncology and Hematology, University Children Hospital, 30-683 Krakow, Poland;
| | - Wojciech Czogała
- Department of Pediatric Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, 30-663 Krakow, Poland; (W.C.); (K.P.-W.); (W.B.); (S.S.)
- Department of Pediatric Oncology and Hematology, University Children Hospital, 30-683 Krakow, Poland;
| | - Katarzyna Pawińska-Wąsikowska
- Department of Pediatric Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, 30-663 Krakow, Poland; (W.C.); (K.P.-W.); (W.B.); (S.S.)
- Department of Pediatric Oncology and Hematology, University Children Hospital, 30-683 Krakow, Poland;
| | - Teofila Książek
- Department of Pediatric Oncology and Hematology, University Children Hospital, 30-683 Krakow, Poland;
- Department of Medical Genetics, Institute of Pediatrics, Jagiellonian University Medical College, 30-663 Krakow, Poland
| | - Karolina Bukowska-Strakova
- Department of Clinical Immunology, Institute of Pediatrics, Jagiellonian University Medical College, 30-663 Krakow, Poland;
| | - Barbara Sikorska-Fic
- Department of Pediatrics, Oncology, Hematology and Transplantology, Medical University of Warsaw, 02-091 Warszawa, Poland; (B.S.-F.); (P.Ł.)
| | - Paweł Łaguna
- Department of Pediatrics, Oncology, Hematology and Transplantology, Medical University of Warsaw, 02-091 Warszawa, Poland; (B.S.-F.); (P.Ł.)
| | - Anna Fałkowska
- Department of Paediatric Haematology and Oncology and Transplantology, Medical University of Lublin, 20-095 Lublin, Poland; (A.F.); (K.D.)
| | - Katarzyna Drabko
- Department of Paediatric Haematology and Oncology and Transplantology, Medical University of Lublin, 20-095 Lublin, Poland; (A.F.); (K.D.)
| | - Katarzyna Muszyńska-Rosłan
- Department of Pediatric Oncology and Hematology, Medical University of Bialystok, 15-089 Bialystok, Poland; (K.M.-R.); (M.K.-R.)
| | - Maryna Krawczuk-Rybak
- Department of Pediatric Oncology and Hematology, Medical University of Bialystok, 15-089 Bialystok, Poland; (K.M.-R.); (M.K.-R.)
| | - Marta Kozłowska
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdansk, 80-210 Gdansk, Poland; (M.K.); (N.I.-J.)
| | - Ninela Irga-Jaworska
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdansk, 80-210 Gdansk, Poland; (M.K.); (N.I.-J.)
| | - Karolina Zielezińska
- Department of Paediatrics, Hemato-Oncology and Gastroenterology, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland; (K.Z.); (T.U.)
| | - Tomasz Urasiński
- Department of Paediatrics, Hemato-Oncology and Gastroenterology, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland; (K.Z.); (T.U.)
| | - Natalia Bartoszewicz
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, 85-094 Bydgoszcz, Poland; (N.B.); (J.S.)
| | - Jan Styczyński
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, 85-094 Bydgoszcz, Poland; (N.B.); (J.S.)
| | - Jolanta Skalska-Sadowska
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, 60-572 Poznan, Poland; (J.S.-S.); (J.W.)
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, 60-572 Poznan, Poland; (J.S.-S.); (J.W.)
| | - Anna Rodziewicz-Konarska
- Department of Bone Marrow Transplantation, Pediatric Oncology and Hematology, Medical University of Wroclaw, 50-556 Wroclaw, Poland; (A.R.-K.); (K.K.)
| | - Krzysztof Kałwak
- Department of Bone Marrow Transplantation, Pediatric Oncology and Hematology, Medical University of Wroclaw, 50-556 Wroclaw, Poland; (A.R.-K.); (K.K.)
| | - Małgorzata Ciebiera
- Clinic of Pediatric Oncology and Hematology, State Hospital 2, 35-301 Rzeszów, Poland; (M.C.); (R.C.)
| | - Radosław Chaber
- Clinic of Pediatric Oncology and Hematology, State Hospital 2, 35-301 Rzeszów, Poland; (M.C.); (R.C.)
- Institute of Medical Sciences, Medical College of Rzeszow University, 35-959 Rzeszów, Poland
| | - Agnieszka Mizia-Malarz
- Department of Oncology, Hematology and Chemotherapy, Upper Silesia Children’s Care Health Centre, 40-752 Katowice, Poland;
- Department of Pediatrics, Medical University of Silesia, Upper Silesia Children’s Care Health Centre, 40-752 Katowice, Poland
| | - Agnieszka Chodała-Grzywacz
- Department of Pediatric Hematology and Oncology, Regional Polyclinic Hospital in Kielce, 25-736 Kielce, Poland; (A.C.-G.); (G.K.)
| | - Grażyna Karolczyk
- Department of Pediatric Hematology and Oncology, Regional Polyclinic Hospital in Kielce, 25-736 Kielce, Poland; (A.C.-G.); (G.K.)
| | - Katarzyna Bobeff
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, 91-738 Lodz, Poland; (K.B.); (W.M.)
| | - Wojciech Młynarski
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, 91-738 Lodz, Poland; (K.B.); (W.M.)
| | - Katarzyna Mycko
- Department of Pediatrics and Hematology and Oncology, Province Children’s Hospital, 10-561 Olsztyn, Poland; (K.M.); (W.B.)
| | - Wanda Badowska
- Department of Pediatrics and Hematology and Oncology, Province Children’s Hospital, 10-561 Olsztyn, Poland; (K.M.); (W.B.)
| | - Renata Tomaszewska
- Department of Pediatric Hematology and Oncology, Zabrze, Medical University of Silesia, 40-055 Katowice, Poland; (R.T.); (T.S.)
| | - Tomasz Szczepański
- Department of Pediatric Hematology and Oncology, Zabrze, Medical University of Silesia, 40-055 Katowice, Poland; (R.T.); (T.S.)
| | - Katarzyna Machnik
- Department of Pediatrics, Hematology and Oncology, City Hospital, 41-500 Chorzow, Poland;
| | - Natalia Zamorska
- Student Scientific Group of Pediatric Oncology and Hematology, Jagiellonian University Medical College, 30-663 Krakow, Poland;
| | - Walentyna Balwierz
- Department of Pediatric Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, 30-663 Krakow, Poland; (W.C.); (K.P.-W.); (W.B.); (S.S.)
- Department of Pediatric Oncology and Hematology, University Children Hospital, 30-683 Krakow, Poland;
| | - Szymon Skoczeń
- Department of Pediatric Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, 30-663 Krakow, Poland; (W.C.); (K.P.-W.); (W.B.); (S.S.)
- Department of Pediatric Oncology and Hematology, University Children Hospital, 30-683 Krakow, Poland;
| |
Collapse
|
25
|
Yilmaz M, Daver N. Optimising maintenance therapy after transplantation: sorafenib's role in patients with FLT3-ITD acute myeloid leukaemia. Lancet Haematol 2023; 10:e559-e561. [PMID: 37532412 DOI: 10.1016/s2352-3026(23)00213-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 07/11/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| |
Collapse
|
26
|
Sartor C, Brunetti L, Audisio E, Cignetti A, Zannoni L, Cristiano G, Nanni J, Ciruolo R, Zingarelli F, Ottaviani E, Patuelli A, Bandini L, Forte D, Sciabolacci S, Cardinali V, Papayannidis C, Cavo M, Martelli MP, Curti A. A venetoclax and azacitidine bridge-to-transplant strategy for NPM1-mutated acute myeloid leukaemia in molecular failure. Br J Haematol 2023; 202:599-607. [PMID: 37226312 DOI: 10.1111/bjh.18887] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/12/2023] [Accepted: 05/16/2023] [Indexed: 05/26/2023]
Abstract
NPM1-mutated acute myeloid leukaemia (NPM1mut AML) represents a mostly favourable/intermediate risk disease that benefits from allogeneic haematopoietic stem cell transplantation (HSCT) in case of measurable residual disease (MRD) relapse or persistence after induction chemotherapy. Although the negative prognostic role of pre-HSCT MRD is established, no recommendations are available for the management of peri-transplant molecular failure (MF). Based on the efficacy data of venetoclax (VEN)-based treatment in NPM1mut AML older patients, we retrospectively analysed the off-label combination of VEN plus azacitidine (AZA) as bridge-to-transplant strategy in 11 NPM1mut MRD-positive fit AML patients. Patients were in MRD-positive complete remission (CRMRDpos ) at the time of treatment: nine in molecular relapse and two in molecular persistence. After a median number of two cycles (range 1-4) of VEN-AZA, 9/11 (81.8%) achieved CRMRD -negative (CRMRDneg ). All 11 patients proceeded to HSCT. With a median follow-up from treatment start of 26 months, and a median post-HSCT follow-up of 19 months, 10/11 patients are alive (1 died from non-relapse mortality), and 9/10 patients are in MRDneg status. This patient series highlights the efficacy and safety of VEN-AZA to prevent overt relapse, achieve deep responses and preserve patient fitness before HSCT, in patients with NPM1mut AML in MF.
