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Graff Z, Wachter F, Eapen M, Lehmann L, Cooper T. Navigating Treatment Options and Communication in Relapsed Pediatric AML. Am Soc Clin Oncol Educ Book 2024; 44:e438690. [PMID: 38862135 DOI: 10.1200/edbk_438690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
Despite improved outcomes in newly diagnosed pediatric AML, relapsed disease remains a therapeutic challenge. Factors contributing to slow progress in improving outcomes include inherent challenges in pediatric clinical trial accrual and the scarcity of novel targeted/immunotherapy agents available for pediatric development. This paradigm is changing, however, as international collaboration grows in parallel with the development of promising targeted agents. In this review, we discuss the therapeutic landscape of relapsed pediatric AML, including conventional chemotherapy, targeted therapies, and the challenges of drug approvals in this patient population. We highlight current efforts to improve communication among academia, industry, and regulatory authorities and discuss the importance of international collaboration to improve access to new therapies. Among the therapeutic options, we highlight the approach to second hematopoietic stem cell transplant (HSCT) and discuss which patients are most likely to benefit from this potentially curative intervention. Importantly, we acknowledge the challenges in providing these high-risk interventions to our patients and their families and the importance of shared communication and decision making when considering early-phase clinical trials and second HSCT.
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Affiliation(s)
- Zachary Graff
- Department of Pediatrics, Division of Hematology, Oncology, and BMT, Medical College of Wisconsin, Milwaukee, WI
| | - Franziska Wachter
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Mary Eapen
- Department of Medicine, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Leslie Lehmann
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Todd Cooper
- Department of Pediatrics, Division of Hematology and Oncology, Seattle Children's Hospital, Seattle, WA
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2
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Zheng H, Wu T, Lin Z, Wang D, Zhang J, Zeng T, Liu L, Shen J, Zhao M, Li JD, Yang M. Targeting BMAL1 reverses drug resistance of acute myeloid leukemia cells and promotes ferroptosis through HMGB1-GPX4 signaling pathway. J Cancer Res Clin Oncol 2024; 150:231. [PMID: 38703241 PMCID: PMC11069489 DOI: 10.1007/s00432-024-05753-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 04/19/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE Acute myeloid leukemia (AML) is a refractory hematologic malignancy that poses a serious threat to human health. Exploring alternative therapeutic strategies capable of inducing alternative modes of cell death, such as ferroptosis, holds great promise as a viable and effective intervention. METHODS We analyzed online database data and collected clinical samples to verify the expression and function of BMAL1 in AML. We conducted experiments on AML cell proliferation, cell cycle, ferroptosis, and chemotherapy resistance by overexpressing/knocking down BMAL1 and using assays such as MDA detection and BODIPY 581/591 C11 staining. We validated the transcriptional regulation of HMGB1 by BMAL1 through ChIP assay, luciferase assay, RNA level detection, and western blotting. Finally, we confirmed the results of our cell experiments at the animal level. RESULTS BMAL1 up-regulation is an observed phenomenon in AML patients. Furthermore, there existed a strong correlation between elevated levels of BMAL1 expression and inferior prognosis in individuals with AML. We found that knocking down BMAL1 inhibited AML cell growth by blocking the cell cycle. Conversely, overexpressing BMAL1 promoted AML cell proliferation. Moreover, our research results revealed that BMAL1 inhibited ferroptosis in AML cells through BMAL1-HMGB1-GPX4 pathway. Finally, knocking down BMAL1 can enhance the efficacy of certain first-line cancer therapeutic drugs, including venetoclax, dasatinib, and sorafenib. CONCLUSION Our research results suggest that BMAL1 plays a crucial regulatory role in AML cell proliferation, drug resistance, and ferroptosis. BMAL1 could be a potential important therapeutic target for AML.
