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Qi J, Choi I, Ota S, Ichikawa S, Fujishima N, Iida H, Sugiura I, Sugiura K, Murata Y, Inoue H, Ohwada S, Wang J. Safety and Pharmacokinetics of Quizartinib Combination Therapy With Standard Induction and Consolidation Chemotherapy in Patients With Newly Diagnosed Acute Myeloid Leukemia: Results from Two Phase 1 Trials in Japan and China. Clin Pharmacol Drug Dev 2024; 13:560-571. [PMID: 38284515 DOI: 10.1002/cpdd.1353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/28/2023] [Indexed: 01/30/2024]
Abstract
Quizartinib is a potent, oral, second-generation, selective type II FMS-like receptor tyrosine kinase 3 (FLT3) inhibitor. It has shown improved overall survival in a randomized, multinational, Phase 3 (QuANTUM-First) study in patients with FLT3-internal tandem duplication (ITD)-positive newly diagnosed acute myeloid leukemia. We conducted 2 Phase 1b studies in Japan and China to evaluate the safety, pharmacokinetics, and efficacy of quizartinib in combination with standard induction and consolidation chemotherapy in patients with newly diagnosed acute myeloid leukemia. Quizartinib was started at a dose level of 20 mg/day and then escalated to 40 mg/day, the dose used in the Phase 3 study. Seven patients were enrolled according to the 3 + 3 dose-escalation method in each study, including 3 patients who were FLT3-ITD positive. No dose-limiting toxicities were observed at dose levels up to 40 mg/day in both studies. Grade 3 or higher, quizartinib-related, treatment-emergent adverse events included febrile neutropenia, hematologic toxicities, and infections. QT prolongation on electrocardiogram was observed in 5 patients. The pharmacokinetics of quizartinib and its metabolite AC886 were similar between the studies and consistent with previous findings in the United States. We confirmed the tolerability of Japanese and Chinese patients to the dose of quizartinib and chemotherapy regimens used in the QuANTUM-First study.
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Affiliation(s)
- Junyuan Qi
- Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Ilseung Choi
- National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | | | | | | | - Hiroatsu Iida
- National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | | | | | | | | | | | - Jianxiang Wang
- Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
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Lopes LM, Nucci M, Portugal RD. Toxicity and outcome of adults with acute myeloid leukemia receiving consolidation with high-dose cytarabine. Hematol Transfus Cell Ther 2023:S2531-1379(23)00161-X. [PMID: 37684163 DOI: 10.1016/j.htct.2023.07.007] [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: 10/04/2022] [Revised: 12/15/2022] [Accepted: 07/20/2023] [Indexed: 09/10/2023] Open
Abstract
INTRODUCTION High-dose cytarabine is considered standard of care as consolidation chemotherapy in adults with acute myeloid leukemia (AML) who are not eligible for allogeneic hematopoietic cell transplantation, but may be associated with significant toxicity. We evaluated the toxicity associated with high-dose cytarabine given as consolidation in AML patients treated at a Brazilian public hospital. METHODS We retrospectively reviewed the charts of all patients with AML treated between 2008 and 2020 who obtained complete remission (CR) after one cycle of induction chemotherapy and received consolidation with at least one cycle of high-dose cytarabine (defined as 3 g/m2 every 12 h days 1, 3 and 5). RESULTS Among 61 patients who received induction remission, 32 obtained CR and 28 received at least one cycle of high-dose cytarabine, for a total of 67 cycles (median 2 cycles per patient, range 1 - 4). In 45 cycles (67.2%) the patient was discharged after the end of chemotherapy, with a median of 6 days at home (range 3 - 8). Readmission occurred in 31 of the 45 cycles (68.9%). The most frequent toxicities were febrile neutropenia (56.7%), nausea and vomiting (23.9%), oral mucositis (14.9%) and diarrhea (11.9%). Bacteremia was documented in 13 cycles (34.2%). There were three cases of typhlitis and two of invasive fungal disease (aspergillosis and candidemia). Four patients died (14.3%), with two deaths considered treatment-related (candidemia and typhlitis). CONCLUSION In the setting of a Brazilian public hospital, high-dose cytarabine as consolidation therapy is feasible, with manageable toxicity profile.
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Affiliation(s)
- Lais Moreira Lopes
- Universidade Federal do Rio de Janeiro (URFJ), Rio de Janeiro, RJ, Brazil
| | - Marcio Nucci
- Universidade Federal do Rio de Janeiro (URFJ), Rio de Janeiro, RJ, Brazil; Grupo Oncoclínicas, São Paulo, SP, Brazil.
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3
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Wang J, Tomlinson B, Lazarus HM. Update on Small Molecule Targeted Therapies for Acute Myeloid Leukemia. Curr Treat Options Oncol 2023; 24:770-801. [PMID: 37195589 DOI: 10.1007/s11864-023-01090-3] [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] [Accepted: 03/27/2023] [Indexed: 05/18/2023]
Abstract
OPINION STATEMENT The search for effective therapies for the highly heterogenous disease acute myeloid leukemia (AML) has remained elusive. While cytotoxic therapies can induce complete remission and even, at times, long-term survival, this approach is associated with significant toxic effects to visceral organs and worsening of immune dysfunction and marrow suppression leading to death. Sophisticated molecular studies have revealed defects within the AML cell that can be exploited by utilizing small molecule agents to target these defects, often dubbed "target therapy." Several medications have already established new standards of care for many patients with AML, including FDA-approved agents that inhibitor IDH1, IDH2, FLT3, and BCL-2. Emerging small molecules hold additional to add to the armamentarium of AML treatment options including MCL-1 inhibitors, TP53 inhibitors, menin inhibitors, and E-selectin antagonists. Moreover, the increasing options also mean that future combinations of these agents need to be explored, including with cytotoxic drugs and other newer emerging strategies such as immunotherapies for AML. Recent investigations continue to show that overcoming many of the challenges of treating AML finally is on the horizon.
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Affiliation(s)
- Jiasheng Wang
- Division of Hematology, Department of Medicine, Seidman Cancer Center, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11000 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Benjamin Tomlinson
- Division of Hematology, Department of Medicine, Seidman Cancer Center, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11000 Euclid Avenue, Cleveland, OH, 44106, USA.
| | - Hillard M Lazarus
- Division of Hematology, Department of Medicine, Seidman Cancer Center, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11000 Euclid Avenue, Cleveland, OH, 44106, USA
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Singh H, Kumar M, Kanungo H. Role of Gene Mutations in Acute Myeloid Leukemia: A Review Article. Glob Med Genet 2023; 10:123-128. [PMID: 37360004 PMCID: PMC10289861 DOI: 10.1055/s-0043-1770768] [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: 06/28/2023] Open
Abstract
Acute myeloid leukemia (AML) is an immensely heterogeneous disease characterized by the clonal growth of promyelocytes or myeloblasts in bone marrow as well as in peripheral blood or tissue. Enhancement in the knowledge of the molecular biology of cancer and recognition of intermittent mutations in AML contribute to favorable circumstances to establish targeted therapies and enhance the clinical outcome. There is high interest in the development of therapies that target definitive abnormalities in AML while eradicating leukemia-initiating cells. In recent years, there has been a better knowledge of the molecular abnormalities that lead to the progression of AML, and the application of new methods in molecular biology techniques has increased that facilitating the advancement of investigational drugs. In this review, literature or information on various gene mutations for AML is discussed. English language articles were scrutinized in plentiful directories or databases like PubMed, Science Direct, Web of Sciences, Google Scholar, and Scopus. The important keywords used for searching databases is "Acute myeloid leukemia", "Gene mutation in Acute myeloid leukemia", "Genetic alteration in Acute myeloid leukemia," and "Genetic abnormalities in Acute myeloid leukemia."
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Affiliation(s)
- Himanshu Singh
- Department of Oral and Maxillofacial Pathology and Oral Microbiology, Index Institute of Dental Sciences, Indore, Madhya Pradesh, India
| | - Magesh Kumar
- Department of Periodontics, Index Institute of Dental Sciences, Indore, Madhya Pradesh, India
| | - Himanshu Kanungo
- Department of Orthodontics and Dentofacial Orthopaedics, Index Institute of Dental Sciences, Indore, Madhya Pradesh, India
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Srinivasan Rajsri K, Roy N, Chakraborty S. Acute Myeloid Leukemia Stem Cells in Minimal/Measurable Residual Disease Detection. Cancers (Basel) 2023; 15:2866. [PMID: 37345204 PMCID: PMC10216329 DOI: 10.3390/cancers15102866] [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: 04/06/2023] [Revised: 05/14/2023] [Accepted: 05/17/2023] [Indexed: 06/23/2023] Open
Abstract
Acute myeloid leukemia (AML) is a hematological malignancy characterized by an abundance of incompletely matured or immature clonally derived hematopoietic precursors called leukemic blasts. Rare leukemia stem cells (LSCs) that can self-renew as well as give rise to leukemic progenitors comprising the bulk of leukemic blasts are considered the cellular reservoir of disease initiation and maintenance. LSCs are widely thought to be relatively resistant as well as adaptive to chemotherapy and can cause disease relapse. Therefore, it is imperative to understand the molecular bases of LSC forms and functions during different stages of disease progression, so we can more accurately identify these cells and design therapies to target them. Irrespective of the morphological, cytogenetic, and cellular heterogeneity of AML, the uniform, singularly important and independently significant prognosticator of disease response to therapy and patient outcome is measurable or minimal residual disease (MRD) detection, defined by residual disease detection below the morphology-based 5% blast threshold. The importance of LSC identification and frequency estimation during MRD detection, in order to make MRD more effective in predicting disease relapse and modifying therapeutic regimen is becoming increasingly apparent. This review focuses on summarizing functional and cellular composition-based LSC identification and linking those studies to current techniques of MRD detection to suggest LSC-inclusive MRD detection as well as outline outstanding questions that need to be addressed to improve the future of AML clinical management and treatment outcomes.
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Affiliation(s)
- Kritika Srinivasan Rajsri
- Department of Pathology, New York University Grossman School of Medicine, New York, NY 10016, USA; (K.S.R.); (N.R.)
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY 10010, USA
| | - Nainita Roy
- Department of Pathology, New York University Grossman School of Medicine, New York, NY 10016, USA; (K.S.R.); (N.R.)
| | - Sohini Chakraborty
- Department of Pathology, New York University Grossman School of Medicine, New York, NY 10016, USA; (K.S.R.); (N.R.)