Collapse
Affiliation(s)
- C Sartor
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
| | - L Brunetti
- Clinica di Ematologia, Azienda Ospedaliero-Universitaria Ospedali Riuniti delle Marche, Ancona, Italy
| | - E Audisio
- SC Ematologia, Dipartimento di Ematologia e Oncologia, AO Città della Salute e della Scienza di Torino, Turin, Italy
| | - A Cignetti
- Department of Hematology and Cell Therapy, A.O. Ordine Mauriziano, Turin, Italy
| | - L Zannoni
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
| | - G Cristiano
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
| | - J Nanni
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
| | - R Ciruolo
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
| | - F Zingarelli
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
| | - E Ottaviani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli" Bologna, Bologna, Italy
| | - A Patuelli
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
| | - L Bandini
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
| | - D Forte
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
| | - S Sciabolacci
- Institute of Hematology, Centro Ricerche Emato-Oncologiche, Ospedale S. Maria della Misericordia, University of Perugia, Perugia, Italy
| | - V Cardinali
- Institute of Hematology, Centro Ricerche Emato-Oncologiche, Ospedale S. Maria della Misericordia, University of Perugia, Perugia, Italy
| | - C Papayannidis
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli" Bologna, Bologna, Italy
| | - M Cavo
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli" Bologna, Bologna, Italy
| | - M P Martelli
- Institute of Hematology, Centro Ricerche Emato-Oncologiche, Ospedale S. Maria della Misericordia, University of Perugia, Perugia, Italy
| | - A Curti
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli" Bologna, Bologna, Italy
| |
Collapse
|
27
|
Xuan L, Wang Y, Yang K, Shao R, Huang F, Fan Z, Chi P, Xu Y, Xu N, Deng L, Li X, Liang X, Luo X, Shi P, Liu H, Wang Z, Jiang L, Lin R, Chen Y, Tu S, Zhang Y, Sun J, Huang X, Liu Q. Sorafenib maintenance after allogeneic haemopoietic stem-cell transplantation in patients with FLT3-ITD acute myeloid leukaemia: long-term follow-up of an open-label, multicentre, randomised, phase 3 trial. Lancet Haematol 2023:S2352-3026(23)00117-5. [PMID: 37414062 DOI: 10.1016/s2352-3026(23)00117-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/02/2023] [Accepted: 04/20/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Our open-label, multicentre, randomised, phase 3 trial showed that sorafenib maintenance after haematopoietic stem-cell transplantation (HSCT) improved overall survival and reduced relapse for patients with FLT3 internal tandem duplication (FLT3-ITD) acute myeloid leukaemia undergoing allogeneic HSCT. Here, we present a post-hoc analysis on the 5-year follow-up data of this trial. METHODS This phase 3 trial, done in seven hospitals in China, included patients with FLT3-ITD acute myeloid leukaemia undergoing allogeneic HSCT, who were aged 18-60 years, had an Eastern Cooperative Oncology Group performance status of 0-2, had composite complete remission before and after transplantation, and had haematopoietic recovery within 60 days after transplantation. Patients were randomly assigned (1:1) to receive sorafenib maintenance (400 mg orally twice daily) or non-maintenance (control) at 30-60 days after transplantation. Randomisation was done with permuted blocks (block size four) via an interactive web-based system. Investigators and participants were not masked to group assignment. The primary endpoint was the 1-year cumulative incidence of relapse, which was reported previously. For this updated analysis, the 5-year endpoints were overall survival; cumulative incidence of relapse; non-relapse mortality; leukaemia-free survival; graft-versus-host disease (GVHD)-free, relapse-free survival (GRFS); cumulative incidence of chronic GVHD; and late effects in the intention-to-treat population. The trial is registered with ClinicalTrials.gov, NCT02474290, and is complete. FINDINGS Between June 20, 2015, and July 21, 2018, 202 patients were randomly assigned to sorafenib maintenance (n=100) or non-maintenance (n=102). Median follow-up was 60·4 months (IQR 16·7-73·3). Extended follow-up showed improved overall survival (72·0% [95% CI 62·1-79·7] vs 55·9% [45·7-64·9]; hazard ratio [HR] 0·55, 95% CI 0·34-0·88; p=0·011), leukaemia-free survival (70·0% [60·0-78·0] vs 49·0% [39·0-58·3]; 0·47, 0·30-0·73; p=0·0007), and GRFS (58·0% [47·7-67·0] vs 39·2% [29·8-48·5]; 0·56, 0·38-0·83; p=0·0030), lower cumulative incidence of relapse (15·0% [8·8-22·7] vs 36·3% [27·0-45·6]; 0·33, 0·18-0·60; p=0·0003), and no increase in non-relapse mortality (15·0% [8·8-22·7] vs 14·7% [8·6-22·3]; 0·79, 0·39-1·62; p=0·98) for patients in the sorafenib group compared with those in the control group. The 5-year cumulative incidence of chronic GVHD (54·0% [43·7-63·2] vs 51·0% [40·8-60·3]; 0·82, 0·56-1·19; p=0·73) did not differ significantly between the two groups and we did not find substantial differences in late effects between the two groups. There were no treatment-related deaths. INTERPRETATION With extended follow-up, sorafenib maintenance after transplantation is associated with improved long-term survival and reduced relapse rates compared with non-maintenance, further supporting this strategy as a standard of care for patients with FLT3-ITD acute myeloid leukaemia undergoing allogeneic HSCT. FUNDING None. TRANSLATION For the Chinese translation of the abstract see Supplementary Materials section.
Collapse
Affiliation(s)
- Li Xuan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, China
| | - Yu Wang
- Department of Hematology, Peking University People's Hospital, Beijing, China
| | - Kaibo Yang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, China
| | - Ruoyang Shao
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, China
| | - Zhiping Fan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, China
| | - Peiru Chi
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, China
| | - Yajing Xu
- Department of Hematology, Xiangya Hospital, Central South University, Changsha, China
| | - Na Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, China
| | - Lan Deng
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China; Department of Hematology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Xudong Li
- Department of Hematology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xinquan Liang
- Department of Hematology, First People's Hospital of Chenzhou, Chenzhou, China
| | - Xiaodan Luo
- Department of Hematology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China; Department of Hematology, Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Pengcheng Shi
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, China
| | - Hui Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, China
| | - Zhixiang Wang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, China
| | - Ling Jiang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, China
| | - Ren Lin
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, China
| | - Yan Chen
- Department of Hematology, Xiangya Hospital, Central South University, Changsha, China
| | - Sanfang Tu
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yu Zhang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, China
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, China
| | - Xiaojun Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, China; Department of Hematology, Peking University People's Hospital, Beijing, China
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, China.
| |
Collapse
|
28
|
Abou Dalle I, Labopin M, Kröger N, Schroeder T, Finke J, Stelljes M, Neubauer A, Blaise D, Yakoub-Agha I, Salmenniemi U, Forcade E, Itäla-Remes M, Dreger P, Bug G, Passweg J, Heuser M, Choi G, Brissot E, Giebel S, Nagler A, Ciceri F, Bazarbachi A, Mohty M. Impact of disease burden on clinical outcomes of AML patients receiving allogeneic hematopoietic cell transplantation: a study from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation. Bone Marrow Transplant 2023; 58:784-790. [PMID: 37041215 DOI: 10.1038/s41409-023-01961-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/27/2023] [Accepted: 03/16/2023] [Indexed: 04/13/2023]
Abstract
Pre-transplant detectable measurable residual disease (MRD) is still associated with high risk of relapse and poor outcomes in acute myeloid leukemia (AML). We aimed at evaluating the impact of disease burden on prediction of relapse and survival in patients receiving allogeneic hematopoietic cell transplantation (allo-HCT) in first remission (CR1). We identified a total of 3202 adult AML patients, of these 1776 patients were in CR1 and MRD positive and 1426 patients were primary refractory at time of transplant. After a median follow-up of 24.4 months, non-relapse mortality and relapse rate were significantly higher in the primary refractory group compared to the CR1 MRD positive group (Hazards Ratio (HR) = 1.82 (95% CI: 1.47-2.24) p < 0.001 and HR = 1.54 (95% CI: 1.34-1.77), p < 0.001), respectively. Leukemia-free survival (LFS) and overall survival (OS) were significantly worse in the primary refractory group (HR = 1.61 (95% CI: 1.44-1.81), p < 0.001 and HR = 1.71 (95% CI: 1.51-1.94), p < 0.001, respectively). Our real-life data suggest that patients in CR1 and MRD positive at time of transplant could still be salvaged by allo-HCT with a 2-year OS of 63%, if negative MRD cannot be obtained and their outcomes are significantly better than patients transplanted with active disease.