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MESH Headings
- Animals
- Female
- Humans
- Male
- Mice
- ARNTL Transcription Factors/genetics
- ARNTL Transcription Factors/metabolism
- Cell Line, Tumor
- Cell Proliferation/drug effects
- Drug Resistance, Neoplasm
- Ferroptosis/drug effects
- HMGB1 Protein/metabolism
- HMGB1 Protein/genetics
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/metabolism
- Leukemia, Myeloid, Acute/pathology
- Leukemia, Myeloid, Acute/genetics
- Mice, Nude
- Phospholipid Hydroperoxide Glutathione Peroxidase/metabolism
- Phospholipid Hydroperoxide Glutathione Peroxidase/genetics
- Prognosis
- Signal Transduction
- Sulfonamides/pharmacology
- Xenograft Model Antitumor Assays
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Affiliation(s)
- Hong Zheng
- Department of Pediatrics, The Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Ting Wu
- Center for Medical Genetics, School of Life Sciences, Central South University, Changsha, 410078, Hunan, China
| | - Zhi Lin
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- Hunan Clinical Research Center of Pediatric Cancer, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- MOE Key Lab of Rare Pediatric Diseases, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Dan Wang
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- Hunan Clinical Research Center of Pediatric Cancer, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- MOE Key Lab of Rare Pediatric Diseases, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Jing Zhang
- Center for Medical Genetics, School of Life Sciences, Central South University, Changsha, 410078, Hunan, China
| | - Ting Zeng
- Department of Pediatrics, The Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Leping Liu
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- Hunan Clinical Research Center of Pediatric Cancer, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- MOE Key Lab of Rare Pediatric Diseases, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Jie Shen
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- Hunan Clinical Research Center of Pediatric Cancer, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- MOE Key Lab of Rare Pediatric Diseases, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Mingyi Zhao
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- Hunan Clinical Research Center of Pediatric Cancer, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- MOE Key Lab of Rare Pediatric Diseases, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Jia-Da Li
- Center for Medical Genetics, School of Life Sciences, Central South University, Changsha, 410078, Hunan, China.
| | - Minghua Yang
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China.
- Hunan Clinical Research Center of Pediatric Cancer, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China.
- MOE Key Lab of Rare Pediatric Diseases, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China.
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Lap CJ, Abrahim MS, Nassereddine S. Perspectives and challenges of small molecule inhibitor therapy for FLT3-mutated acute myeloid leukemia. Ann Hematol 2023:10.1007/s00277-023-05545-3. [PMID: 37975931 DOI: 10.1007/s00277-023-05545-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
Acute myeloid leukemia (AML) is a heterogeneous clonal disease characterized overall by an aggressive clinical course. The underlying genetic abnormalities present in leukemic cells contribute significantly to the AML phenotype. Mutations in FMS-like tyrosine kinase 3 (FLT3) are one of the most common genetic abnormalities identified in AML, and the presence of these mutations strongly influences disease presentation and negatively impacts prognosis. Since mutations in FLT3 were identified in AML, they have been recognized as a valid therapeutic target resulting in decades of research to develop effective small molecule inhibitor treatment that could improve outcome for these patients. Despite the approval of several FLT3 inhibitors over the last couple of years, the treatment of patients with FLT3-mutated AML remains challenging and many questions still need to be addressed. This review will provide an up-to-date overview of our current understanding of FLT3-mutated AML and discuss what the current status is of the available FLT3 inhibitors for the day-to-day management of this aggressive disease.
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Affiliation(s)
- Coen J Lap
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Marwa Sh Abrahim
- The George Washington Cancer Center, George Washington University, Washington, DC, USA
| | - Samah Nassereddine
- The George Washington Cancer Center, George Washington University, Washington, DC, USA.