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Erba HP, Montesinos P, Kim HJ, Patkowska E, Vrhovac R, Žák P, Wang PN, Mitov T, Hanyok J, Kamel YM, Rohrbach JEC, Liu L, Benzohra A, Lesegretain A, Cortes J, Perl AE, Sekeres MA, Dombret H, Amadori S, Wang J, Levis MJ, Schlenk RF. Quizartinib plus chemotherapy in newly diagnosed patients with FLT3-internal-tandem-duplication-positive acute myeloid leukaemia (QuANTUM-First): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 2023; 401:1571-1583. [PMID: 37116523 DOI: 10.1016/s0140-6736(23)00464-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/31/2023] [Accepted: 02/15/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Patients with acute myeloid leukaemia (AML) positive for internal tandem duplication (ITD) mutations of FLT3 have poor outcomes. Quizartinib, an oral, highly potent, selective, type 2 FLT3 inhibitor, plus chemotherapy showed antitumour activity with an acceptable safety profile in patients with FLT3-ITD-positive newly diagnosed AML. The aim of the study was to compare the effect of quizartinib versus placebo on overall survival in patients with FLT3-ITD-positive newly diagnosed AML aged 18-75 years. METHODS We conducted a randomised, double-blind, placebo-controlled, phase 3 trial comparing quizartinib and placebo in combination with chemotherapy in induction and consolidation, followed by quizartinib or placebo single-agent continuation, in patients with FLT3-ITD-positive newly diagnosed AML at 193 hospitals and clinics in 26 countries in Europe; North America; and Asia, Australia, and South America. Patients aged 18-75 years were eligible. Patients were randomly assigned (1:1) to the quizartinib group or the placebo group by an independent biostatistician through an interactive web and voice response system, stratified by region, age, and white blood cell count at diagnosis. Patients, investigators, funders, and contract research organisations were masked to treatments assigned. Induction therapy comprised a standard 7 + 3 induction regimen of cytarabine 100 mg/m2 per day (or 200 mg/m2 per day allowed if institutional or local standard) by continuous intravenous infusion from day 1 to day 7 and anthracycline (daunorubicin 60 mg/m2 per day or idarubicin 12 mg/m2 per day) by intravenous infusion on days 1, 2, and 3, then quizartinib 40 mg orally or placebo once per day, starting on day 8, for 14 days. Patients with complete remission or complete remission with incomplete neutrophil or platelet recovery received standard consolidation with high-dose cytarabine plus quizartinib (40 mg per day orally) or placebo, allogeneic haematopoietic cell transplantation (allo-HCT), or both as consolidation therapy, followed by continuation of single-agent quizartinib or placebo for up to 3 years. The primary outcome was overall survival, defined as time from randomisation until death from any cause and assessed in the intention-to-treat population. Safety was evaluated in all patients who received at least one dose of quizartinib or placebo. This study is registered with ClinicalTrials.gov (NCT02668653). FINDINGS Between Sept 27, 2016, and Aug 14, 2019, 3468 patients with AML were screened and 539 patients (294 [55%] male patients and 245 [45%] female patients) with FLT3-ITD-positive AML were included and randomly assigned to the quizartinib group (n=268) or placebo group (n=271). 148 (55%) of 268 patients in the quizartinib group and 168 (62%) of 271 patients in the placebo group discontinued the study, primarily because of death (133 [90%] of 148 in the quizartinib group vs 158 [94%] of 168 in the placebo group) or withdrawal of consent (13 [9%] of 148 in the quizartinib group vs 9 [5%] of 168 in the placebo group). Median age was 56 years (range 20-75, IQR 46·0-65·0). At a median follow-up of 39·2 months (IQR 31·9-45·8), median overall survival was 31·9 months (95% CI 21·0-not estimable) for quizartinib versus 15·1 months (13·2-26·2) for placebo (hazard ratio 0·78, 95% CI 0·62-0·98, p=0·032). Similar proportions of patients in the quizartinib and placebo groups had at least one adverse event (264 [100%] of 265 in the quizartinib group and 265 [99%] of 268 in the placebo group) and one grade 3 or higher adverse event (244 [92%] of 265 in the quizartinib group and 240 [90%] of 268 in the placebo group). The most common grade 3 or 4 adverse events were febrile neutropenia, hypokalaemia, and pneumonia in both groups and neutropenia in the quizartinib group. INTERPRETATION The addition of quizartinib to standard chemotherapy with or without allo-HCT, followed by continuation monotherapy for up to 3 years, resulted in improved overall survival in adults aged 18-75 years with FLT3-ITD-positive newly diagnosed AML. Based on the results from the QuANTUM-First trial, quizartinib provides a new, effective, and generally well tolerated treatment option for adult patients with FLT3-ITD-positive newly diagnosed AML. FUNDING Daiichi Sankyo.
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Affiliation(s)
| | - Pau Montesinos
- Hematology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Hee-Je Kim
- Department of Hematology, Catholic Hematology Hospital, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | | | - Radovan Vrhovac
- Division of Hematology, University Hospital Centre Zagreb, University of Zagreb School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Pavel Žák
- Department of Internal Medicine-Haematology, University Hospital Hradec Kralove, Hradec Kralove, Czechia
| | - Po-Nan Wang
- Chang Gung Medical Foundation, Linkou, Taiwan
| | | | | | | | | | - Li Liu
- Daiichi Sankyo, Basking Ridge, NJ, USA
| | | | | | - Jorge Cortes
- Augusta University Medical Center, Augusta University, Augusta, GA, USA
| | - Alexander E Perl
- Division of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Mikkael A Sekeres
- Sylvester Cancer Center, University of Miami Health System, Miami, FL, USA
| | - Hervé Dombret
- Saint Louis Hospital, University of Paris, Paris, France
| | | | - Jianxiang Wang
- Institute of Hematology and Blood Diseases Hospital, Tianjin, China
| | - Mark J Levis
- Division of Hematologic Malignancies, Johns Hopkins University, Baltimore, MD, USA
| | - Richard F Schlenk
- National Center of Tumor Diseases Trial Center, German Cancer Research Center, Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
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Przespolewski AC, Griffiths EA. FLT3-mutated acute myeloid leukaemia: a new opportunity. Lancet 2023; 401:1546-1548. [PMID: 37116522 DOI: 10.1016/s0140-6736(23)00617-7] [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: 03/02/2023] [Accepted: 03/20/2023] [Indexed: 04/30/2023]
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Anderson NR, Sheth V, Li H, Harris MW, Qiu S, Crossman DK, Kumar H, Agarwal P, Nagasawa T, Paterson AJ, Welner RS, Bhatia R. Microenvironmental CXCL12 deletion enhances Flt3-ITD acute myeloid leukemia stem cell response to therapy by reducing p38 MAPK signaling. Leukemia 2023; 37:560-570. [PMID: 36550214 PMCID: PMC10750268 DOI: 10.1038/s41375-022-01798-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
Fms-like tyrosine kinase 3 (Flt3) tyrosine kinase inhibitors (Flt3-TKI) have improved outcomes for patients with Flt3-mutated acute myeloid leukemia (AML) but are limited by resistance and relapse, indicating persistence of leukemia stem cells (LSC). Here utilizing a Flt3-internal tandem duplication (Flt3-ITD) and Tet2-deleted AML genetic mouse model we determined that FLT3-ITD AML LSC were enriched within the primitive ST-HSC population. FLT3-ITD LSC showed increased expression of the CXCL12 receptor CXCR4. CXCL12-abundant reticular (CAR) cells were increased in Flt3-ITD AML marrow. CXCL12 deletion from the microenvironment enhanced targeting of AML cells by Flt3-TKI plus chemotherapy treatment, including enhanced LSC targeting. Both treatment and CXCL12 deletion partially reduced p38 mitogen-activated protein kinase (p38) signaling in AML cells and further reduction was seen after treatment in CXCL12 deleted mice. p38 inhibition reduced CXCL12-dependent and -independent maintenance of both murine and human Flt3-ITD AML LSC by MSC and enhanced their sensitivity to treatment. p38 inhibition in combination with chemotherapy plus TKI treatment leads to greater depletion of Flt3-ITD AML LSC compared with CXCL12 deletion. Our studies support roles for CXCL12 and p38 signaling in microenvironmental protection of AML LSC and provide a rationale for inhibiting p38 signaling to enhance Flt3-ITD AML targeting.
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Affiliation(s)
- Nicholas R Anderson
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Vipul Sheth
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hui Li
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mason W Harris
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Shaowei Qiu
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
| | - David K Crossman
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Harish Kumar
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Puneet Agarwal
- Division of Experimental Hematology & Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Takashi Nagasawa
- Laboratory of Stem Cell Biology & Developmental Immunology, Graduate School of Frontier Biosciences, Osaka University, Osaka, Japan
| | - Andrew J Paterson
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert S Welner
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ravi Bhatia
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
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Bystrom R, Levis MJ. An Update on FLT3 in Acute Myeloid Leukemia: Pathophysiology and Therapeutic Landscape. Curr Oncol Rep 2023; 25:369-378. [PMID: 36808557 DOI: 10.1007/s11912-023-01389-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2022] [Indexed: 02/21/2023]
Abstract
PURPOSE OF REVIEW This review aims to summarize the pathophysiology, clinical presentation, and management of acute myeloid leukemia (AML) with FMS-like tyrosine kinase-3 (FLT3) mutations. RECENT FINDINGS The recent European Leukemia Net (ELN2022) recommendations re-classified AML with FLT3 internal tandem duplications (FLT3-ITD) as intermediate risk regardless of Nucleophosmin 1 (NPM1) co-mutation or the FLT3 allelic ratio. Allogeneic hematopoietic cell transplantation (alloHCT) is now recommended for all eligible patients with FLT3-ITD AML. This review outlines the role of FLT3 inhibitors in induction and consolidation, as well as for post-alloHCT maintenance. It outlines the unique challenges and advantages of assessing FLT3 measurable residual disease (MRD) and discusses the pre-clinical basis for the combination of FLT3 and menin inhibitors. And, for the older or unfit patient ineligible for upfront intensive chemotherapy, it discusses the recent clinical trials incorporating FLT3 inhibitors into azacytidine- and venetoclax-based regimens. Finally, it proposes a rational sequential approach for integrating FLT3 inhibitors into less intensive regimens, with a focus on improved tolerability in the older and unfit patient population. The management of AML with FLT3 mutation remains a challenge in clinical practice. This review provides an update on the pathophysiology and therapeutic landscape of FLT3 AML, as well as a clinical management framework for managing the older or unfit patient ineligible for intensive chemotherapy.
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Affiliation(s)
- Rebecca Bystrom
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mark J Levis
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA.