Collapse
Affiliation(s)
- Iman Abou Dalle
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Myriam Labopin
- Department of Haematology, Hopital Saint-Antoine, INSERM, Paris, France
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Schroeder
- Dept. of Bone Marrow Transplantation, University Hospital, Essen, Germany
| | - Jürgen Finke
- Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine and Medical Center-University of Freiburg, Freiburg, Germany
| | - Matthias Stelljes
- Department of Medicine A/Hematology and Oncology, University of Muenster, Muenster, Germany
| | - Andreas Neubauer
- Klinik für Innere Medizin mit SP Hämatologie, Onkologie und Immunologie, Philipps-Universität, Marburg, Germany
| | | | | | - Urpu Salmenniemi
- Department of Hematology, Helsinki University Hospital, Comprehensive Cancer Center and University of Helsinki, Helsinki, Finland
| | - Edouard Forcade
- CHU Bordeaux, Service d'hématologie Clinique et Thérapie Cellulaire, 33000, Pessac, France
| | - Maija Itäla-Remes
- Department of Medicine, Turku University Central Hospital, PL 52, Turku, Finland
| | - Peter Dreger
- Department Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Gesine Bug
- Department of Medicine II, University Hospital, Frankfurt, Germany
| | - Jakob Passweg
- EBMT Activity Survey Office, Hematology Division, University Hospital, Basel, Switzerland
| | - Michael Heuser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Goda Choi
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Eolia Brissot
- Department of Hematology, Hospital Saint Antoine, Paris, France
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Oncohematology, Maria Sklodowska-Curie Institute, Oncology Center-Gliwice, Gliwice, Poland
| | - Arnon Nagler
- Department of Bone Marrow Transplantation, Chaim Sheba Medical Center-Tel-Hashomer, Tel-Hashomer, Israel
| | - Fabio Ciceri
- Ospedale San Raffaele s.r.l., Haematology and BMT, Milano, Italy
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Mohamad Mohty
- Department of Haematology, Hopital Saint-Antoine, INSERM, Paris, France
| |
Collapse
|
29
|
Hodroj MH, Abou Dalle I, Moukalled N, El Cheikh J, Mohty M, Bazarbachi A. Novel strategies to prevent and overcome relapse after allogeneic hematopoietic cell transplantation in acute lymphoblastic leukemia. Front Immunol 2023; 14:1191912. [PMID: 37359547 PMCID: PMC10285443 DOI: 10.3389/fimmu.2023.1191912] [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: 03/22/2023] [Accepted: 05/26/2023] [Indexed: 06/28/2023] Open
Abstract
The outcome of B-cell acute lymphoblastic leukemia (B-ALL) has improved over time with the incorporation of multi-agent chemotherapy in the treatment landscape as well as the recent approval of immunotherapeutic agents allowing a larger proportion of patients to undergo allogeneic hematopoietic cell transplantation (allo-HCT) which is still considered a potential curative approach. However, relapse post-transplant is still occurring and constitutes a common cause of treatment failure in B-ALL. The present review aims to discuss the novel strategies and therapies used to prevent and overcome relapse post allo-HCT in patients with ALL, focusing on the role of tyrosine kinase inhibitors in Philadelphia chromosome positive B-ALL, the role of innovative agents such as blinatumomab and inotuzumab ozogamicin, and finally the role of cellular therapy.
Collapse
Affiliation(s)
- Mohammad Hassan Hodroj
- Division of Hematology & Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Iman Abou Dalle
- Division of Hematology & Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Bone Marrow Transplantation Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nour Moukalled
- Division of Hematology & Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Bone Marrow Transplantation Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jean El Cheikh
- Division of Hematology & Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Bone Marrow Transplantation Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohamad Mohty
- Sorbonne University, Saint-Antoine Hospital, AP-HP, INSERM UMRs 938, Paris, France
| | - Ali Bazarbachi
- Division of Hematology & Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Bone Marrow Transplantation Program, American University of Beirut Medical Center, Beirut, Lebanon
| |
Collapse
|
30
|
Al-Shaibani E, Novitzky-Basso I, Mattsson J, Kim DDH. Post-transplant maintenance therapy in acute myeloid leukemia after allogeneic hematopoietic stem cell transplantation harmonizing multiple therapeutic modalities including targeted therapy, immunotherapy and cellular therapy. Int J Hematol 2023:10.1007/s12185-023-03614-x. [PMID: 37212948 DOI: 10.1007/s12185-023-03614-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/11/2023] [Accepted: 04/28/2023] [Indexed: 05/23/2023]
Abstract
Allogeneic hematopoietic stem cell transplant (HCT) has improved survival for patients with acute myeloid leukemia (AML), especially for those at high risk of relapse. However, relapse remains the leading cause of treatment failure post-HCT, occurring in around 35-45% of patients, and leading to dismal outcomes. Strategies to reduce relapse risk are urgently needed, especially in the early post-transplant period before activation of the graft-versus-leukemia (GVL) effect. Maintenance therapy is a course of treatment given post-HCT with the expectation of reducing relapse risk. While there are currently no therapies approved for maintenance therapy for AML after HCT, there are a number of studies and ongoing investigations examining the role of maintenance therapies that include targeted agents against FLT3-ITD, BCL2, or IDH mutations, hypomethylating agents, immunomodulatory therapies and cellular therapies. In this review, we discuss the mechanistic and clinical data for post-transplant maintenance therapies in AML and strategies for maintenance therapy for AML after HCT.
Collapse
Affiliation(s)
- Eshrak Al-Shaibani
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, 610 University Ave, OPG Rm 6-222, Toronto, ON, Canada
| | - Igor Novitzky-Basso
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, 610 University Ave, OPG Rm 6-222, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, M5G 2M9, Canada
| | - Jonas Mattsson
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, 610 University Ave, OPG Rm 6-222, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, M5G 2M9, Canada
| | - Dennis Dong Hwan Kim
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, 610 University Ave, OPG Rm 6-222, Toronto, ON, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, M5G 2M9, Canada.
| |
Collapse
|
31
|
De Cicco M, Lagreca I, Basso S, Barozzi P, Muscianisi S, Bianco A, Riva G, Di Vincenzo S, Pulvirenti C, Sapuppo D, Siciliano M, Rosti V, Candoni A, Zecca M, Forghieri F, Luppi M, Comoli P. Preclinical Validation of an Advanced Therapy Medicinal Product Based on Cytotoxic T Lymphocytes Specific for Mutated Nucleophosmin (NPM1 mut) for the Treatment of NPM1 mut-Acute Myeloid Leukemia. Cancers (Basel) 2023; 15:2731. [PMID: 37345068 DOI: 10.3390/cancers15102731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/05/2023] [Accepted: 05/10/2023] [Indexed: 06/23/2023] Open
Abstract
Acute myeloid leukemia (AML) with nucleophosmin (NPM1) genetic mutations is the most common subtype in adult patients. Refractory or relapsed disease in unfit patients or after allogeneic hematopoietic stem cell transplantation (allo-HSCT) has a poor prognosis. NPM1-mutated protein, stably expressed on tumor cells but not on normal tissues, may serve as an ideal target for NPM1-mutated AML immunotherapy. The study aim was to investigate the feasibility of producing mutated-NPM1-specific cytotoxic T cells (CTLs) suitable for somatic cell therapy to prevent or treat hematologic relapse in patients with NPM1-mutated AML. T cells were expanded or primed from patient or donor peripheral blood mononuclear cells by NPM1-mutated protein-derived peptides, and tested for leukemia antigen-targeted cytotoxic activity, cytokine production and hematopoietic precursor inhibitory effect. We found that mutated-NPM1-specific CTLs, displaying specific cytokine production and high-level cytotoxicity against patients' leukemia blasts, and limited inhibitory activity in clonogenic assays, could be obtained from both patients and donors. The polyfunctional mutated-NPM1-specific CTLs included both CD8+ and CD4+ T cells endowed with strong lytic capacity. Our results suggest that mutated-NPM1-targeted CTLs may be a useful therapeutic option to control low-tumor burden relapse following conventional chemotherapy in older NPM1-mutated AML patients or eradicate persistent MRD after HSCT.