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4
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Montoro J, Balaguer-Roselló A, Sanz J. Recent advances in allogeneic transplantation for acute myeloid leukemia. Curr Opin Oncol 2023; 35:564-573. [PMID: 37820092 DOI: 10.1097/cco.0000000000000992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
PURPOSE OF REVIEW This review highlights recent advancements in allogeneic hematopoietic stem cell transplantation (allo-HSCT) for patients with acute myeloid leukemia (AML). RECENT FINDINGS Important improvements have been observed throughout the allo-HSCT procedure and patient management. Universal donor availability and reduced risk of graft-versus-host disease (GVHD) have been achieved with the introduction of posttransplant cyclophosphamide for GVHD prophylaxis. It has contributed, together with advances in conditioning regimens, GVHD treatment and supportive care, to a reduced overall toxicity of the procedure. Relapse is now the most frequent cause of transplant failure. With increased knowledge of the biological characterization of AML, better prediction of transplant risks and more profound and standardized minimal residual disease (MRD) monitoring, pharmacological, and immunological strategies to prevent relapse are been developed. SUMMARY Allo-HSCT remains the standard of care for high-risk AML. Increased access to transplant, reduced toxicity and relapse are improving patient outcomes. Further research is needed to optimize MRD monitoring, refine conditioning regimens, and explore new GVHD management and relapse prevention therapies.
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Affiliation(s)
- Juan Montoro
- Hematology Department, Hospital Universitario y Politécnico La Fe
- Departamento de Medicina, Universidad Católica de Valencia
| | - Aitana Balaguer-Roselló
- Hematology Department, Hospital Universitario y Politécnico La Fe
- CIBERONC, Instituto Carlos III, Madrid
| | - Jaime Sanz
- Hematology Department, Hospital Universitario y Politécnico La Fe
- CIBERONC, Instituto Carlos III, Madrid
- Departamento de Medicina, Universidad de Valencia, Spain
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5
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Bazarbachi A, Labopin M, Gedde-Dahl T, Remenyi P, Forcade E, Kröger N, Socié G, Craddock C, Bourhis JH, Versluis J, Yakoub-Agha I, Salmenniemi U, El-Cheikh J, Bug G, Esteve J, Nagler A, Ciceri F, Mohty M. Improved Posttransplant Outcomes in Recent Years for AML Patients with FLT3-ITD and Wild-type NPM1: A Report from the EBMT Acute Leukemia Working Party. Clin Cancer Res 2023; 29:4441-4448. [PMID: 37603683 DOI: 10.1158/1078-0432.ccr-23-0954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/17/2023] [Accepted: 08/14/2023] [Indexed: 08/23/2023]
Abstract
PURPOSE Allogeneic hematopoietic cell transplantation (allo-HCT) is recommended in first complete remission (CR1) in patients with acute myeloid leukemia (AML) harboring FMS-like tyrosine kinase 3-internal tandem duplication (FLT3-ITD). We assessed changes over time in transplant characteristics and outcomes in patients with AML age 60 years and younger with a FLT3-ITD. EXPERIMENTAL DESIGN We identified 1,827 adult patients with AML (median age 49 years, range 18-60) with FLT3-ITD and intermediate karyotype, allografted between 2012 and 2021 in CR1. RESULTS NPM1 was mutated in 72% of patients. We compared changes over time in 688 patients transplanted between 2012 and 2016, and 1,139 patients transplanted between 2017 and 2021. For patients with wild-type NPM1, the 2-year leukemia-free survival (LFS) and overall survival (OS) significantly improved over time from 54% to 64% (HR = 0.67; P = 0.011) and from 63% to 71% (HR = 0.66; P = 0.021), respectively. Allo-HCT in recent years significantly reduced the cumulative incidence of relapse (CIR). For patients with NPM1 mutation, no significant changes over time were noted. CONCLUSIONS In patients with AML with FLT3-ITD and wild-type NPM1, we noticed a significant decrease over time in the CIR and improvement of LFS and OS, likely reflecting the efficacy of FLT-3 inhibitors, including when used as posttransplant maintenance, in this high-risk setting. On the contrary, no significant change over time was noticed in outcomes of patients harboring a FLT3 and NPM1 mutation.