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Kayser S, Levis MJ. The clinical impact of the molecular landscape of acute myeloid leukemia. Haematologica 2023; 108:308-320. [PMID: 36722402 PMCID: PMC9890016 DOI: 10.3324/haematol.2022.280801] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Indexed: 02/02/2023] Open
Abstract
Research into the underlying pathogenic mechanisms of acute myeloid leukemia (AML) has led to remarkable advances in our understanding of the disease. Mutations now allow us to explore the enormous diversity among cytogenetically defined subsets of AML, particularly the large subset of cytogenetically normal AML. Despite the progress in unraveling the tumor genome, only a small number of recurrent mutations have been incorporated into risk-stratification schemes and have been proven to be clinically relevant, targetable lesions. The current World Health Organization Classification of myeloid neoplasms and leukemia includes eight AML categories defined by recurrent genetic abnormalities as well as three categories defined by gene mutations. We here discuss the utility of molecular markers in AML in prognostication and treatment decision-making. New therapies based on targetable markers include IDH inhibitors (ivosidenib, enasidenib), venetoclax-based therapy, FLT3 inhibitors (midostaurin, gilteritinib, and quizartinib), gemtuzumab ozogamicin, magrolimab and menin inhibitors.
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Affiliation(s)
- Sabine Kayser
- NCT Trial Center, National Center of Tumor Diseases, German Cancer Research Center (DKFZ), Heidelberg.
| | - Mark J. Levis
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University Baltimore, MD, USA
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Garciaz S, Hospital MA. FMS-Like Tyrosine Kinase 3 Inhibitors in the Treatment of Acute Myeloid Leukemia: An Update on the Emerging Evidence and Safety Profile. Onco Targets Ther 2023; 16:31-45. [PMID: 36698434 PMCID: PMC9869913 DOI: 10.2147/ott.s236740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 01/11/2023] [Indexed: 01/19/2023] Open
Abstract
FMS-like tyrosine kinase 3 (FLT3) is one of the most frequently mutated genes in acute myeloid leukemia (AML). Approximately 30% of the adult cases harbor an internal tandem duplication (FLT3-ITD) and 5-10% a tyrosine kinase domain (TKD) amino acid substitution (FLT3-TKD). The treatment paradigm of AML patients harboring FLT3 mutations (30%) has been modified by the discovery of tyrosine kinase inhibitors. First- and second-generation inhibitors classify FLT3 inhibitors according to FLT3 specificity: first-generation FLT3 inhibitors include sorafenib and midostaurin and second-generation inhibitors are represented by quizartinib, gilteritinib and crenolanib, among others. Activity of these inhibitors depends on their mechanism of receptor binding (active vs inactive conformation) and efficacy against the FLT3-ITD and -TKD mutations (type 1 inhibitors are active both on FLT3-ITD and TKD, whereas type 2 inhibitors are active only on FLT3-ITD). The FLT3 inhibitors sorafenib, midostaurin, quizartinib and gilteritinib have been tested in monotherapy in several settings including refractory or relapsed AML (R/R AML), post-transplant maintenance as well as in combination with intensive chemotherapy (ICT) or non-intensity regimens. The results of published randomized studies support the use of sorafenib in a post-transplant setting (SORMAIN trial), midostaurin in combination with ICT based (RATIFY trial) and gilteritinib for R/R AML (ADMIRAL trial). Gilteritinib in combination with hypomethylating agent as well as quizartinib are not supported by solid randomized trial results for their use in FLT3-mutated AML patients.
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Affiliation(s)
- Sylvain Garciaz
- Department of Hematology, Institut Paoli-Calmettes, Aix-Marseille Université, Centre National de la Recherche Scientifique, UMR7258, Centre de Recherche en Cancérologie de Marseille, INSERM U1068, Marseille, France,Correspondence: Sylvain Garciaz, Institut Paoli-Calmettes, Hematology Department, 232 Bd Sainte-Marguerite, Marseille, 13009, France, Tel + 33 4 91 22 37 54, Fax + 33 4 91 22 30 63, Email
| | - Marie-Anne Hospital
- Department of Hematology, Institut Paoli-Calmettes, Aix-Marseille Université, Centre National de la Recherche Scientifique, UMR7258, Centre de Recherche en Cancérologie de Marseille, INSERM U1068, Marseille, France
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12
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Saeed RF, Awan UA, Saeed S, Mumtaz S, Akhtar N, Aslam S. Targeted Therapy and Personalized Medicine. Cancer Treat Res 2023; 185:177-205. [PMID: 37306910 DOI: 10.1007/978-3-031-27156-4_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Targeted therapy and personalized medicine are novel emerging disciplines of cancer research intended for treatment and prevention. One of the most significant advancements in modern oncology is the shift from an organ-centric strategy to a personalized strategy guided by deep molecular analysis. This shift in view, which focuses on the tumour's precise molecular changes, has paved the way for individualized treatment. Researchers and clinicians are using targeted therapies to select the best treatment available based on the molecular characterization of malignant cancer. In the treatment of a cancer, personalized medicine entails the use of genetic, immunological, and proteomic profiling to provide therapeutic alternatives as well as prognostic information about cancer. In this book, targeted therapies and personalized medicine have been covered for specific malignancies, including latest FDA-approved targeted therapies and it also sheds light on effective anti-cancer regimens and drug resistance. This will help to enhance our ability to conduct individualized health planning, make early diagnoses, and choose optimal medications for each cancer patient with predictable side effects and outcomes in a quickly evolving era. Various applications and tools' capacity have been improved for early diagnosis of cancer and the growing number of clinical trials that choose specific molecular targets reflects this predicament. Nevertheless, there are several limitations that must need to be addressed. Hence, in this chapter, we will discuss recent advancements, challenges, and opportunities in personalized medicine for various cancers, with a specific emphasis on target therapies in diagnostics and therapeutics.
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Affiliation(s)
- Rida Fatima Saeed
- Department of Biological Sciences, National University of Medical Sciences, Rawalpindi, Pakistan.
| | - Uzma Azeem Awan
- Department of Biological Sciences, National University of Medical Sciences, Rawalpindi, Pakistan
| | | | - Sara Mumtaz
- Department of Biological Sciences, National University of Medical Sciences, Rawalpindi, Pakistan
| | - Nosheen Akhtar
- Department of Biological Sciences, National University of Medical Sciences, Rawalpindi, Pakistan
| | - Shaista Aslam
- Department of Biological Sciences, National University of Medical Sciences, Rawalpindi, Pakistan
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13
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Liu G, Chen T, Zhang X, Ma X, Shi H. Small molecule inhibitors targeting the cancers. MedComm (Beijing) 2022; 3:e181. [PMID: 36254250 PMCID: PMC9560750 DOI: 10.1002/mco2.181] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 08/23/2022] [Accepted: 08/30/2022] [Indexed: 11/23/2022] Open
Abstract
Compared with traditional therapies, targeted therapy has merits in selectivity, efficacy, and tolerability. Small molecule inhibitors are one of the primary targeted therapies for cancer. Due to their advantages in a wide range of targets, convenient medication, and the ability to penetrate into the central nervous system, many efforts have been devoted to developing more small molecule inhibitors. To date, 88 small molecule inhibitors have been approved by the United States Food and Drug Administration to treat cancers. Despite remarkable progress, small molecule inhibitors in cancer treatment still face many obstacles, such as low response rate, short duration of response, toxicity, biomarkers, and resistance. To better promote the development of small molecule inhibitors targeting cancers, we comprehensively reviewed small molecule inhibitors involved in all the approved agents and pivotal drug candidates in clinical trials arranged by the signaling pathways and the classification of small molecule inhibitors. We discussed lessons learned from the development of these agents, the proper strategies to overcome resistance arising from different mechanisms, and combination therapies concerned with small molecule inhibitors. Through our review, we hoped to provide insights and perspectives for the research and development of small molecule inhibitors in cancer treatment.
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Affiliation(s)
- Gui‐Hong Liu
- Department of BiotherapyState Key Laboratory of BiotherapyCancer Center, West China HospitalSichuan UniversityChengduChina
| | - Tao Chen
- Department of CardiologyThe First Affiliated Hospital of China Medical UniversityShenyangLiaoningChina
| | - Xin Zhang
- Department of BiotherapyState Key Laboratory of BiotherapyCancer Center, West China HospitalSichuan UniversityChengduChina
| | - Xue‐Lei Ma
- Department of BiotherapyState Key Laboratory of BiotherapyCancer Center, West China HospitalSichuan UniversityChengduChina
| | - Hua‐Shan Shi
- Department of BiotherapyState Key Laboratory of BiotherapyCancer Center, West China HospitalSichuan UniversityChengduChina
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14
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Visani G, Chiarucci M, Paolasini S, Loscocco F, Isidori A. Treatment options for acute myeloid leukemia patients aged <60 years. Front Oncol 2022; 12:897220. [PMID: 36276074 PMCID: PMC9581198 DOI: 10.3389/fonc.2022.897220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 08/31/2022] [Indexed: 11/17/2022] Open
Abstract
Treatment of acute myeloid leukemia (AML) has changed over the last few years, after the discovery of new drugs selectively targeting AML blasts. Although 3/7 remains the standard of care for most AML patients, several new targeted agents (such as FLT3 inhibitors, CPX-351, gemtuzumab ozogamicin, BCL-2 inhibitor, and oral azacitidine), either as single agents or combined with standard chemotherapy, are approaching clinical practice, starting a new era in AML management. Moreover, emerging evidence has demonstrated that high-risk AML patients might benefit from both allogeneic stem cell transplant and maintenance therapy, providing new opportunities, as well as new challenges, for treating clinicians. In this review, we summarize available data on first-line therapy in young AML patients focusing on targeted therapies, integrating established practice with new evidence, in the effort to outline the contours of a new therapeutic paradigm, that of a “total therapy”, which goes beyond obtaining complete remission.
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15
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Yuan W, Zhang S, Zhu H. Advances in clinical studies of FLT3 inhibitors in acute myeloid leukemia. Zhejiang Da Xue Xue Bao Yi Xue Ban 2022; 51:507-514. [PMID: 37202100 DOI: 10.3724/zdxbyxb-2022-0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Acute myeloid leukemia (AML) is a highly heterogeneous hematological malignancy. AML patients with FLT3 mutations tend to have a high relapse rate and poor outcome, so FLT3 gene has become an important target for AML treatment, and a series of FLT3 inhibitors have been developed. According to the characteristics of FLT3 inhibitors, they can be divided into first-generation FLT3 inhibitors and second-generation FLT3 inhibitors. So far, totally eight FLT3 inhibitors have been undergone clinical trials and only three were approved for the treatment of AML patients, including Midostourin, Quizartinib and Gilteritinib. FLT3 inhibitors can improve the response rate of patients by combining with standard chemotherapy; in the follow-up maintenance treatment, FLT3 inhibitors can also reduce the disease recurrence rate and improve the overall prognosis of patients. However, the primary drug resistance caused by the bone marrow microenvironment, as well as secondary resistance caused by other mutations may result in poor efficacy of FLT3 inhibitors. For such patients, the combination of FLT3 inhibitor with other drugs may reduce the occurrence of drug resistance and improve the subsequent efficacy of patients. This article reviews the current status of FLT3 inhibitors in clinical research of AML patients and the treatment of FLT3-resistant patients to provide reference for clinicians.