Collapse
Affiliation(s)
- Marica De Cicco
- SSD Cell Factory e Center for Advanced Therapies, Department of Woman and Child Health, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Ivana Lagreca
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, 41124 Modena, Italy
| | - Sabrina Basso
- SSD Cell Factory e Center for Advanced Therapies, Department of Woman and Child Health, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Patrizia Barozzi
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, 41124 Modena, Italy
| | - Stella Muscianisi
- SSD Cell Factory e Center for Advanced Therapies, Department of Woman and Child Health, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- SC Pediatric Hematology/Oncology, Department of Woman and Child Health, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Alba Bianco
- SSD Cell Factory e Center for Advanced Therapies, Department of Woman and Child Health, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- SC Pediatric Hematology/Oncology, Department of Woman and Child Health, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Giovanni Riva
- Department of Laboratory Medicine and Pathology, Unità Sanitaria Locale, 41126 Modena, Italy
| | - Sara Di Vincenzo
- SSD Cell Factory e Center for Advanced Therapies, Department of Woman and Child Health, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Chiara Pulvirenti
- SSD Cell Factory e Center for Advanced Therapies, Department of Woman and Child Health, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- SC Pediatric Hematology/Oncology, Department of Woman and Child Health, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Davide Sapuppo
- SSD Cell Factory e Center for Advanced Therapies, Department of Woman and Child Health, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- SC Pediatric Hematology/Oncology, Department of Woman and Child Health, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Mariangela Siciliano
- SSD Cell Factory e Center for Advanced Therapies, Department of Woman and Child Health, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Vittorio Rosti
- Center for the Study of Myelofibrosis, General Medicine 2, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Anna Candoni
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, 41124 Modena, Italy
| | - Marco Zecca
- SC Pediatric Hematology/Oncology, Department of Woman and Child Health, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Fabio Forghieri
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, 41124 Modena, Italy
| | - Mario Luppi
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, 41124 Modena, Italy
| | - Patrizia Comoli
- SSD Cell Factory e Center for Advanced Therapies, Department of Woman and Child Health, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, 41124 Modena, Italy
| |
Collapse
|
32
|
Fedorov K, Maiti A, Konopleva M. Targeting FLT3 Mutation in Acute Myeloid Leukemia: Current Strategies and Future Directions. Cancers (Basel) 2023; 15:cancers15082312. [PMID: 37190240 DOI: 10.3390/cancers15082312] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 05/17/2023] Open
Abstract
FLT3 mutations are present in 30% of newly diagnosed patients with acute myeloid leukemia. Two broad categories of FLT3 mutations are ITD and TKD, with the former having substantial clinical significance. Patients with FLT3-ITD mutation present with a higher disease burden and have inferior overall survival, due to high relapse rates after achieving remission. The development of targeted therapies with FLT3 inhibitors over the past decade has substantially improved clinical outcomes. Currently, two FLT3 inhibitors are approved for use in patients with acute myeloid leukemia: midostaurin in the frontline setting, in combination with intensive chemotherapy; and gilteritinib as monotherapy in the relapsed refractory setting. The addition of FLT3 inhibitors to hypomethylating agents and venetoclax offers superior responses in several completed and ongoing studies, with encouraging preliminary data. However, responses to FLT3 inhibitors are of limited duration due to the emergence of resistance. A protective environment within the bone marrow makes eradication of FLT3mut leukemic cells difficult, while prior exposure to FLT3 inhibitors leads to the development of alternative FLT3 mutations as well as activating mutations in downstream signaling, promoting resistance to currently available therapies. Multiple novel therapeutic strategies are under investigation, including BCL-2, menin, and MERTK inhibitors, as well as FLT3-directed BiTEs and CAR-T therapy.
Collapse
Affiliation(s)
- Kateryna Fedorov
- Department of Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Abhishek Maiti
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Marina Konopleva
- Department of Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA
| |
Collapse
|
33
|
Perl AE, Larson RA, Podoltsev NA, Strickland S, Wang ES, Atallah E, Schiller GJ, Martinelli G, Neubauer A, Sierra J, Montesinos P, Recher C, Yoon SS, Maeda Y, Hosono N, Onozawa M, Kato T, Kim HJ, Hasabou N, Nuthethi R, Tiu R, Levis MJ. Outcomes in Patients with FLT3-Mutated Relapsed/ Refractory Acute Myelogenous Leukemia Who Underwent Transplantation in the Phase 3 ADMIRAL Trial of Gilteritinib versus Salvage Chemotherapy. Transplant Cell Ther 2023; 29:265.e1-265.e10. [PMID: 36526260 PMCID: PMC10189888 DOI: 10.1016/j.jtct.2022.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/04/2022] [Accepted: 12/07/2022] [Indexed: 12/15/2022]
Abstract
The fms-like tyrosine kinase 3 (FLT3) inhibitor gilteritinib improved the survival of patients with relapsed or refractory (R/R) FLT3-mutated acute myelogenous leukemia (AML) in the phase 3 ADMIRAL trial. In this study, we assessed survival and relapse rates of patients in the ADMIRAL trial who underwent hematopoietic stem cell transplantation (HSCT), as well as safety outcomes in patients who received post-transplantation gilteritinib maintenance therapy. ADMIRAL was a global phase 3 randomized controlled trial that enrolled adult patients with FLT3-mutated R/R AML. Patients with R/R AML who harbored FLT3 internal tandem duplication mutations in the juxtamembrane domain or D835/I836 point mutations in the tyrosine kinase domain were randomized (2:1) to gilteritinib (120 mg/day) or to preselected high- or low-intensity salvage chemotherapy (1 or 2 cycles). Patients in the gilteritinib arm who proceeded to HSCT could receive post-transplantation gilteritinib maintenance therapy if they were within 30 to 90 days post-transplantation and had achieved composite complete remission (CRc) with successful engraftment and no post-transplantation complications. Adverse events (AEs) during HSCT were recorded in the gilteritinib arm only. Survival outcomes and the cumulative incidence of relapse were assessed in patients who underwent HSCT during the trial. Treatment-emergent AEs were evaluated in patients who restarted gilteritinib as post-transplantation maintenance therapy. Patients in the gilteritinib arm underwent HSCT more frequently than those in the chemotherapy arm (26% [n = 64] versus 15% [n = 19]). For all transplantation recipients, 12- and 24-month overall survival (OS) rates were 68% and 47%, respectively. Despite a trend toward longer OS after pretransplantation CRc, post-transplantation survival was comparable in the 2 arms. Patients who resumed gilteritinib after HSCT had a low relapse rate after pretransplantation CRc (20%) or CR (0%). The most common AEs observed with post-transplantation gilteritinib therapy were increased alanine aminotransferase level (45%), pyrexia (43%), and diarrhea (40%); grade ≥3 AEs were related primarily to myelosuppression. The incidences of grade ≥III acute graft-versus-host disease and related mortality were low. Post-transplantation survival was similar across the 2 study arms in the ADMIRAL trial, but higher remission rates with gilteritinib facilitated receipt of HSCT. Gilteritinib as post-transplantation maintenance therapy had a stable safety and tolerability profile and was associated with low relapse rates. Taken together, these data support a preference for bridging therapy with gilteritinib over chemotherapy in transplantation-eligible patients.