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Affiliation(s)
- Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Myriam Labopin
- EBMT Statistical Unit, Sorbonne University, Saint-Antoine Hospital, AP-HP, INSERM UMRs 938, Paris, France
| | - Tobias Gedde-Dahl
- Oslo University Hospital, Rikshospitalet, Clinic for Cancer Medicine, Department of Hematology, Section for Stem Cell Transplantation, Oslo, Norway
| | - Peter Remenyi
- Dél-pesti Centrumkórház-Országos Hematológiai és Infektológiai Intézet, Department of Haematology and Stem Cell Transplant, Albert, Budapest, Hungary
| | - Edouard Forcade
- Service d'Hématologie Clinique et Thérapie Cellulaire, CHU Bordeaux, Bordeaux, France
| | - Nicolaus Kröger
- Department for Stem Cell Transplantation, University Medical Center Hamburg, Hamburg, Germany
| | - Gerard Socié
- Hopital St. Louis, Department of Hematology-BMT, Paris, France
| | - Charles Craddock
- University Hospital Birmingham NHS Trust, Queen Elizabeth Medical Centre, Edgbaston, Department of Haematology, Birmingham, England
| | - Jean Henri Bourhis
- Gustave Roussy Cancer Campus, BMT Service, Department of Hematology, Villejuif, France
| | - Jurjen Versluis
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Hematology, Rotterdam, the Netherlands
| | | | - Urpu Salmenniemi
- HUCH Comprehensive Cancer Center, Stem Cell Transplantation Unit, Helsinki, Finland
| | - Jean El-Cheikh
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Gesine Bug
- Goethe University Frankfurt, Department of Medicine 2, Hematology and Oncology, Frankfurt am Main, Germany
| | - Jordi Esteve
- Hospital Clínic of Barcelona, IDIBAPS, Barcelona, Spain
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - Fabio Ciceri
- University Vita-Salute, IRCCS Ospedale San Raffaele, Haematology and BMT, Milano, Italy
| | - Mohamad Mohty
- Sorbonne University, Saint-Antoine Hospital, AP-HP, INSERM UMRs 938, Paris, France
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6
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Shao R, Zhang Y, He J, Huang F, Fan Z, Yang K, Xu Y, Xu N, Luo Y, Deng L, Zhang X, Chen J, Han M, Li X, Yu S, Liu H, Liang X, Luo X, Shi P, Wang Z, Jiang L, Zhou X, Lin R, Chen Y, Tu S, Sun J, Wang Y, Liu Q, Xuan L. Impact of genetic patterns on sorafenib efficacy in patients with FLT3-ITD acute myeloid leukemia undergoing allogeneic hematopoietic stem cell transplantation: a multi-center, cohort study. Signal Transduct Target Ther 2023; 8:348. [PMID: 37704613 PMCID: PMC10499827 DOI: 10.1038/s41392-023-01614-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 08/14/2023] [Accepted: 08/21/2023] [Indexed: 09/15/2023] Open
Abstract
Sorafenib therapy improves overall survival (OS) in patients with FLT3 internal tandem duplication (ITD) acute myeloid leukemia (AML) undergoing allogeneic hematopoietic stem cell transplantation. We explored the efficacy of sorafenib therapy in this population with different concomitant genetic patterns. In this multi-center, cohort study, we enrolled patients with FLT3-ITD AML undergoing allogenic hematopoietic cell transplantation. Patients with sorafenib maintenance post-transplantation for at least four weeks were allocated to the sorafenib group, and otherwise to the control group. Endpoints were OS, disease-free survival, and relapse for the whole cohort and OS for genetic pattern subgroups. Among 613 patients enrolled, 275 were in the sorafenib and 338 the control group. Median follow-up was 36.5 (interquartile range (IQR), 25.2-44.7) months post-transplantation. The 3-year OS post-transplantation was 79.6% (95% confidential interval (CI) 74.8%-84.6%) and 65.2% (95% CI 60.3%-70.6%) (Hazard ratio (HR) 0.50, 95% CI 0.37-0.69; P < 0.0001) in both groups. Sorafenib maintenance post-transplantation improved OS in the favorable (HR 0.33, 95% CI 0.14-0.77; P = 0.011) and adverse (HR 0.56, 95% CI 0.33-0.93; P = 0.026) ELN 2017 risk subgroups. Patients with mutated NPM1, DNMT3A, co-occurring NPM1/DNMT3A, "activated signaling" and "DNA methylation" genes benefited in OS from sorafenib maintenance, while those carrying CEBPA, "tumor suppressors" and "myeloid transcription factors" genes did not. Patients with FLT3-ITDhigh and FLT3-ITDlow AML both benefited in OS from sorafenib maintenance. Our results identify the response of genetic patterns to sorafenib maintenance, providing new viewpoints for the optimal use of sorafenib in FLT3-ITD AML in the transplantation setting.