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Affiliation(s)
- Wei Yuan
- 1. Medical College of China Three Gorges University, Yichang 443000, Hubei Province, China
- 2. Third-grade Pharmacological Laboratory on Traditional Chinese Medicine, China Three Gorges University, Yichang 443000, Hubei Province, China
| | - Shizhong Zhang
- 1. Medical College of China Three Gorges University, Yichang 443000, Hubei Province, China
- 2. Third-grade Pharmacological Laboratory on Traditional Chinese Medicine, China Three Gorges University, Yichang 443000, Hubei Province, China
| | - Honghu Zhu
- 3. Department of Hematology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
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16
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FLT3-targeted treatment for acute myeloid leukemia. Int J Hematol 2022; 116:351-363. [DOI: 10.1007/s12185-022-03374-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 12/17/2022]
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17
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Infectious complications of targeted drugs and biotherapies in acute leukemia. Clinical practice guidelines by the European Conference on Infections in Leukemia (ECIL), a joint venture of the European Group for Blood and Marrow Transplantation (EBMT), the European Organization for Research and Treatment of Cancer (EORTC), the International Immunocompromised Host Society (ICHS) and the European Leukemia Net (ELN). Leukemia 2022; 36:1215-1226. [PMID: 35368047 PMCID: PMC9061290 DOI: 10.1038/s41375-022-01556-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/17/2022] [Accepted: 03/22/2022] [Indexed: 01/14/2023]
Abstract
AbstractThe 9th web-based European Conference on Infections in Leukemia (ECIL-9), held September 16-17, 2021, reviewed the risk of infections and febrile neutropenia associated with more recently approved immunotherapeutic agents and molecular targeted drugs for the treatment of acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL). Novel antibody based treatment approaches (inotuzumab ozogamicin, gemtuzumab ozogamicin, flotetuzumab), isocitrate dehydrogenases inhibitors (ivosidenib, enasidenib, olutasidenib), FLT3 kinase inhibitors (gilteritinib, midostaurin, quizartinib), a hedgehog inhibitor (glasdegib) as well as a BCL2 inhibitor (venetoclax) were reviewed with respect to their mode of action, their immunosuppressive potential, their current approval and the infectious complications and febrile neutropenia reported from clinical studies. Evidence-based recommendations for prevention and management of infectious complications and specific alerts regarding the potential for drug-drug interactions were developed and discussed in a plenary session with the panel of experts until consensus was reached. The set of recommendations was posted on the ECIL website for a month for comments from members of EBMT, EORTC, ICHS and ELN before final approval by the panelists. While a majority of these agents are not associated with a significantly increased risk when used as monotherapy, caution is required with combination therapy such as venetoclax plus hypomethylating agents, gemtuzumab ozogamicin plus cytotoxic drugs or midostaurin added to conventional AML chemotherapy.
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18
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Senapati J, Kadia TM. Which FLT3 Inhibitor for Treatment of AML? Curr Treat Options Oncol 2022; 23:359-380. [PMID: 35258791 DOI: 10.1007/s11864-022-00952-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2022] [Indexed: 12/17/2022]
Abstract
OPINION STATEMENT Treatment options in acute myeloid leukemia (AML) have improved significantly over the last decade with better understanding of disease biology and availability of a multitude of targeted therapies. The use of FLT3 inhibitors (FLT3i) in FLT3-mutated (FLT3mut) AML is one such development; however, the clinical decisions that govern their use and dictate the choice of the FLT3i are evolving. Midostaurin and gilteritinib are FDA-approved in specific situations; however, available data from clinical trials also shed light on the utility of sorafenib maintenance post-allogeneic stem cell transplantation (allo-SCT) and quizartinib as part of combination therapy in FLT3mut AML. The knowledge of the patient's concurrent myeloid mutations, type of FLT3 mutation, prior FLT3i use, and eligibility for allo-SCT helps to refine the choice of FLT3i. Data from ongoing studies will further precisely define their use and help in making more informed choices. Despite improvements in FLT3i therapy, the definitive aim is to enable the eligible patient with FLT3mut AML (esp. ITD) to proceed to allo-SCT with regimens containing FLT3i incorporated prior to SCT and as maintenance after SCT.
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Affiliation(s)
- Jayastu Senapati
- Department of Leukemia, MD Anderson Cancer Center, 1515 Holcombe Blvd. - Unit 428, Houston, 77030, USA
| | - Tapan Mahendra Kadia
- Department of Leukemia, MD Anderson Cancer Center, 1515 Holcombe Blvd. - Unit 428, Houston, 77030, USA.
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19
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Zhao JC, Agarwal S, Ahmad H, Amin K, Bewersdorf JP, Zeidan AM. A review of FLT3 inhibitors in acute myeloid leukemia. Blood Rev 2022; 52:100905. [PMID: 34774343 PMCID: PMC9846716 DOI: 10.1016/j.blre.2021.100905] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 01/26/2023]
Abstract
FLT3 mutations are the most common genetic aberrations found in acute myeloid leukemia (AML) and associated with poor prognosis. Since the discovery of FLT3 mutations and their prognostic implications, multiple FLT3-targeted molecules have been evaluated. Midostaurin is approved in the U.S. and Europe for newly diagnosed FLT3 mutated AML in combination with standard induction and consolidation chemotherapy based on data from the RATIFY study. Gilteritinib is approved for relapsed or refractory FLT3 mutated AML as monotherapy based on the ADMIRAL study. Although significant progress has been made in the treatment of AML with FLT3-targeting, many challenges remain. Several drug resistance mechanisms have been identified, including clonal selection, stromal protection, FLT3-associated mutations, and off-target mutations. The benefit of FLT3 inhibitor maintenance therapy, either post-chemotherapy or post-transplant, remains controversial, although several studies are ongoing.
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Affiliation(s)
- Jennifer C Zhao
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Sonal Agarwal
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Hiba Ahmad
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Kejal Amin
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Jan Philipp Bewersdorf
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA.
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20
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Suga M, Fukushima K, Ueda T, Arai Y, Nakagawa S, Minami Y, Toda J, Hino A, Fujita J, Yokota T, Hosen N. Clinical implications of combination therapy with quizartinib and craniospinal irradiation for refractory acute myeloid leukemia positive for FMS‐like tyrosine kinase 3‐internal tandem duplication with central nervous system involvement. Clin Case Rep 2022; 10:e05384. [PMID: 35140970 PMCID: PMC8815089 DOI: 10.1002/ccr3.5384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/10/2022] [Accepted: 01/17/2022] [Indexed: 11/10/2022] Open
Abstract
FMS‐like tyrosine kinase 3‐internal tandem duplication (FLT3‐ITD) mutation‐positive acute myeloid leukemia (AML) has a poor prognosis. We report the first case of successful bridge therapy of novel FLT3 inhibitor, quizartinib, to umbilical cord blood stem cell transplantation for FLT3‐ITD‐positive AML‐primary induction failure patients with central nervous system involvement.
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Affiliation(s)
- Makiko Suga
- Department of Hematology and Oncology Osaka University Graduate School of Medicine Suita Japan
| | - Kentaro Fukushima
- Department of Hematology and Oncology Osaka University Graduate School of Medicine Suita Japan
| | - Tomoaki Ueda
- Department of Hematology and Oncology Osaka University Graduate School of Medicine Suita Japan
| | - Yasuyuki Arai
- Department of Hematology and Oncology Kyoto University Hospital Kyoto Japan
| | - Shunsaku Nakagawa
- Department of Clinical Pharmacology and Therapeutics Kyoto University Hospital Kyoto Japan
| | - Yosuke Minami
- Department of Hematology National Cancer Center Hospital East Kashiwa Japan
| | - Jun Toda
- Department of Hematology and Oncology Osaka University Graduate School of Medicine Suita Japan
| | - Akihisa Hino
- Department of Hematology and Oncology Osaka University Graduate School of Medicine Suita Japan
| | - Jiro Fujita
- Department of Hematology and Oncology Osaka University Graduate School of Medicine Suita Japan
| | - Takafumi Yokota
- Department of Hematology and Oncology Osaka University Graduate School of Medicine Suita Japan
| | - Naoki Hosen
- Department of Hematology and Oncology Osaka University Graduate School of Medicine Suita Japan
- Laboratory of Cellular Immunotherapy, World Premier Interenational Immunology Frontier Research Center Osaka University Suita Japan
- Integrated Frontier Research for Medical Science Division, Institute for Open and Transdisciplinary Research Initiatives (OTRI) Osaka University Suita Japan
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21
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Solana-Altabella A, Ballesta-López O, Megías-Vericat JE, Martínez-Cuadrón D, Montesinos P. Emerging FLT3 inhibitors for the treatment of acute myeloid leukemia. Expert Opin Emerg Drugs 2022; 27:1-18. [DOI: 10.1080/14728214.2021.2009800] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Antonio Solana-Altabella
- Servicio de Farmacia, Área del Medicamento. Hospital Universitari i Politècnic La Fe. Av. Fernando Abril Martorell, Valencia– Spain
- Instituto de Investigación Sanitaria La Fe (IISLAFE). Av. Fernando Abril Martorell, Valencia–Spain
| | - Octavio Ballesta-López
- Servicio de Farmacia, Área del Medicamento. Hospital Universitari i Politècnic La Fe. Av. Fernando Abril Martorell, Valencia– Spain
- Instituto de Investigación Sanitaria La Fe (IISLAFE). Av. Fernando Abril Martorell, Valencia–Spain
| | - Juan Eduardo Megías-Vericat
- Servicio de Farmacia, Área del Medicamento. Hospital Universitari i Politècnic La Fe. Av. Fernando Abril Martorell, Valencia– Spain
| | - David Martínez-Cuadrón
- Servicio de Farmacia, Área del Medicamento. Hospital Universitari i Politècnic La Fe. Av. Fernando Abril Martorell, Valencia– Spain
- Instituto de Investigación Sanitaria La Fe (IISLAFE). Av. Fernando Abril Martorell, Valencia–Spain
| | - Pau Montesinos
- Instituto de Investigación Sanitaria La Fe (IISLAFE). Av. Fernando Abril Martorell, Valencia–Spain
- Servicio de Hematología y Hemoterapia. Hospital Universitari i Politècnic La Fe. Av. Fernando Abril Martorell, Valencia-Spain
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22
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Incorporation of FLT3 Inhibitors Into the Treatment Regimens for FLT3 Mutated Acute Myeloid Leukemia. Cancer J 2022; 28:14-20. [DOI: 10.1097/ppo.0000000000000576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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23
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Cerchione C, Peleteiro Raíndo A, Mosquera Orgueira A, Mosquera Torre A, Bao Pérez L, Marconi G, Isidori A, Pérez Encinas MM, Martinelli G. Safety of FLT3 inhibitors in patients with acute myeloid leukemia. Expert Rev Hematol 2021; 14:851-865. [PMID: 34424108 DOI: 10.1080/17474086.2021.1969911] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Introduction: Acute myeloblastic leukemia (AML) is the most frequent type of acute leukemia in adults with an incidence of 4.2 cases per 100,000 inhabitants and poor 5-year survival. Patients with mutations in the FMS-like tyrosine kinase 3 (FLT3) gene have poor survival and higher relapse rates compared with wild-type cases.Areas covered: Several FLT3 inhibitors have been proved in FLT3mut AML patients, with differences in their pharmacokinetics, kinase inhibitory and adverse events profiles. First-generation multi-kinase inhibitors (midostaurin, sorafenib, lestaurtinib) target multiple proteins, whereassecond-generation inhibitors (crenolanib, quizartinib, gilteritinib) are more specific and potent inhibitors of FLT3, so they are associated with less off-target toxic effects. All of these drugs have primary and acquired mechanisms of resistance, and therefore their combinations with other drugs (checkpoint inhibitors, hypomethylating agents, standard chemotherapy) and its application in different clinical settings are under study.Expert opinion: The recent clinical development of various FLT3 inhibitors for the treatment of FLT3mut AML is an effective therapeutic strategy. However, there are unique toxicities and drug-drug interactions that need to be resolved. It is necessary to understand the mechanisms of toxicity in order to recognize and manage them adequately.