Collapse
Affiliation(s)
- Alexander E Perl
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Richard A Larson
- Division of the Biological Sciences, University of Chicago, Chicago, Illinois
| | - Nikolai A Podoltsev
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Stephen Strickland
- Department of Internal Medicine, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Eunice S Wang
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Ehab Atallah
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Gary J Schiller
- Division of Hematology and Oncology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Giovanni Martinelli
- IRCCS Istituto Scientifico Romagnolo per lo Studio dei Tumori "Dino Amadori" IRST S.r.l, Meldola, Italy
| | | | - Jorge Sierra
- Hospital de la Santa Creu i Sant Pau and Josep Carreras Leukemia Research Institute, Barcelona, Spain
| | - Pau Montesinos
- Department of Hematology, University Hospital La Fe, Valencia, Spain
| | - Christian Recher
- Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Université de Toulouse 3 Paul Sabatier, Toulouse, France
| | - Sung-Soo Yoon
- Department of Hemato Oncology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yoshinobu Maeda
- Department of Hematology and Oncology, Okayama University Hospital, Okoyama, Japan
| | - Naoko Hosono
- Department of Internal Medicine, University of Fukui, Fukui, Japan
| | | | - Takayasu Kato
- Department of Hematology, University of Tsukuba, Tsukuba, Japan
| | - Hee-Je Kim
- Catholic Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | | | | | - Ramon Tiu
- Astellas Pharma US, Inc., Northbrook, Illinois
| | - Mark J Levis
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
34
|
Tamefusa K, Ishida H, Kanamitsu K, Ochi M, Fujiwara K, Tatebe Y, Aoe M, Nodomi S, Washio K. Posttransplant gilteritinib maintenance therapy for pediatric acute myeloid leukemia with myelodysplasia-related changes with FLT3-internal tandem duplication. Pediatr Blood Cancer 2023; 70:e30108. [PMID: 36495539 DOI: 10.1002/pbc.30108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 10/28/2022] [Accepted: 10/31/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Kosuke Tamefusa
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Hisashi Ishida
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Kiichiro Kanamitsu
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan.,Department of Pediatrics, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Motoharu Ochi
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Kaori Fujiwara
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Yasuhisa Tatebe
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
| | - Michinori Aoe
- Division of Medical Support, Okayama University Hospital, Okayama, Japan
| | - Seishiro Nodomi
- Department of Pediatrics, Kurashiki Central Hospital, Okayama, Japan
| | - Kana Washio
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| |
Collapse
|
35
|
Li F, Liu YP, Zhu H, Hong M, Qian SX, Zhu Y, Shen WY, Chen LJ, He GS, Wu HX, Lu H, Li JY, Miao KR. [Clinical study of induction chemotherapy followed by allogeneic hematopoietic stem cell transplantation in the treatment of FLT3-ITD(+) acute myeloid leukemia with normal karyotype]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:230-235. [PMID: 37356985 PMCID: PMC10119728 DOI: 10.3760/cma.j.issn.0253-2727.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Indexed: 06/27/2023]
Abstract
Objective: To assess the efficacy of induction chemotherapy followed by allogeneic hematopoietic stem cell transplantation (allo-HSCT) in the treatment of FLT3-ITD(+) acute myeloid leukemia (AML) with normal karyotype. Methods: The clinical data of FLT3-ITD(+) AML patients with normal karyotype in the First Affiliated Hospital of Nanjing Medical University from Jan 2018 to March 2021 were retrospectively analyzed. Results: The study included 49 patients with FLT3-ITD(+)AML, 31 males, and 18 females, with a median age of 46 (16-59) years old. All patients received induction chemotherapy, and 24 patients received sequential allo-HSCT (transplantation group) . The median follow-up time was 465 days, the one-year overall survival (OS) from diagnosis was (70.0 ± 7.4) %, and one-year disease-free survival (DFS) was (70.3±7.4) %. The one-year OS was significantly different between the transplantation group and the non-transplantation group [ (85.2 ± 7.9) % vs (52.6 ± 12.3) %, P=0.049]. but one-year DFS [ (84.7 ± 8.1) % vs (55.2 ± 11.9) %, P=0.061] was not. No significance was found in one-year OS between patients with low-frequency and high-frequency FLT3-ITD(+) (P>0.05) . There were 12 patients with high-frequency FLT3-ITD(+) in the transplantation and the non-transplantation groups, respectively. The one-year OS [ (68.8 ± 15.7) % in the transplantation group vs (26.2 ± 15.3) % in the non-transplantation group, P=0.027] and one-year DFS [ (45.5 ± 21.3) % in the transplantation group vs (27.8±15.8) % in the non-transplantation group, P=0.032] were significantly different between the two groups. Conclusion: Induction chemotherapy followed by allo-HSCT can enhance the prognosis of FLT3-ITD(+) patients, particularly those with FLT3-ITD high-frequency mutation.
Collapse
Affiliation(s)
- F Li
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Y P Liu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - H Zhu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - M Hong
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - S X Qian
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Y Zhu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - W Y Shen
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - L J Chen
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - G S He
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - H X Wu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - H Lu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - J Y Li
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - K R Miao
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| |
Collapse
|
36
|
Jentzsch M, Bischof L, Brauer D, Backhaus D, Ussmann J, Franke GN, Vucinic V, Platzbecker U, Schwind S. Clinical Implications of the FLT3-ITD Allelic Ratio in Acute Myeloid Leukemia in the Context of an Allogeneic Stem Cell Transplantation. Cancers (Basel) 2023; 15:1312. [PMID: 36831653 PMCID: PMC9954047 DOI: 10.3390/cancers15041312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/07/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
Although the presence of FLT3-ITD, as well as levels of the FLT3-ITD allelic ratio, have been described as prognostic factors in acute myeloid leukemia (AML), little is known about how the FLT3-ITD allelic ratio impacts patients' outcomes when receiving an allogeneic hematopoietic stem cell transplantation (HSCT). We analyzed 118 patients (median age at diagnosis 58.3, range 14.3-82.3 years) harboring FLT3-ITD, of whom 94 patients were consolidated with an allogeneic HSCT and included in outcome analyses. A high FLT3-ITD allelic ratio was associated with a higher white blood cell count, higher blood and bone marrow blasts, and worse ELN2017 risk at diagnosis. Patients with a high FLT3-ITD allelic ratio more often had NPM1 mutations, while patients with a low allelic ratio more often had FLT3-TKD mutations. Patients with a high FLT3-ITD allelic ratio were less likely to achieve a measurable residual disease (MRD)-negative remission prior to allogeneic HSCT and had a trend for a shorter time to relapse. However, there was no distinct cumulative incidence of relapse, non-relapse mortality, or overall survival according to the FLT3-ITD allelic ratio in transplanted patients. While co-mutated FLT3-TKD was associated with better outcomes, the MRD status at HSCT was the most significant factor for outcomes. While our data indicates that an allogeneic HSCT may mitigate the adverse effect of a high FLT3-ITD allelic ratio, comparative studies are needed to evaluate which FLT3-ITD mutated patients benefit from which consolidation strategy.
Collapse
Affiliation(s)
- Madlen Jentzsch
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy and Hemostaseology, University of Leipzig Medical Center, 04103 Leipzig, Germany
| | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Mohty R, El Hamed R, Brissot E, Bazarbachi A, Mohty M. New drugs before, during, and after hematopoietic stem cell transplantation for patients with acute myeloid leukemia. Haematologica 2023; 108:321-341. [PMID: 36722403 PMCID: PMC9890036 DOI: 10.3324/haematol.2022.280798] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 09/02/2022] [Indexed: 02/02/2023] Open
Abstract
The treatment of acute myeloid leukemia (AML) has evolved over the past few years with the advent of next-generation sequencing. Targeted therapies alone or in combination with low-dose or high-intensity chemotherapy have improved the outcome of patients with AML treated in the frontline and relapsed/refractory settings. Despite these advances, allogeneic stem cell transplantation (allo-HCT) remains essential as consolidation therapy following frontline treatment in intermediate-and adverse-risk and relapsed/refractory disease. However, many patients relapse, with limited treatment options, hence the need for post-transplant strategies to mitigate relapse risk. Maintenance therapy following allo-HCT was developed for this specific purpose and can exploit either a direct anti-leukemia effect and/or enhance the bona fide graft-versus-leukemia effect without increasing the risk of graft-versus-host disease. In this paper, we summarize novel therapies for AML before, during, and after allo-HCT and review ongoing studies.