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Affiliation(s)
- Ruoyang Shao
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Yu Zhang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Jinping He
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Zhiping Fan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Kaibo Yang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Yajing Xu
- Department of Hematology, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Na Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Yi Luo
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Lan Deng
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, 510280, China
- Department of Hematology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200125, China
| | - Xi Zhang
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Jia Chen
- The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Mingzhe Han
- Hematopoietic Stem Cell Transplantation Center, Institute of Hematology and Blood Diseases Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Tianjin, 300020, China
| | - Xudong Li
- Department of Hematology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Sijian Yu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Hui Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Xinquan Liang
- Department of Hematology, the First People's Hospital of Chenzhou, Chenzhou, 423099, China
| | - Xiaodan Luo
- Department of Hematology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
- Department of Hematology, the Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510799, China
| | - Pengcheng Shi
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Zhixiang Wang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Ling Jiang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Xuan Zhou
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Ren Lin
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Yan Chen
- Department of Hematology, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Sanfang Tu
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, 510280, China
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China
| | - Yu Wang
- Department of Hematology, Peking University People's Hospital, Beijing, 100044, China.
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China.
- Guangdong Provincial Key Laboratory of Digital Medicine and Biomechanics, National Key Discipline of Human Anatomy, School of Basic Medical Sciences, Southern Medical University, Guangzhou, 510515, China.
| | - Li Xuan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
- Clinical Medical Research Center of Hematology Diseases of Guangdong Province, Guangzhou, 510515, China.
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7
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Shah NA. Donor lymphocyte infusion in Acute Myeloid Leukemia. Best Pract Res Clin Haematol 2023; 36:101484. [PMID: 37612002 DOI: 10.1016/j.beha.2023.101484] [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: 04/17/2023] [Revised: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 08/25/2023]
Abstract
Donor lymphocyte infusion (DLI) is an important treatment modality in the management of relapsed hematological malignancies after allogeneic hematopoietic cell transplantation (allo-HCT). Donor T lymphocytes can be used in a therapeutic, pre-emptive or prophylactic manner in an attempt to stimulate a graft versus leukemia (GVL) effect and eradicate residual disease or even prevent relapse in a high-risk setting. DLIs are not without complications, however, graft versus host disease (GVHD) in particular. Data to date is limited to retrospective and small prospective studies. This review summarizes the available literature on approaches to managing relapse, dosing and timing of DLI, complications and potential future therapies.
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8
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Al-Shaibani E, Novitzky-Basso I, Mattsson J, Kim DDH. Post-transplant maintenance therapy in acute myeloid leukemia after allogeneic hematopoietic stem cell transplantation harmonizing multiple therapeutic modalities including targeted therapy, immunotherapy and cellular therapy. Int J Hematol 2023:10.1007/s12185-023-03614-x. [PMID: 37212948 DOI: 10.1007/s12185-023-03614-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/11/2023] [Accepted: 04/28/2023] [Indexed: 05/23/2023]
Abstract
Allogeneic hematopoietic stem cell transplant (HCT) has improved survival for patients with acute myeloid leukemia (AML), especially for those at high risk of relapse. However, relapse remains the leading cause of treatment failure post-HCT, occurring in around 35-45% of patients, and leading to dismal outcomes. Strategies to reduce relapse risk are urgently needed, especially in the early post-transplant period before activation of the graft-versus-leukemia (GVL) effect. Maintenance therapy is a course of treatment given post-HCT with the expectation of reducing relapse risk. While there are currently no therapies approved for maintenance therapy for AML after HCT, there are a number of studies and ongoing investigations examining the role of maintenance therapies that include targeted agents against FLT3-ITD, BCL2, or IDH mutations, hypomethylating agents, immunomodulatory therapies and cellular therapies. In this review, we discuss the mechanistic and clinical data for post-transplant maintenance therapies in AML and strategies for maintenance therapy for AML after HCT.