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Affiliation(s)
- Claudio Cerchione
- Hematology Unit, IRCCS Istituto Scientifico Romagnolo per Lo Studio Dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Andrés Peleteiro Raíndo
- Health Research Institute of Santiago De Compostela (Idis), Santiago De Compostela, Spain.,Division of Hematology, Complejo Hospitalario Universitario De Santiago (Chus), Santiago De Compostela, Spain
| | - Adrián Mosquera Orgueira
- Health Research Institute of Santiago De Compostela (Idis), Santiago De Compostela, Spain.,Division of Hematology, Complejo Hospitalario Universitario De Santiago (Chus), Santiago De Compostela, Spain
| | - Alicia Mosquera Torre
- Health Research Institute of Santiago De Compostela (Idis), Santiago De Compostela, Spain.,Division of Hematology, Complejo Hospitalario Universitario De Santiago (Chus), Santiago De Compostela, Spain
| | - Laura Bao Pérez
- Health Research Institute of Santiago De Compostela (Idis), Santiago De Compostela, Spain.,Division of Hematology, Complejo Hospitalario Universitario De Santiago (Chus), Santiago De Compostela, Spain
| | - Giovanni Marconi
- Hematology Unit, IRCCS Istituto Scientifico Romagnolo per Lo Studio Dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Alessandro Isidori
- Hematology and Stem Cell Transplant Center, Aormn Hospital, Pesaro, Italy
| | - Manuel Mateo Pérez Encinas
- Health Research Institute of Santiago De Compostela (Idis), Santiago De Compostela, Spain.,Division of Hematology, Complejo Hospitalario Universitario De Santiago (Chus), Santiago De Compostela, Spain.,University of Santiago De Compostela, Santiago De Compostela, Spain
| | - Giovanni Martinelli
- Hematology Unit, IRCCS Istituto Scientifico Romagnolo per Lo Studio Dei Tumori (IRST) "Dino Amadori", Meldola, Italy
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Hogan FL, Williams V, Knapper S. FLT3 Inhibition in Acute Myeloid Leukaemia - Current Knowledge and Future Prospects. Curr Cancer Drug Targets 2021; 20:513-531. [PMID: 32418523 DOI: 10.2174/1570163817666200518075820] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 03/12/2020] [Accepted: 03/29/2020] [Indexed: 12/20/2022]
Abstract
Activating mutations of FMS-like tyrosine kinase 3 (FLT3) are present in 30% of acute myeloid leukaemia (AML) patients at diagnosis and confer an adverse clinical prognosis. Mutated FLT3 has emerged as a viable therapeutic target and a number of FLT3-directed tyrosine kinase inhibitors have progressed through clinical development over the last 10-15 years. The last two years have seen United States Food and Drug Administration (US FDA) approvals of the multi-kinase inhibitor midostaurin for newly-diagnosed FLT3-mutated patients, when used in combination with intensive chemotherapy, and of the more FLT3-selective agent gilteritinib, used as monotherapy, for patients with relapsed or treatment-refractory FLT3-mutated AML. The 'second generation' agents, quizartinib and crenolanib, are also at advanced stages of clinical development. Significant challenges remain in negotiating a variety of potential acquired drug resistance mechanisms and in optimizing sequencing of FLT3 inhibitory drugs with existing and novel treatment approaches in different clinical settings, including frontline therapy, relapsed/refractory disease, and maintenance treatment. In this review, the biology of FLT3, the clinical challenge posed by FLT3-mutated AML, the developmental history of the key FLT3-inhibitory compounds, mechanisms of disease resistance, and the future outlook for this group of agents, including current and planned clinical trials, is discussed.
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Affiliation(s)
- Francesca L Hogan
- Department of Haematology, University Hospital of Wales, Cardiff, United Kingdom
| | - Victoria Williams
- Department of Haematology, University Hospital of Wales, Cardiff, United Kingdom
| | - Steven Knapper
- School of Medicine, Cardiff University, Cardiff, United Kingdom
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25
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Bernasconi P, Borsani O. Eradication of Measurable Residual Disease in AML: A Challenging Clinical Goal. Cancers (Basel) 2021; 13:3170. [PMID: 34202000 PMCID: PMC8268140 DOI: 10.3390/cancers13133170] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 06/15/2021] [Accepted: 06/19/2021] [Indexed: 12/18/2022] Open
Abstract
In non-promyelocytic (non-M3) AML measurable residual disease (MRD) detected by multi-parameter flow cytometry and molecular technologies, which are guided by Consensus-based guidelines and discover very low leukemic cell numbers far below the 5% threshold of morphological assessment, has emerged as the most relevant predictor of clinical outcome. Currently, it is well-established that MRD positivity after standard induction and consolidation chemotherapy, as well as during the period preceding an allogeneic hematopoietic stem cell transplant (allo-HSCT), portends to a significantly inferior relapse-free survival (RFS) and overall survival (OS). In addition, it has become absolutely clear that conversion from an MRD-positive to an MRD-negative state provides a favorable clinical outcome similar to that associated with early MRD negativity. Thus, the complete eradication of MRD, i.e., the clearance of the few leukemic stem cells-which, due to their chemo-radiotherapy resistance, might eventually be responsible of disease recurrence-has become an un-met clinical need in AML. Nowadays, this goal might potentially be achieved thanks to the development of novel innovative treatment strategies, including those targeting driver mutations, apoptosis, methylation patterns and leukemic proteins. The aim of this review is to analyze these strategies and to suggest any potential combination able to induce MRD negativity in the pre- and post-HSCT period.
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Affiliation(s)
- Paolo Bernasconi
- Department of Molecular Medicine, University of Pavia, 27100 Pavia, Italy;
- Hematology Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Oscar Borsani
- Department of Molecular Medicine, University of Pavia, 27100 Pavia, Italy;
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26
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FLT3 Tyrosine Kinase Inhibitors for the Treatment of Fit and Unfit Patients with FLT3-Mutated AML: A Systematic Review. Int J Mol Sci 2021; 22:ijms22115873. [PMID: 34070902 PMCID: PMC8198781 DOI: 10.3390/ijms22115873] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 05/25/2021] [Accepted: 05/26/2021] [Indexed: 11/17/2022] Open
Abstract
FLT3-mutated acute myeloid leukemia accounts for around 30% of acute myeloid leukemia (AML). The mutation carried a poor prognosis until the rise of tyrosine kinase inhibitors (TKIs). New potent and specific inhibitors have successfully altered the course of the disease, increasing the complete response rate and the survival of patients with FLT3-mutated AML. The aim of this article is to review all the current knowledge on these game-changing drugs as well as the unsolved issues raised by their use for fit and unfit FLT3-mutated AML patients. To this end, we analyzed the results of phase I, II, III clinical trials evaluating FLT3-TKI both in the first-line, relapse monotherapy or in combination referenced in the PubMed, the American Society of Hematology, the European Hematology Association, and the Clinicaltrials.gov databases, as well as basic science reports on TKI resistance from the same databases. The review follows a chronological presentation of the different trials that allowed the development of first- and second-generation TKI and ends with a review of the current lines of evidence on leukemic blasts resistance mechanisms that allow them to escape TKI.
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27
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Daver N, Venugopal S, Ravandi F. FLT3 mutated acute myeloid leukemia: 2021 treatment algorithm. Blood Cancer J 2021; 11:104. [PMID: 34045454 PMCID: PMC8159924 DOI: 10.1038/s41408-021-00495-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/22/2021] [Accepted: 05/05/2021] [Indexed: 12/23/2022] Open
Abstract
Approximately 30% of patients with newly diagnosed acute myeloid leukemia (AML) harbor mutations in the fms-like tyrosine kinase 3 (FLT3) gene. While the adverse prognostic impact of FLT3-ITDmut in AML has been clearly proven, the prognostic significance of FLT3-TKDmut remains speculative. Current guidelines recommend rapid molecular testing for FLT3mut at diagnosis and earlier incorporation of targeted agents to achieve deeper remissions and early consideration for allogeneic stem cell transplant (ASCT). Mounting evidence suggests that FLT3mut can emerge at any timepoint in the disease spectrum emphasizing the need for repetitive mutational testing not only at diagnosis but also at each relapse. The approval of multi-kinase FLT3 inhibitor (FLT3i) midostaurin with induction therapy for newly diagnosed FLT3mut AML, and a more specific, potent FLT3i, gilteritinib as monotherapy for relapsed/refractory (R/R) FLT3mut AML have improved outcomes in patients with FLT3mut AML. Nevertheless, the short duration of remission with single-agent FLT3i's in R/R FLT3mut AML in the absence of ASCT, limited options in patients refractory to gilteritinib therapy, and diverse primary and secondary mechanisms of resistance to different FLT3i's remain ongoing challenges that compel the development and rapid implementation of multi-agent combinatorial or sequential therapies for FLT3mut AML.