Collapse
Affiliation(s)
- Razan Mohty
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL
| | - Rama El Hamed
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Eolia Brissot
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, Paris, France; INSERM, Saint-Antoine Research Center, Paris
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, Paris, France; INSERM, Saint-Antoine Research Center, Paris.
| |
Collapse
|
38
|
Azacitidine in Combination with Venetoclax Maintenance Post-allogeneic Hematopoietic Stem Cell Transplantation in T Cell Acute Lymphoblastic Leukemia. Clin Hematol Int 2023; 5:52-55. [PMID: 36595164 PMCID: PMC10063763 DOI: 10.1007/s44228-022-00019-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/09/2022] [Indexed: 01/04/2023] Open
|
39
|
Jiang S, Yan H, Lu X, Wei R, Chen H, Zhang A, Shi W, Xia L. How to improve the outcomes of elderly acute myeloid leukemia patients through allogeneic hematopoietic stem cell transplantation. Front Immunol 2023; 14:1102966. [PMID: 37207218 PMCID: PMC10189056 DOI: 10.3389/fimmu.2023.1102966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 04/19/2023] [Indexed: 05/21/2023] Open
Abstract
In recent years, with the gradual advancement of haploidentical transplantation technology, the availability of donors has increased significantly, along with the widespread use of reduced-intensity conditioning and the improvement of nursing techniques, giving more elderly acute myeloid leukemia (AML) patients the chance to receive allogeneic hematopoietic stem cell transplantation. We have summarized the classic and recently proposed pre-transplant assessment methods and assessed the various sources of donors, conditioning regimens, and post-transplant complication management based on the outcomes of large-scale clinical studies for elderly AML patients.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Wei Shi
- *Correspondence: Linghui Xia, ; Wei Shi,
| | | |
Collapse
|
40
|
Gołos A, Góra-Tybor J, Robak T. Experimental drugs in clinical trials for acute myeloid leukemia: innovations, trends, and opportunities. Expert Opin Investig Drugs 2023; 32:53-67. [PMID: 36669827 DOI: 10.1080/13543784.2023.2171860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Acute myeloid leukemia (AML) is a heterogeneous disease characterized by many cytogenetic and molecular alterations. Due to better knowledge of the molecular basis of AML, many targeted therapies have been introduced and registered, e.g. FMS-like tyrosine kinase 3 inhibitors, isocitrate dehydrogenase 1/2 mutation inhibitors, and Bcl-2 inhibitor. Despite that, the cure for AML remains an unmet clinical need in most patients. AREAS COVERED The review aims to present new, not yet registered drugs for AML. We searched the English literature for articles concerning AML, targeted drugs, menin inhibitors, DOT1L, BET, IDH inhibitors, FLT3, hedgehog inhibitors, Polo-like kinase inhibitors, RNA splicing, and immune therapies via PubMed. Publications from January 2000 to August 2022 were scrutinized. Additional relevant publications were obtained by reviewing the references from the chosen articles and Google search. Conference proceedings from the previous 5 years of The American Society of Hematology, the European Hematology Association, and the American Society of Clinical Oncology were searched manually. Additional relevant publications were obtained by reviewing the references. EXPERT OPINION For several years, the therapeutic approach in AML has become more individualized. Novel groups of drugs give hope for greater curability. High response rates have agents that restore the activity of the p53 protein. In addition, agents that work independently of a particular mutation seem promising for AML without any known mutation.
Collapse
Affiliation(s)
- Aleksandra Gołos
- Department of Hematooncology, Copernicus Memorial Hospital, Lodz, Poland
| | - Joanna Góra-Tybor
- Department of Hematooncology, Copernicus Memorial Hospital, Lodz, Poland.,Department of Hematology, Medical University of Lodz, Lodz, Poland
| | - Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Lodz, Poland.,Department of General Hematology, Copernicus Memorial Hospital, Lodz, Poland
| |
Collapse
|
41
|
Cordella S, Parisotto A, Bettelli F, Morselli M, Barbieri E, Pozzi S, Aquilino A, Repaci G, Cuoghi A, Bresciani P, Messerotti A, Colasante C, Gilioli A, Pioli V, Giusti D, Colaci E, Cassanelli L, Ceccherelli G, Bevini M, Malavolti R, Venturelli D, Paolini A, Martinelli S, Maffei R, Riva G, Nasillo V, Trenti T, Comoli P, Tagliafico E, Manfredini R, Barozzi P, Potenza L, Marasca R, Luppi M, Forghieri F. Feasibility of autologous peripheral blood stem cell mobilization and harvest in adult patients with FLT3-mutated acute myeloid leukemia receiving chemotherapy combined with midostaurin: a single-center experience. Ann Hematol 2023; 102:213-217. [PMID: 36261597 DOI: 10.1007/s00277-022-05013-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/10/2022] [Indexed: 01/05/2023]
Affiliation(s)
- Stefano Cordella
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Angelica Parisotto
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Francesca Bettelli
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Monica Morselli
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Emiliano Barbieri
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Stefano Pozzi
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Anna Aquilino
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Gianluca Repaci
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Angela Cuoghi
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Paola Bresciani
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Andrea Messerotti
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Corrado Colasante
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Andrea Gilioli
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Valeria Pioli
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Davide Giusti
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Elisabetta Colaci
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Luca Cassanelli
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Giovanni Ceccherelli
- Immuno-Transfusional Medicine Unit, Azienda Ospedaliero-Universitaria Di Modena, Modena, Italy
| | - Mirco Bevini
- Immuno-Transfusional Medicine Unit, Azienda Ospedaliero-Universitaria Di Modena, Modena, Italy
| | - Roberta Malavolti
- Immuno-Transfusional Medicine Unit, Azienda Ospedaliero-Universitaria Di Modena, Modena, Italy
| | - Donatella Venturelli
- Immuno-Transfusional Medicine Unit, Azienda Ospedaliero-Universitaria Di Modena, Modena, Italy
| | - Ambra Paolini
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Silvia Martinelli
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Rossana Maffei
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Giovanni Riva
- Department of Laboratory Medicine and Pathology, Azienda Unità Sanitaria Locale Di Modena, Modena, Italy
| | - Vincenzo Nasillo
- Department of Laboratory Medicine and Pathology, Azienda Unità Sanitaria Locale Di Modena, Modena, Italy
| | - Tommaso Trenti
- Department of Laboratory Medicine and Pathology, Azienda Unità Sanitaria Locale Di Modena, Modena, Italy
| | - Patrizia Comoli
- Pediatric Hematology Unit and Cell Factory, Istituto Di Ricovero E Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo Di Pavia, Pavia, Italy
| | - Enrico Tagliafico
- Center for Genome Research, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Modena, Italy
| | - Rossella Manfredini
- Center for Regenerative Medicine "Stefano Ferrari", Department of Life Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Patrizia Barozzi
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Leonardo Potenza
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Roberto Marasca
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Mario Luppi
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy.
| | - Fabio Forghieri
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy.
| |
Collapse
|
42
|
Babakhanlou R, Ravandi-Kashani F. SOHO State of the Art Updates and Next Questions |The Role of Maintenance Therapy in Acute Myeloid Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:1-7. [PMID: 36456394 DOI: 10.1016/j.clml.2022.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/06/2022] [Accepted: 11/07/2022] [Indexed: 11/13/2022]
Abstract
Acute myeloid leukemia (AML) is an aggressive disease predominantly affecting the elderly population. Although, up to 65% of patients with AML achieve a complete remission with standard induction chemotherapy, the majority of patients will relapse and succumb to the disease. Although maintenance therapy is a component of standard management for various hematological malignancies, such as acute lymphoblastic leukemia (ALL), acute promyelocytic leukemia (APL) or multiple myeloma, past studies investigating the role of maintenance therapy in AML were unable to demonstrate an advantage in overall survival, and therefore, it has not been an established practice in the treatment of AML. For patients, who are not candidates for stem cell transplant, effective AML maintenance therapies are needed in order to reduce the risk of relapse. Over the past decades, many investigators have examined the role of various maintenance strategies in AML; with the intention to prolong remission and overall survival. This review will provide an overview of prior and ongoing approaches and strategies to maintenance therapy for AML.