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Affiliation(s)
- Eshrak Al-Shaibani
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, 610 University Ave, OPG Rm 6-222, Toronto, ON, Canada
| | - Igor Novitzky-Basso
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, 610 University Ave, OPG Rm 6-222, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, M5G 2M9, Canada
| | - Jonas Mattsson
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, 610 University Ave, OPG Rm 6-222, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, M5G 2M9, Canada
| | - Dennis Dong Hwan Kim
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, 610 University Ave, OPG Rm 6-222, Toronto, ON, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, M5G 2M9, Canada.
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9
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El-Cheikh J, Bidaoui G, Saleh M, Moukalled N, Abou Dalle I, Bazarbachi A. Venetoclax: A New Partner in the Novel Treatment Era for Acute Myeloid Leukemia and Myelodysplastic Syndrome. Clin Hematol Int 2023:10.1007/s44228-023-00041-x. [PMID: 37071328 DOI: 10.1007/s44228-023-00041-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/09/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Acute Myeloid Leukemia (AML) and Myelodysplastic Syndrome (MDS) are two closely related blood cancers that are more frequent in older adults. AML is the most common type of adult acute leukemia, and MDS is characterized by ineffective blood cell production and abnormalities in the bone marrow and blood. Both can be resistant to treatment, often due to dysfunction in the process of apoptosis, the body's natural mechanism for cell death. Venetoclax, an orally-administered medication that selectively targets the BCL-2 protein, has shown promise in enhancing treatment sensitivity in some hematological malignancies by reducing the apoptotic threshold. This review aims to evaluate the effectiveness of venetoclax in treating AML and MDS, as well as potential mechanisms of resistance to the medication. METHODS A literature search was conducted utilizing PUBMED to capture all relevant research articles on the use of venetoclax as a therapy for both diseases. The MeSH terms "acute myeloid leukemia", "myelodysplastic syndrome" and "venetoclax" were searched. Furthermore, Clinicaltrials.gov was accessed to ensure the inclusion of all ongoing clinical trials. RESULTS Although Venetoclax showed modest results as a single-agent therapy in AML, venetoclax-based combination therapies? mainly with hypomethylating agents or low-dose cytarabine? yielded significantly positive results. Preliminary results oN the use of venetoclax-based combination therapy with HMA, mainly azacitidine, in unfit high-risk MDS also yielded optimistic results. Identification of mutations for which various drugs have been approved has spurred active investigation of venetoclax in combination trials. CONCLUSION Venetoclax-based combination therapies have been shown to induce rapid responses and increase overall survival in AML patients unfit for intensive chemotherapy. These therapies are also yielding positive preliminary results in high-risk MDS patients in phase I trials. Resistance to venetoclax and drug-related toxicity are two main obstacles that need to be overcome to reap the full benefits of this therapy.
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Affiliation(s)
- Jean El-Cheikh
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
- Department of Internal Medicine, Medical Center, Bone Marrow Transplantation Program, American University of Beirut, P.O. Box 113-6044, Beirut, Lebanon.