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Affiliation(s)
- Naval Daver
- Department of Leukemia, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA.
| | - Sangeetha Venugopal
- Department of Leukemia, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA
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Keiffer G, Aderhold KL, Palmisiano ND. Upfront Treatment of FLT3-Mutated AML: A Look Back at the RATIFY Trial and Beyond. Front Oncol 2021; 10:562219. [PMID: 33415071 PMCID: PMC7783448 DOI: 10.3389/fonc.2020.562219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 11/19/2020] [Indexed: 11/18/2022] Open
Affiliation(s)
- Gina Keiffer
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Kimberly L Aderhold
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Neil D Palmisiano
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
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29
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Targeted inhibition of cooperative mutation- and therapy-induced AKT activation in AML effectively enhances response to chemotherapy. Leukemia 2020; 35:2030-2042. [PMID: 33299144 DOI: 10.1038/s41375-020-01094-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/30/2020] [Accepted: 11/09/2020] [Indexed: 11/09/2022]
Abstract
Most AML patients exhibit mutational activation of the PI3K/AKT signaling pathway, which promotes downstream effects including growth, survival, DNA repair, and resistance to chemotherapy. Herein we demonstrate that the inv(16)/KITD816Y AML mouse model exhibits constitutive activation of PI3K/AKT signaling, which was enhanced by chemotherapy-induced DNA damage through DNA-PK-dependent AKT phosphorylation. Strikingly, inhibitors of either PI3K or DNA-PK markedly reduced chemotherapy-induced AKT phosphorylation and signaling leading to increased DNA damage and apoptosis of inv(16)/KITD816Y AML cells in response to chemotherapy. Consistently, combinations of chemotherapy and PI3K or DNA-PK inhibitors synergistically inhibited growth and survival of clonogenic AML cells without substantially inhibiting normal clonogenic bone marrow cells. Moreover, treatment of inv(16)/KITD816Y AML mice with combinations of chemotherapy and PI3K or DNA-PK inhibitors significantly prolonged survival compared to untreated/single-treated mice. Mechanistically, our findings implicate that constitutive activation of PI3K/AKT signaling driven by mutant KIT, and potentially other mutational activators such as FLT3 and RAS, cooperates with chemotherapy-induced DNA-PK-dependent activation of AKT to promote survival, DNA repair, and chemotherapy resistance in AML. Hence, our study provides a rationale to select AML patients exhibiting constitutive PI3K/AKT activation for simultaneous treatment with chemotherapy and inhibitors of DNA-PK and PI3K to improve chemotherapy response and clinical outcome.
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30
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Tyrosine kinase inhibitors for acute myeloid leukemia: A step toward disease control? Blood Rev 2020; 44:100675. [DOI: 10.1016/j.blre.2020.100675] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/17/2020] [Accepted: 02/11/2020] [Indexed: 12/24/2022]
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31
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Shi W, Jin W, Xia L, Hu Y. Novel agents targeting leukemia cells and immune microenvironment for prevention and treatment of relapse of acute myeloid leukemia after allogeneic hematopoietic stem cell transplantation. Acta Pharm Sin B 2020; 10:2125-2139. [PMID: 32837873 PMCID: PMC7326461 DOI: 10.1016/j.apsb.2020.06.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/27/2020] [Accepted: 06/05/2020] [Indexed: 12/20/2022] Open
Abstract
Relapse remains the worst life-threatening complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT) in patients with acute myeloid leukemia (AML), whose prognosis has been historically dismal. Given the rapid development of genomics and immunotherapies, the interference strategies for AML recurrence have been changing these years. More and more novel targeting agents that have received the U.S. Food and Drug Administration (FDA) approval for de novo AML treatment have been administrated in the salvage or maintenance therapy of post-HSCT relapse. Targeted strategies that regulate the immune microenvironment of and optimize the graft versus leukemia (GVL) effect of immune cells are gradually improved. Such agents not only have been proven to achieve clinical benefits from a single drug, but if combined with classic therapies, can significantly improve the poor prognosis of AML patients who relapse after allo-HSCT. This review will focus on currently available and promising upcoming agents and also discuss the challenges and limitations of targeted therapies in the allogeneic hematopoietic stem cell transplantation community.
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Affiliation(s)
- Wei Shi
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024, USA
| | - Weiwei Jin
- Department of Cardiovascular, Optical Valley School District, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan 430061, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan 430074, China
| | - Linghui Xia
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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32
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Shi L, Huang Y, Huang X, Zhou W, Wei J, Deng D, Lai Y. Analyzing the key gene expression and prognostics values for acute myeloid leukemia. Transl Cancer Res 2020; 9:7284-7298. [PMID: 35117330 PMCID: PMC8797974 DOI: 10.21037/tcr-20-3177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 11/11/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND Acute myeloid leukemia (AML) is one of the first tumor types sequenced at the whole genome level. However, numbers of the mutated genes expression levels, functions, and prognostics values still unclear. METHODS To most ordinary mutated genes were analyzed via cancer virtual cohort discovery analysis platform (CVCDAP), and further investigated the mutational conversions, variant allele frequencies (VAF), driver genes, and potential druggable mutated genes in AML. The top mutated gene mRNA expression levels and the relationship between gene expression levels and prognosis for AML patients were performed by Gene Expression Profiling Interactive Analysis (GEPIA). Moreover, we used the UALCAN dataset to confirm the association between gene expression levels and prognosis for AML patients. Enrichment functions of the top mutated genes of AML were analyzed through Metascape. Finally, the role of these defined genes in cancer pathways and potential drug targets were analyzed by gene set cancer analysis (GSCALite). RESULTS The top 20 mutated genes for AML included FLT3, HPS3, ABCA6, PCLO, SLIT2, and other ones. Compared to normal control samples, NPM1 and GABRB3 were significantly downregulated in AML samples, but TP53, DNMT3A, HPS3, FLT3, SENP6, and RUNX1 were significantly overexpressed (all these genes P value <0.01). Overexpression of FLT3 and PCLO indicated a poor prognosis, but the overexpression of SLIT3 functioned as a protector for AML via GEPIA. HSP3 indicates the favorable factor for AML, but overexpression of ABCA6 (P=0.066) may act as the adverse factor by UALCAN analysis. Enrichment function analysis shows the functions of defining genes, including negative regulation of cell differentiation, small GTPase mediated signal transduction, and immune system process. Finally, these genes participate in apoptosis, cell cycle, PI3K/AKT, and RAS/MAPK signaling pathway, and FLT3 is sensitive to 5-Fluorouracil, Methotrexate, ATRA. DNMT3A and IDH2 are resistant to Trametinib. RUNX1 and TP53 were sensitive to I-BET-762 and Tubastatin A. CONCLUSIONS Present study showed overexpression of FLT3, ABCA6, and PCLO indicated the poor prognosis of AML, but overexpression of SLIT3 and HSP3 functioned as an AML protector. There are several drugs and small molecules that target the top 20 mutated genes in AML.
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Affiliation(s)
- Lingling Shi
- Department of Hematology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yan Huang
- Department of Hematology and Rheumatology, People’s Hospital of Baise, Baise, China
| | - Xunjun Huang
- Department of Hematology and Rheumatology, People’s Hospital of Baise, Baise, China
| | - Weijie Zhou
- Department of Hematology and Rheumatology, People’s Hospital of Baise, Baise, China
| | - Jie Wei
- Department of Hematology and Rheumatology, People’s Hospital of Baise, Baise, China
| | - Donghong Deng
- Department of Hematology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yongrong Lai
- Department of Hematology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Mosquera Orgueira A, Bao Pérez L, Mosquera Torre A, Peleteiro Raíndo A, Cid López M, Díaz Arias JÁ, Ferreiro Ferro R, Antelo Rodríguez B, González Pérez MS, Albors Ferreiro M, Alonso Vence N, Pérez Encinas MM, Bello López JL, Martinelli G, Cerchione C. FLT3 inhibitors in the treatment of acute myeloid leukemia: current status and future perspectives. Minerva Med 2020; 111:427-442. [PMID: 32955823 DOI: 10.23736/s0026-4806.20.06989-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Mutations in the FMS-like tyrosine kinase 3 (FLT3) gene arise in 25-30% of all acute myeloid leukemia (AML) patients. These mutations lead to constitutive activation of the protein product and are divided in two broad types: internal tandem duplication (ITD) of the juxtamembrane domain (25% of cases) and point mutations in the tyrosine kinase domain (TKD). Patients with FLT3 ITD mutations have a high relapse risk and inferior cure rates, whereas the role of FLT3 TKD mutations still remains to be clarified. Additionally, growing research indicates that FLT3 status evolves through a disease continuum (clonal evolution), where AML cases can acquire FLT3 mutations at relapse - not present in the moment of diagnosis. Several FLT3 inhibitors have been tested in patients with FLT3-mutated AML. These drugs exhibit different kinase inhibitory profiles, pharmacokinetics and adverse events. First-generation multi-kinase inhibitors (sorafenib, midostaurin, lestaurtinib) are characterized by a broad-spectrum of drug targets, whereas second-generation inhibitors (quizartinib, crenolanib, gilteritinib) show more potent and specific FLT3 inhibition, and are thereby accompanied by less toxic effects. Notwithstanding, all FLT3 inhibitors face primary and acquired mechanisms of resistance, and therefore the combinations with other drugs (standard chemotherapy, hypomethylating agents, checkpoint inhibitors) and its application in different clinical settings (upfront therapy, maintenance, relapsed or refractory disease) are under study in a myriad of clinical trials. This review focuses on the role of FLT3 mutations in AML, pharmacological features of FLT3 inhibitors, known mechanisms of drug resistance and accumulated evidence for the use of FLT3 inhibitors in different clinical settings.