Collapse
Affiliation(s)
- Rodrick Babakhanlou
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX.
| | | |
Collapse
|
43
|
Nannya Y, Viswabandya A, Lu P. Advances in Allogeneic Hematopoietic Stem Cell Transplantation for Acute Leukemia. BLOOD CELL THERAPY 2022; 5:S25-S33. [PMID: 37220610 PMCID: PMC10200363 DOI: 10.31547/bct-2022-015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/31/2022] [Indexed: 05/25/2023]
Abstract
In acute leukemia, advances have been made in therapeutic strategies centered on allogeneic hematopoietic stem cell transplantation (allo-SCT), three of which are presented here. The indication of allo-SCT for acute myeloid leukemia (AML) in 1st complete remission (CR1) has been debated. Genomic medicine has helped us gain a deeper understanding of this disease, some of which may serve as prognostic factors. Such genetic abnormalities could also help measure minimal residual disease (MRD) and provide additional clues to estimate the efficacy of chemotherapy. Combined with existing prognostic factors, these data can be used to construct a more accurate prognostic model, providing an optimal indication of allo-SCT for AML in CR1. Furthermore, overall treatment algorithms for high-risk AML after allo-SCT should include prophylactic and pre-emptive treatment to prevent relapse. These include immunotherapy using donor lymphocyte infusion (DLI), FLT3 inhibitors in FLT3-mutated AML, hypomethylating agents, or a combination of DLI with these agents. Clinical trials are currently ongoing to elucidate the role of these strategies, which will lead to a risk-adapted treatment for preventing relapse in high-risk AML. CD19-targeted chimeric antigen receptor (CAR) T-cell therapy induces a remarkable response in B-acute lymphoid leukemia (B-ALL); however, relapse remains a major problem. In this regard, allo-SCT as a consolidation treatment after CAR-T cell therapy for B-ALL is recommended for pediatric and adult patients. Achieving complete remission (CR) with CAR-T cell therapy is considered a promising bridging therapy to allo-SCT. Novel CAR-T treatment techniques are being developed to change their role as a pre-transplant treatment.
Collapse
Affiliation(s)
- Yasuhito Nannya
- Division of Hematopoietic Disease Control, Institute of Medical Science, The University of Tokyo
| | - Auro Viswabandya
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre
| | - Peihua Lu
- Lu Daopei Hospital, Beijing Lu Daopei Institute of Hematology
| |
Collapse
|
44
|
Nagler A. In 2022, which is preferred: haploidentical or cord transplant? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:64-73. [PMID: 36485156 PMCID: PMC9820258 DOI: 10.1182/hematology.2022000327] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation is the treatment of choice for high-risk hematological malignancies such as acute myeloid and lymphocytic leukemia, myelodysplastic syndrome, and myeloproliferative disorders. Alternative donor transplantation from either haploidentical (haplo-SCT) or cord blood donor (CBT) is an established therapeutic alternative for patients who need transplants but lack a human leukocyte antigen-matched donor. Although haplo-SCT (mainly non-T-cell-depleted haplo-SCT with posttransplant cyclophosphamide) is increasing while CBT is decreasing worldwide (Figure 1), recent developments in CBT, especially cord blood expansion and other strategies to improve engraftment and immune reconstitution post-CBT, make CBT still a valuable option. This article discusses the 2 options based on the currently available data, focusing on adults, and tries to give some clues to help the transplant physician choose a haploidentical vs a cord blood donor. Given the limited numbers of published or ongoing well-designed randomized controlled trials comparing haplo-SCT to CBT and the overall similar clinical results in the available, mostly registry-based, and single-center studies, with substantial heterogeneity and variability, the decision to perform haplo-SCT or CBT in a given patient depends not only on the patient, disease, and donor characteristics and donor availability (although most if not all patients should have in principle an alternative donor) but also on the transplant physician's discretion and, most importantly, the center's experience and preference and ongoing protocols and strategies.
Collapse
Affiliation(s)
- Arnon Nagler
- Division of Hematology, Bone Marrow Transplantation, and Hemato-Oncology Center, Chaim Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Acute Leukemia Working Party, European Society for Blood and Marrow Transplantation, Paris, France
| |
Collapse
|
45
|
Tecik M, Adan A. Therapeutic Targeting of FLT3 in Acute Myeloid Leukemia: Current Status and Novel Approaches. Onco Targets Ther 2022; 15:1449-1478. [PMID: 36474506 PMCID: PMC9719701 DOI: 10.2147/ott.s384293] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/19/2022] [Indexed: 08/13/2023] Open
Abstract
FMS-like tyrosine kinase 3 (FLT3) is mutated in approximately 30% of acute myeloid leukemia (AML) patients. The presence of FLT3-ITD (internal tandem duplication, 20-25%) mutation and, to a lesser extent, FLT3-TKD (tyrosine kinase domain, 5-10%) mutation is associated with poorer diagnosis and therapy response since the leukemic cells become hyperproliferative and resistant to apoptosis after continuous activation of FLT3 signaling. Targeting FLT3 has been the focus of many pre-clinical and clinical studies. Hence, many small-molecule FLT3 inhibitors (FLT3is) have been developed, some of which are approved such as midostaurin and gilteritinib to be used in different clinical settings, either in combination with chemotherapy or alone. However, many questions regarding the best treatment strategy remain to be answered. On the other hand, various FLT3-dependent and -independent resistance mechanisms could be evolved during FLT3i therapy which limit their clinical impact. Therefore, identifying molecular mechanisms of resistance and developing novel strategies to overcome this obstacle is a current interest in the field. In this review, recent studies of approved FLT3i and knowledge about major resistance mechanisms of clinically approved FLT3i's will be discussed together with novel treatment approaches such as designing novel FLT3i and dual FLT3i and combination strategies including approved FLT3i plus small-molecule agents targeting altered molecules in the resistant cells to abrogate resistance. Moreover, how to choose an appropriate FLT3i for the patients will be summarized based on what is currently known from available clinical data. In addition, strategies beyond FLT3i's including immunotherapeutics, small-molecule FLT3 degraders, and flavonoids will be summarized to highlight potential alternatives in FLT3-mutated AML therapy.
Collapse
Affiliation(s)
- Melisa Tecik
- Bioengineering Program, Graduate School of Engineering and Science, Abdullah Gul University, Kayseri, Turkey
| | - Aysun Adan
- Department of Molecular Biology and Genetics, Faculty of Life and Natural Sciences, Abdullah Gul University, Kayseri, Turkey
| |
Collapse
|
46
|
Maffini E, Ursi M, Barbato F, Dicataldo M, Roberto M, Campanini E, Dan E, De Felice F, De Matteis S, Storci G, Bonafè M, Arpinati M, Bonifazi F. The prevention of disease relapse after allogeneic hematopoietic cell transplantation in acute myeloid leukemia. Front Oncol 2022; 12:1066285. [DOI: 10.3389/fonc.2022.1066285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/11/2022] [Indexed: 12/02/2022] Open
Abstract
Disease relapse represents by far the most frequent cause of hematopoietic cell transplantation (HCT) failure. Patients with acute leukemia suffering relapse after HCT have limited conventional treatment options with little possibility of cure and represent, de facto, suitable candidates for the evaluation of novel cellular and biological-based therapies. Donor lymphocyte infusions (DLI) has been one of the first cellular therapies adopted to treat post HCT relapse of acute leukemia patients and still now, it is widely adopted in preemptive and prophylactic settings, with renewed interest for manipulated cellular products such as NK-DLI. The acquisition of novel biological insights into pathobiology of leukemia relapse are translating into the clinic, with novel combinations of target therapies and novel agents, helping delineate new therapeutical landscapes. Hypomethylating agents alone or in combination with novel drugs demonstrated their efficacy in pre-clinical models and controlled trials. FLT3 inhibitors represent an essential therapeutical instrument incorporated in post-transplant maintenance strategies. The Holy grail of allogeneic transplantation lies in the separation of graft-vs.-host disease from graft vs. tumor effects and after more than five decades, is still the most ambitious goal to reach and many ways to accomplish are on their way.