| | - Ghassan Bidaoui
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mustafa Saleh
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Nour Moukalled
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Iman Abou Dalle
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Bazarbachi
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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10
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Morin S, Giannotti F, Mamez AC, Pradier A, Masouridi-Levrat S, Simonetta F, Chalandon Y. Real-world experience of sorafenib maintenance after allogeneic hematopoietic stem cell transplantation for FLT3-ITD AML reveals high rates of toxicity-related treatment interruption. Front Oncol 2023; 13:1095870. [PMID: 37007116 PMCID: PMC10050716 DOI: 10.3389/fonc.2023.1095870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 02/27/2023] [Indexed: 03/17/2023] Open
Abstract
Sorafenib significantly improves survival of FLT3-ITD mutated AML patients when used as a post-allogeneic HSCT maintenance. Importantly, clinical trials reported a low rate of toxicities requiring sorafenib discontinuation. The aim of our analysis was to evaluate the real-world experience in patients treated with post-allogeneic HSCT sorafenib maintenance therapy for FLT3-ITD AML with a particular focus on tolerability and toxicity-related treatment interruption. We conducted a single-center retrospective study on 30 FLT3-ITD AML patients undergoing allogeneic HSCT in complete remission between 2017 and 2020 and who received sorafenib maintenance. 26 patients (87%) experienced toxicities leading to dose reduction (n=9) or direct interruption (n=17). Average time on sorafenib was 125 days (range 1-765). Most common toxicities were skin, gastrointestinal, and hematologic. Among patients who had a dose reduction, 4 eventually interrupted the drug and 5 were able to continue. Among patients who interrupted sorafenib because of toxicities, 7 were re-challenged with good tolerance in 3 cases. Overall, 18 patients (60% of the entire cohort) definitively discontinued sorafenib because of toxicities. 14 patients were thereafter switched to midostaurin. Importantly, with a median follow-up of 12 months, the median overall survival was not reached suggesting a positive impact of sorafenib maintenance despite the high rates of treatment interruption. In conclusion, our real-world analysis reveals high rates of toxicity-related interruption of sorafenib maintenance after allogeneic HSCT. Interestingly, our results suggest the feasibility of re-challenging with sorafenib and/or of switching to other maintenance approaches in case of intolerance.
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Affiliation(s)
- Sarah Morin
- Division of Hematology, Department of Oncology, Geneva University Hospitals, Geneva, Switzerland
- *Correspondence: Sarah Morin, ; Yves Chalandon,
| | - Federica Giannotti
- Division of Hematology, Department of Oncology, Geneva University Hospitals, Geneva, Switzerland
| | - Anne-Claire Mamez
- Division of Hematology, Department of Oncology, Geneva University Hospitals, Geneva, Switzerland
| | - Amandine Pradier
- Division of Hematology, Department of Oncology, Geneva University Hospitals, Geneva, Switzerland
| | | | - Federico Simonetta
- Division of Hematology, Department of Oncology, Geneva University Hospitals, Geneva, Switzerland
- Translational Research Center for Oncohematology, Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Yves Chalandon
- Division of Hematology, Department of Oncology, Geneva University Hospitals, Geneva, Switzerland
- Translational Research Center for Oncohematology, Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- *Correspondence: Sarah Morin, ; Yves Chalandon,
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11
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Malard F, Jenq RR. The Microbiome and Its Impact on Allogeneic Hematopoietic Cell Transplantation. Cancer J 2023; 29:75-83. [PMID: 36957977 PMCID: PMC10037670 DOI: 10.1097/ppo.0000000000000645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
ABSTRACT Allogeneic hematopoietic cell transplantation (alloHCT) is a standard curative therapy for a variety of benign and malignant hematological diseases. Previously, patients who underwent alloHCT were at high risk for complications with potentially life-threatening toxicities, including a variety of opportunistic infections as well as acute and chronic manifestations of graft-versus-host disease (GVHD), where the transplanted immune system can produce inflammatory damage to the patient. With recent advances, including newer conditioning regimens, advances in viral and fungal infection prophylaxis, and novel GVHD prophylactic and treatment strategies, improvements in clinical outcomes have steadily improved. One modality with great potential that has yet to be fully realized is targeting the microbiome to further improve clinical outcomes.In recent years, the intestinal microbiota, which includes bacteria, fungi, viruses, and other microbes that reside within the intestinal tract, has become established as a potent modulator of alloHCT outcomes. The composition of intestinal bacteria, in particular, has been found in large multicenter prospective studies to be strongly associated with GVHD, treatment-related mortality, and overall survival. Murine studies have demonstrated a causal relationship between intestinal microbiota injury and aggravated GVHD, and more recently, clinical interventional studies of repleting the intestinal microbiota with fecal microbiota transplantation have emerged as effective therapies for GVHD. How the composition of the intestinal bacterial microbiota, which is often highly variable in alloHCT patients, can modulate GVHD and other outcomes is not fully understood. Recent studies, however, have begun to make substantial headway, including identifying particular bacterial subsets and/or bacterial-derived metabolites that can mediate harm or benefit. Here, the authors review recent studies that have improved our mechanistic understanding of the relationship between the microbiota and alloHCT outcomes, as well as studies that are beginning to establish strategies to modulate the microbiota with the hope of optimizing clinical outcomes.