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Affiliation(s)
- Adrián Mosquera Orgueira
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain - .,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain - .,University of Santiago de Compostela, Santiago de Compostela, Spain -
| | - Laura Bao Pérez
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain
| | - Alicia Mosquera Torre
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain
| | - Andrés Peleteiro Raíndo
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain.,University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Miguel Cid López
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain.,University of Santiago de Compostela, Santiago de Compostela, Spain
| | - José Á Díaz Arias
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain
| | - Roi Ferreiro Ferro
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Beatriz Antelo Rodríguez
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain.,University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Marta S González Pérez
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain
| | - Manuel Albors Ferreiro
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain
| | - Natalia Alonso Vence
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain
| | - Manuel M Pérez Encinas
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain.,University of Santiago de Compostela, Santiago de Compostela, Spain
| | - José L Bello López
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS - SERGAS), Santiago de Compostela, Spain.,University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Giovanni Martinelli
- Unit of Hematology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy
| | - Claudio Cerchione
- Unit of Hematology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy
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34
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Garcia-Horton A, Yee KW. Quizartinib for the treatment of acute myeloid leukemia. Expert Opin Pharmacother 2020; 21:2077-2090. [DOI: 10.1080/14656566.2020.1801637] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Alejandro Garcia-Horton
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, CANADA
| | - Karen Wl Yee
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, CANADA
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35
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Eguchi M, Minami Y, Kuzume A, Chi S. Mechanisms Underlying Resistance to FLT3 Inhibitors in Acute Myeloid Leukemia. Biomedicines 2020; 8:biomedicines8080245. [PMID: 32722298 PMCID: PMC7459983 DOI: 10.3390/biomedicines8080245] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/10/2020] [Accepted: 07/16/2020] [Indexed: 01/03/2023] Open
Abstract
FLT3-ITD and FLT3-TKD mutations were observed in approximately 20 and 10% of acute myeloid leukemia (AML) cases, respectively. FLT3 inhibitors such as midostaurin, gilteritinib and quizartinib show excellent response rates in patients with FLT3-mutated AML, but its duration of response may not be sufficient yet. The majority of cases gain secondary resistance either by on-target and off-target abnormalities. On-target mutations (i.e., FLT3-TKD) such as D835Y keep the TK domain in its active form, abrogating pharmacodynamics of type II FLT3 inhibitors (e.g., midostaurin and quizartinib). Second generation type I inhibitors such as gilteritinib are consistently active against FLT3-TKD as well as FLT3-ITD. However, a “gatekeeper” mutation F691L shows universal resistance to all currently available FLT3 inhibitors. Off-target abnormalities are consisted with a variety of somatic mutations such as NRAS, AXL and PIM1 that bypass or reinforce FLT3 signaling. Off-target mutations can occur just in the primary FLT3-mutated clone or be gained by the evolution of other clones. A small number of cases show primary resistance by an FL-dependent, FGF2-dependent, and stromal CYP3A4-mediated manner. To overcome these mechanisms, the development of novel agents such as covalently-coupling FLT3 inhibitor FF-10101 and the investigation of combination therapy with different class agents are now ongoing. Along with novel agents, gene sequencing may improve clinical approaches by detecting additional targetable mutations and determining individual patterns of clonal evolution.
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Affiliation(s)
- Motoki Eguchi
- Department of Hematology, National Cancer Center Hospital East, Kashiwa 277-8577, Japan; (M.E.); (A.K.); (S.C.)
| | - Yosuke Minami
- Department of Hematology, National Cancer Center Hospital East, Kashiwa 277-8577, Japan; (M.E.); (A.K.); (S.C.)
- Correspondence: ; Tel.: +81-4-7133-1111; Fax: +81-7133-6502
| | - Ayumi Kuzume
- Department of Hematology, National Cancer Center Hospital East, Kashiwa 277-8577, Japan; (M.E.); (A.K.); (S.C.)
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa 296-8602, Japan
| | - SungGi Chi
- Department of Hematology, National Cancer Center Hospital East, Kashiwa 277-8577, Japan; (M.E.); (A.K.); (S.C.)
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36
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Ball B, Stein EM. Which are the most promising targets for minimal residual disease-directed therapy in acute myeloid leukemia prior to allogeneic stem cell transplant? Haematologica 2020; 104:1521-1531. [PMID: 31366466 PMCID: PMC6669154 DOI: 10.3324/haematol.2018.208587] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/01/2019] [Indexed: 12/19/2022] Open
Abstract
Minimal residual disease has emerged as an important prognostic factor for relapse and survival in acute myeloid leukemia. Eradication of minimal residual disease may increase the number of patients with long-term survival; however, to date, strategies that specifically target minimal residual disease are limited. Consensus guidelines on minimal residual disease detection by immunophenotypic and molecular methods are an essential initial step for clinical trials evaluating minimal residual disease. Here, we review promising targets of minimal residual disease prior to allogeneic stem cell transplantation. Specifically, the focus of this review is on the rationale and clinical development of therapies targeting: oncogenic driver mutations, apoptosis, methylation, and leukemic immune targets. We review the progress made in the clinical development of therapies against each target and the challenges that lie ahead.
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Affiliation(s)
- Brian Ball
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eytan M Stein
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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37
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Yilmaz M, Kadia T, Ravandi F. Identifying effective drug combinations for patients with acute myeloid leukemia. Expert Rev Anticancer Ther 2020; 20:591-601. [DOI: 10.1080/14737140.2020.1782749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Musa Yilmaz
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan Kadia
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
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38
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Yu J, Jiang PYZ, Sun H, Zhang X, Jiang Z, Li Y, Song Y. Advances in targeted therapy for acute myeloid leukemia. Biomark Res 2020; 8:17. [PMID: 32477567 PMCID: PMC7238648 DOI: 10.1186/s40364-020-00196-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 05/10/2020] [Indexed: 02/07/2023] Open
Abstract
Acute myeloid leukemia (AML) is a clonal malignancy characterized by genetic heterogeneity due to recurrent gene mutations. Treatment with cytotoxic chemotherapy has been the standard of care for more than half of a century. Although much progress has been made toward improving treatment related mortality rate in the past few decades, long term overall survival has stagnated. Exciting developments of gene mutation-targeted therapeutic agents are now changing the landscape in AML treatment. New agents offer more clinical options for patients and also confer a more promising outcome. Since Midostaurin, a FLT3 inhibitor, was first approved by US FDA in 2017 as the first gene mutation-targeted therapeutic agent, an array of new gene mutation-targeted agents are now available for AML treatment. In this review, we will summarize the recent advances in gene mutation-targeted therapies for patients with AML.
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Affiliation(s)
- Jifeng Yu
- 1The First Affiliated Hospital of Zhengzhou University, #1 East Jianshe Road, Zhengzhou, 450052 China.,2Academy of Medical and Pharmaceutical Sciences of Zhengzhou University, #1 East Jianshe Road, Zhengzhou, 450052 China
| | - Peter Y Z Jiang
- 3Department of Hematology and Oncology, The Everett Clinic and Providence Regional Cancer Partnership, 1717 13th Street, Everett, WA 98201 USA
| | - Hao Sun
- 1The First Affiliated Hospital of Zhengzhou University, #1 East Jianshe Road, Zhengzhou, 450052 China
| | - Xia Zhang
- 1The First Affiliated Hospital of Zhengzhou University, #1 East Jianshe Road, Zhengzhou, 450052 China
| | - Zhongxing Jiang
- 1The First Affiliated Hospital of Zhengzhou University, #1 East Jianshe Road, Zhengzhou, 450052 China
| | - Yingmei Li
- 1The First Affiliated Hospital of Zhengzhou University, #1 East Jianshe Road, Zhengzhou, 450052 China
| | - Yongping Song
- 4The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, 127 Dongming Road, Zhengzhou, 450008 China
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39
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Thomas X, Elhamri M, Heiblig M. Emerging pharmacotherapies for elderly acute myeloid leukemia patients. Expert Rev Hematol 2020; 13:619-643. [PMID: 32311298 DOI: 10.1080/17474086.2020.1758058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Acute myeloid leukemia (AML) is a disease mainly seen in the elderly, for which treatment is undergoing rapid changes. Although recent studies have supported the survival benefit of induction chemotherapy in fit patients and that of hypomethylating agents (HMAs) in non-induction candidates, treatment of this patient age population remains a significant challenge for the treating oncologist. AREAS COVERED In this review, we will examine effectiveness and safety outcomes of upcoming novel treatment strategies in elderly (≥60 years old) patients with AML, highlight the current literature and ongoing trials able to maximize therapeutic options in this heterogeneous patient population. EXPERT OPINION Current developments including new chemotherapeutic strategies and combinations of HMAs with novel drugs targeting epigenetic or immunomodulatory pathways are underway to improve patient survival and quality of life.
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Affiliation(s)
- Xavier Thomas
- Hospices Civils de Lyon, Hematology Department, Lyon-Sud University Hospital , Pierre Bénite, France
| | - Mohamed Elhamri
- Hospices Civils de Lyon, Hematology Department, Lyon-Sud University Hospital , Pierre Bénite, France
| | - Maël Heiblig
- Hospices Civils de Lyon, Hematology Department, Lyon-Sud University Hospital , Pierre Bénite, France
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40
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Shallis RM, Boddu PC, Bewersdorf JP, Zeidan AM. The golden age for patients in their golden years: The progressive upheaval of age and the treatment of newly-diagnosed acute myeloid leukemia. Blood Rev 2020; 40:100639. [DOI: 10.1016/j.blre.2019.100639] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/29/2019] [Accepted: 11/05/2019] [Indexed: 12/25/2022]
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41
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Hunter BD, Chen YB. Current Approaches to Transplantation for FLT3-ITD AML. Curr Hematol Malig Rep 2020; 15:1-8. [DOI: 10.1007/s11899-020-00558-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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42
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Li J, Holmes M, Kankam M, Trone D, Mendell J, Gammon G. Effect of Food on the Pharmacokinetics of Quizartinib. Clin Pharmacol Drug Dev 2020; 9:277-286. [PMID: 31916418 PMCID: PMC7027461 DOI: 10.1002/cpdd.770] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 11/26/2019] [Indexed: 11/28/2022]
Abstract
Quizartinib is an oral, highly potent, and selective type II FMS‐like tyrosine kinase 3 inhibitor in development for acute myeloid leukemia. This parallel‐group study evaluated potential food effects on quizartinib absorption in healthy subjects who received a single 30‐mg dose after overnight fasting (n = 34) or a high‐fat, high‐calorie meal (n = 30). Blood samples were collected through 504 hours after dosing, and pharmacokinetic parameters calculated were maximum observed concentration (Cmax) and area under plasma concentration–time curve from time 0 to last quantifiable concentration (AUClast) and from time 0 to infinity (AUCinf). Mean quizartinib pharmacokinetic profiles were similar under fasted and fed conditions. The geometric least squares means ratios (%) for fed/fasted and associated 90% confidence intervals (CIs) for Cmax, AUClast, and AUCinf were 91.58 (82.15‐102.08), 105.39 (90.79‐122.35), and 108.39 (91.54‐128.34), respectively. The 90%CI for the ratio fell within the 80% to 125% limits for Cmax and AUClast, with 90%CI for AUCinf slightly outside the limits (ie, 128%). Food delayed quizartinib time to Cmax by 2 hours. All adverse events were either mild or moderate; no discontinuations due to adverse events occurred. Based on these results, quizartinib can be administered without regard to food.