Collapse
|
47
|
Blackmon A, Aldoss I, Ball BJ. FLT3 Inhibitors as Maintenance Therapy after Allogeneic Stem-Cell Transplantation. Blood Lymphat Cancer 2022; 12:137-147. [PMID: 36097605 PMCID: PMC9464008 DOI: 10.2147/blctt.s281252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/19/2022] [Indexed: 11/23/2022]
Abstract
Mutations in the FLT3 gene are associated with poor prognosis in patients with AML, even after consolidation with allogeneic hematopoietic cell transplantation (alloHCT) in first remission. Treatment failure in FLT3-mutated AML is largely driven by excessive risk of relapse compared to other genetic subtypes, including in patients post-alloHCT. As a result, there is substantial interest in studying posttransplant maintenance therapy in FLT3-mutated AML as an approach to optimize disease control and improve long-term outcomes. Clinical trials utilizing posttransplant FLT3 inhibitors, such as sorafenib and midostaurin, have shown feasibility, safety, and encouraging posttransplant outcomes, and there are ongoing studies using newer-generation tyrosine-kinase inhibitors as posttransplant maintenance therapy. Here, we review the toxicities and efficacy of FLT3 inhibitors as posttransplant maintenance, recommendations on the use of FLT3 inhibitors by international consensus guidelines, and highlight key remaining questions.
Collapse
Affiliation(s)
- Amanda Blackmon
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Brian J Ball
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| |
Collapse
|
48
|
Xu X, Fan Z, Wang Y, Huang F, Xu Y, Sun J, Xu N, Deng L, Li X, Liang X, Luo X, Shi P, Liu H, Chen Y, Tu S, Huang X, Liu Q, Xuan L. Effect of sorafenib maintenance on Epstein-Barr virus and cytomegalovirus infections in patients with FLT3-ITD AML undergoing allogeneic hematopoietic stem cell transplantation: a secondary analysis of a randomized clinical trial. BMC Med 2022; 20:282. [PMID: 36050712 PMCID: PMC9436457 DOI: 10.1186/s12916-022-02479-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Use of kinase inhibitors such as dasatinib and imatinib might increase the risk of opportunistic infections, especially Epstein-Barr virus (EBV) and cytomegalovirus (CMV) infections. However, the effect of sorafenib on EBV and CMV infections remains unclear. The aim of this study was to investigate the effect of sorafenib maintenance post-transplantation on the incidence and mortality of EBV and CMV infections in patients with FLT3-ITD acute myeloid leukemia. METHODS This was a follow-up of our randomized controlled trial undertaken at seven hospitals in China. The primary endpoint was EBV and CMV infections within 3 years post-transplantation. Secondary endpoints included the cumulative incidences of relapse, non-relapse mortality (NRM), overall survival (OS), leukemia-free survival (LFS), and graft-versus-host disease (GVHD)-free/relapse-free survival (GRFS) at 3 years. RESULTS Two hundred two patients were assigned to sorafenib maintenance (n=100) or non-maintenance (control, n=102). Median extended follow-up post-transplantation was 36.8 (range, 2.5-67.1) months. The 3-year cumulative incidences of EBV-DNAemia and EBV-associated diseases were 24.0% (95% CI: 16.1-32.8%) and 5.0% (1.8-10.6%) in the sorafenib group, and 24.5% (16.6-33.2%) and 5.9% (2.4-11.6%) in the control group (P=0.937; P=0.771). The 3-year cumulative incidences of CMV-DNAemia and CMV-associated diseases were 56.0% (45.6-65.1%) and 8.0% (3.7-14.4%) in the sorafenib group, and 52.9% (42.7-62.1%) and 8.8% (4.3-15.3%) in the control group (P=0.997; P=0.826). The 3-year cumulative mortality of EBV- and CMV-associated diseases was 0.0% (0.0-0.0%) and 2.0% (0.4-6.4%) in the sorafenib group, and 1.0% (0.1-4.8%) and 2.0% (0.4-6.3%) in the control group (P=0.322, P=0.980). The 3-year cumulative incidences of relapse, NRM, OS, LFS, and GRFS were 13.0%, 11.1%, 79.0%, 75.9%, and 65.8% in the sorafenib group and 34.8%, 12.7%, 61.4%, 52.5%, and 46.6% in the control group, respectively (P<0.001, P=0.656, P=0.005, P<0.001, P=0.003). The reconstitution of T lymphocyte subsets, B lymphocytes, and natural killer cells was similar between the two groups (all P>0.05). CONCLUSIONS Sorafenib maintenance post-transplantation does not increase the incidence and mortality of EBV and CMV infections, demonstrating a favorable safety profile. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02474290 . Registered on June 14, 2015.
Collapse
Affiliation(s)
- Xin Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Zhiping Fan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Yu Wang
- Institute of Hematology, Peking University People's Hospital, Beijing, 100044, China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Yajing Xu
- Department of Hematology, Xiangya Hospital, Central South University, Changsha, China
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Na Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Lan Deng
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Xudong Li
- Department of Hematology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xinquan Liang
- Department of Hematology, the First People's Hospital of Chenzhou, Chenzhou, China
| | - Xiaodan Luo
- Department of Hematology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Pengcheng Shi
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Hui Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Yan Chen
- Department of Hematology, Xiangya Hospital, Central South University, Changsha, China
| | - Sanfang Tu
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaojun Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
- Institute of Hematology, Peking University People's Hospital, Beijing, 100044, China.
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
| | - Li Xuan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
| |
Collapse
|
49
|
Biavasco F, Zeiser R. FLT3-inhibitor therapy for prevention and treatment of relapse after allogeneic hematopoietic cell transplantation. Int J Hematol 2022; 116:341-350. [PMID: 35460465 PMCID: PMC9392688 DOI: 10.1007/s12185-022-03352-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 02/05/2023]
Abstract
The curative potential of allogeneic hematopoietic cell transplantation (allo-HCT) for acute myeloid leukemia (AML) relies on the graft-versus-leukemia (GVL)-effect. Relapse after allo-HCT occurs in a considerable proportion of patients, and has a dismal prognosis with very limited curative potential, especially for patients with FLT-ITD-mutated AML. Since the first description of sorafenib for treatment of FLT3-ITD-mutated AML, several clinical trials have tried to determine the efficacy of FLT3 inhibitors for preventing and treating AML relapse after allo-HSCT, but many questions regarding differences among compounds and mechanisms of action remain unanswered. This review provides an overview on the established and evolving use of FLT3 inhibitors to prevent or treat relapse of AML in the context of allo-HCT, focusing on the recently discovered immunogenic potential of some FLT3 inhibitors and addressing the possible mechanisms of leukemia drug-escape.
Collapse
Affiliation(s)
- Francesca Biavasco
- Department of Internal Medicine I, Hematology, Oncology and Stem Cell Transplantation, University Medical Center Freiburg, University Hospital Freiburg, 79106, Freiburg, Germany
| | - Robert Zeiser
- Department of Internal Medicine I, Hematology, Oncology and Stem Cell Transplantation, University Medical Center Freiburg, University Hospital Freiburg, 79106, Freiburg, Germany.
| |
Collapse
|
50
|
Allogeneic hematopoietic stem cell transplantation for pediatric acute myeloid leukemia in first complete remission: a meta-analysis. Ann Hematol 2022; 101:2497-2506. [PMID: 36038660 PMCID: PMC9546991 DOI: 10.1007/s00277-022-04965-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/19/2022] [Indexed: 11/01/2022]
Abstract
Identification of pediatric patients with acute myeloid leukemia (AML) candidates to receive allogeneic hematopoietic stem cell transplantation (allo-HSCT) in first complete remission (CR1) is still a matter of debate. Currently, transplantation is reserved to patients considered at high risk of relapse based on cytogenetics, molecular biology, and minimal residual disease (MRD) assessment. However, no randomized clinical trial exists in the literature comparing transplantation with other types of consolidation therapy. Here, we provide an up-to-date meta-analysis of studies comparing allo-HSCT in CR1 with chemotherapy alone as a post-remission treatment in high-risk pediatric AML. The literature search strategy identified 10 cohorts from 9 studies performing as-treated analysis. The quantitative synthesis showed improved overall survival (OS) (relative risk, 1.15; 95% confidence interval [CI], 1.06-1.24; P = 0.0006) and disease-free survival (relative risk, 1.31; 95% CI, 1.17-1.47; P = 0.0001) in the allo-HSCT group, with increased relapse rate in the chemotherapy group (relative risk, 1.26; 95% CI, 1.07-1.49; P = 0.006). Sensitivity analysis including prospective studies alone and excluding studies that reported the comparison only on intermediate-risk patients confirmed the benefit of allo-HSCT on OS. Further research should focus on individualizing allo-HSCT indications based on molecular stratification and MRD monitoring.
Collapse
|