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Affiliation(s)
- Jianke Li
- Formerly Daiichi Sankyo, Inc., San Diego, California, USA
| | - Melissa Holmes
- Formerly Daiichi Sankyo, Inc., San Diego, California, USA
| | | | - Denise Trone
- Formerly Daiichi Sankyo, Inc., San Diego, California, USA
| | | | - Guy Gammon
- Formerly Daiichi Sankyo, Inc., San Diego, California, USA
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43
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How I treat acute myeloid leukemia in the era of new drugs. Blood 2020; 135:85-96. [DOI: 10.1182/blood.2019001239] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/18/2019] [Indexed: 12/15/2022] Open
Abstract
AbstractThe acute myeloid leukemia (AML) treatment landscape has changed substantially since 2017. New targeted drugs have emerged, including venetoclax to target B-cell lymphoma 2, midostaurin and gilteritinib to target FLT3, and ivosidenib and enasidenib to target mutant isocitrate dehydrogenase 1 and 2, respectively. Other additions include reapproval of gemtuzumab ozogomycin to target CD33, glasdegib to target the hedgehog pathway, and a liposomal formulation of daunorubicin and cytarabine (CPX-351). Genomically heterogeneous AML has a tendency to evolve, particularly under selective treatment pressure. For decades, treatment decisions have largely centered around chemotherapy drug intensity. Physicians now have access to an increasing number of drugs with novel mechanisms of action and distinctive side-effect profiles. Key issues faced by hematologists in this era of new drugs include (1) the timely identification of actionable mutations at diagnosis and at relapse; (2) deciding which drug to use among several therapeutic options; and (3) increasing awareness of how to anticipate, mitigate, and manage common complications associated with these new agents. This article will use 3 case presentations to discuss some of the new treatment challenges encountered in AML management, with the goal of providing practical guidance to aid the practicing physician.
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44
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Antar AI, Otrock ZK, Jabbour E, Mohty M, Bazarbachi A. FLT3 inhibitors in acute myeloid leukemia: ten frequently asked questions. Leukemia 2020; 34:682-696. [PMID: 31919472 DOI: 10.1038/s41375-019-0694-3] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/22/2019] [Accepted: 12/06/2019] [Indexed: 12/18/2022]
Abstract
The FMS-like tyrosine kinase 3 (FLT3) gene is mutated in approximately one third of patients with acute myeloid leukemia (AML), either by internal tandem duplications (FLT3-ITD), or by a point mutation mainly involving the tyrosine kinase domain (FLT3-TKD). Patients with FLT3-ITD have a high risk of relapse and low cure rates. Several FLT3 tyrosine kinase inhibitors have been developed in the last few years with variable kinase inhibitory properties, pharmacokinetics, and toxicity profiles. FLT3 inhibitors are divided into first generation multi-kinase inhibitors (such as sorafenib, lestaurtinib, midostaurin) and next generation inhibitors (such as quizartinib, crenolanib, gilteritinib) based on their potency and specificity of FLT3 inhibition. These diverse FLT3 inhibitors have been evaluated in myriad clinical trials as monotherapy or in combination with conventional chemotherapy or hypomethylating agents and in various settings, including front-line, relapsed or refractory disease, and maintenance therapy after consolidation chemotherapy or allogeneic stem cell transplantation. In this practical question-and-answer-based review, the main issues faced by the leukemia specialists on the use of FLT3 inhibitors in AML are addressed.
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Affiliation(s)
- Ahmad I Antar
- Department of Hematology and Oncology, Hammoud Hospital University Medical Center, Saida, Lebanon
| | - Zaher K Otrock
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mohamad Mohty
- Service d'hématologie clinique et thérapie cellulaire, Hôpital Saint-Antoine, INSERM UMRs 938 and université Sorbonne, Paris, France
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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Fletcher L, Joshi SK, Traer E. Profile of Quizartinib for the Treatment of Adult Patients with Relapsed/Refractory FLT3-ITD-Positive Acute Myeloid Leukemia: Evidence to Date. Cancer Manag Res 2020; 12:151-163. [PMID: 32021432 PMCID: PMC6955578 DOI: 10.2147/cmar.s196568] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 12/05/2019] [Indexed: 01/16/2023] Open
Abstract
Acute myeloid leukemia (AML) is a clonal hematologic neoplasm characterized by rapid, uncontrolled cell growth of immature myeloid cells (blasts). There are numerous genetic abnormalities in AML, many of which are prognostic, but an increasing number are targets for drug therapy. One of the most common genetic abnormalities in AML are activating mutations in the FMS-like tyrosine kinase 3 receptor (FLT3). As a receptor tyrosine kinase, FLT3 was the first targetable genetic abnormality in AML. The first generation of FLT3 inhibitors were broad-spectrum kinase inhibitors that inhibited FLT3 among other proteins. Although clinically active, first-generation FLT3 inhibitors had limited success as single agents. This led to the development of a second generation of more selective FLT3 inhibitors. This review focuses on quizartinib, a potent second-generation FLT3 inhibitor. We discuss the clinical trial development, mechanisms of resistance, and the recent FDA decision to deny approval for quizartinib as a single agent in relapsed/refractory AML.
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Affiliation(s)
- Luke Fletcher
- Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, OR 97239, USA.,Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Sunil K Joshi
- Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, OR 97239, USA.,Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA.,School of Medicine, Oregon Health & Science University, Portland, OR 97239, USA
| | - Elie Traer
- Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, OR 97239, USA.,Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
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46
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Smith CC. The growing landscape of FLT3 inhibition in AML. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:539-547. [PMID: 31808872 PMCID: PMC6913436 DOI: 10.1182/hematology.2019000058] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Midostaurin and gilteritinib are FLT3 inhibitors that have been recently approved for use in FLT3-mutant acute myeloid leukemia (AML). These approved drugs represent a new standard of care for patients with FLT3 mutations in both the first-line and salvage settings. The success of midostaurin used in combination with induction chemotherapy has prompted exploration of newer, more potent and targeted inhibitors (including gilteritinib) in the first-line setting in combination with chemotherapy. At the same time, the success of gilteritinib and other newer FLT3 inhibitors as monotherapy in the salvage setting has been tempered by the development of resistance because of diverse mechanisms. Investigational strategies that incorporate FLT3 inhibitors in combination with hypomethylating agents and as maintenance therapy after allogeneic stem cell transplantation have shown promise. Other novel combination strategies are also undergoing clinical investigation. In this article, we review the current landscape of approved and investigational FLT3 inhibitors in AML, including the current standard of care and investigational strategies.
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Affiliation(s)
- Catherine C Smith
- Divsion of Hematology/Oncology, Department of Medicine, University of California, San Francisco, CA
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47
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Beyond midostaurin: Which are the most promising FLT3 inhibitors in AML? Best Pract Res Clin Haematol 2019; 32:101103. [DOI: 10.1016/j.beha.2019.101103] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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48
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Thekkudan SF, Lima M, Metheny L. Prevention of relapse after allogeneic stem cell transplantation in acute myeloid leukemia: Updates and challenges. ACTA ACUST UNITED AC 2019. [DOI: 10.1002/acg2.77] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Shinto F. Thekkudan
- Stem Cell Transplant Program University Hospitals Cleveland Medical Center Case Western Reserve University Cleveland OH USA
- Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | - Marcos Lima
- Stem Cell Transplant Program University Hospitals Cleveland Medical Center Case Western Reserve University Cleveland OH USA
| | - Leland Metheny
- Stem Cell Transplant Program University Hospitals Cleveland Medical Center Case Western Reserve University Cleveland OH USA
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49
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Bazarbachi AH, Al Hamed R, Malard F, Mohty M, Bazarbachi A. Allogeneic transplant for FLT3- ITD mutated AML: a focus on FLT3 inhibitors before, during, and after transplant. Ther Adv Hematol 2019; 10:2040620719882666. [PMID: 31700594 PMCID: PMC6826920 DOI: 10.1177/2040620719882666] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/25/2019] [Indexed: 01/17/2023] Open
Abstract
FMS-like tyrosine kinase 3 (FLT3) mutations are one of the most frequently encountered genetic alterations in acute myeloid leukemia (AML), and are generally associated with unfavorable outcomes. Several tools are currently available to provide an accurate prognosis for patients with these mutations, including FLT3 mutation type (internal tandem duplication versus tyrosine kinase domain), mutation allelic ratio (high versus low), and concurrent nucleophosmin-1 (NPM1) mutation, to help decide on optimal treatment. Recent advances in targeted therapies have paved the way for modern treatment strategies, such as the development of FLT3 kinase inhibitors. These novel drugs can be incorporated into any treatment component, including induction and consolidation, the relapse/refractory setting, bridging for transplant, salvage post-transplant, and as prophylactic long-term post-transplant maintenance. Many challenges remain though, such as their intolerability with high-dose chemotherapy in frail patients; whether their optimal use involves watchful waiting for molecular or hematologic relapse compared with prophylactic use as maintenance; and the exact role and indication for allogeneic stem cell transplantation, which arguably remains the only curative option for these high-risk patients.
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Affiliation(s)
- Abdul Hamid Bazarbachi
- Department of Haematology, Saint Antoine Hospital, Paris, France, INSERM UMR 938, Paris, France
- Sorbonne University, Paris, Île-de-France, France
| | - Rama Al Hamed
- Department of Haematology, Saint Antoine Hospital, Paris, France, INSERM UMR 938, Paris, France
- Sorbonne University, Paris, Île-de-France, France
| | - Florent Malard
- Department of Haematology, Saint Antoine Hospital, Paris, France, INSERM UMR 938, Paris, France
- Sorbonne University, Paris, Île-de-France, France
| | - Mohamad Mohty
- Department of Haematology, Saint Antoine Hospital, Paris, France, INSERM UMR 938, Paris, France
- Sorbonne University, Paris, Île-de-France, France
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, PO Box 113-6044, Beirut, Lebanon
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50
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Abbas HA, Alfayez M, Kadia T, Ravandi-Kashani F, Daver N. Midostaurin In Acute Myeloid Leukemia: An Evidence-Based Review And Patient Selection. Cancer Manag Res 2019; 11:8817-8828. [PMID: 31632141 PMCID: PMC6782026 DOI: 10.2147/cmar.s177894] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 09/12/2019] [Indexed: 01/08/2023] Open
Abstract
Fms-related-tyrosine kinase 3 (FLT3) mutations occur in approximately a third of acute myeloid leukemia (AML) patients and confer an adverse prognosis. Numerous studies have evaluated FLT3 targeting as single agent and in combination approaches in frontline and relapsed AML. At this time, midostaurin, a multikinase inhibitor, is the only FLT3-inhibitor that is US FDA approved to be used in combination with induction therapy in the frontline FLT3-mutated AML setting based on improved overall survival noted in the RATIFY Phase III trial. The utility of midostaurin in maintenance post stem cell transplantation has shown promising results and further studies are still ongoing. In this review, we discuss the studies that led to the inception of midostaurin as a targeted kinase inhibitor, its evaluation in AML, the early clinical trials and the large Phase III clinical trial that led to its eventual US FDA-approval in FLT3-mutated AML. Our review also discusses data on midostaurin adverse effects, mechanisms of resistance and limitations of its utility. We further discuss emerging second-generation FLT3 inhibitors, with a focus on quizartinib and gilteritinib and future directions to enhance FLT3-inhibitor efficacy and overcome mechanisms of resistance.
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Affiliation(s)
- Hussein A Abbas
- Department of Leukemia, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Mansour Alfayez
- Department of Leukemia, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Tapan Kadia
- Department of Leukemia, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi-Kashani
- Department of Leukemia, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Naval Daver
- Department of Leukemia, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
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