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12
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Mohty R, El Hamed R, Brissot E, Bazarbachi A, Mohty M. New drugs before, during, and after hematopoietic stem cell transplantation for patients with acute myeloid leukemia. Haematologica 2023; 108:321-341. [PMID: 36722403 PMCID: PMC9890036 DOI: 10.3324/haematol.2022.280798] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 09/02/2022] [Indexed: 02/02/2023] Open
Abstract
The treatment of acute myeloid leukemia (AML) has evolved over the past few years with the advent of next-generation sequencing. Targeted therapies alone or in combination with low-dose or high-intensity chemotherapy have improved the outcome of patients with AML treated in the frontline and relapsed/refractory settings. Despite these advances, allogeneic stem cell transplantation (allo-HCT) remains essential as consolidation therapy following frontline treatment in intermediate-and adverse-risk and relapsed/refractory disease. However, many patients relapse, with limited treatment options, hence the need for post-transplant strategies to mitigate relapse risk. Maintenance therapy following allo-HCT was developed for this specific purpose and can exploit either a direct anti-leukemia effect and/or enhance the bona fide graft-versus-leukemia effect without increasing the risk of graft-versus-host disease. In this paper, we summarize novel therapies for AML before, during, and after allo-HCT and review ongoing studies.
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Affiliation(s)
- Razan Mohty
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL
| | - Rama El Hamed
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Eolia Brissot
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, Paris, France; INSERM, Saint-Antoine Research Center, Paris
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, Paris, France; INSERM, Saint-Antoine Research Center, Paris.
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13
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Babakhanlou R, Ravandi-Kashani F. SOHO State of the Art Updates and Next Questions |The Role of Maintenance Therapy in Acute Myeloid Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:1-7. [PMID: 36456394 DOI: 10.1016/j.clml.2022.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/06/2022] [Accepted: 11/07/2022] [Indexed: 11/13/2022]
Abstract
Acute myeloid leukemia (AML) is an aggressive disease predominantly affecting the elderly population. Although, up to 65% of patients with AML achieve a complete remission with standard induction chemotherapy, the majority of patients will relapse and succumb to the disease. Although maintenance therapy is a component of standard management for various hematological malignancies, such as acute lymphoblastic leukemia (ALL), acute promyelocytic leukemia (APL) or multiple myeloma, past studies investigating the role of maintenance therapy in AML were unable to demonstrate an advantage in overall survival, and therefore, it has not been an established practice in the treatment of AML. For patients, who are not candidates for stem cell transplant, effective AML maintenance therapies are needed in order to reduce the risk of relapse. Over the past decades, many investigators have examined the role of various maintenance strategies in AML; with the intention to prolong remission and overall survival. This review will provide an overview of prior and ongoing approaches and strategies to maintenance therapy for AML.
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Affiliation(s)
- Rodrick Babakhanlou
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX.
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14
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Blackmon A, Aldoss I, Ball BJ. FLT3 Inhibitors as Maintenance Therapy after Allogeneic Stem-Cell Transplantation. Blood Lymphat Cancer 2022; 12:137-147. [PMID: 36097605 PMCID: PMC9464008 DOI: 10.2147/blctt.s281252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/19/2022] [Indexed: 11/23/2022] Open
Abstract
Mutations in the FLT3 gene are associated with poor prognosis in patients with AML, even after consolidation with allogeneic hematopoietic cell transplantation (alloHCT) in first remission. Treatment failure in FLT3-mutated AML is largely driven by excessive risk of relapse compared to other genetic subtypes, including in patients post-alloHCT. As a result, there is substantial interest in studying posttransplant maintenance therapy in FLT3-mutated AML as an approach to optimize disease control and improve long-term outcomes. Clinical trials utilizing posttransplant FLT3 inhibitors, such as sorafenib and midostaurin, have shown feasibility, safety, and encouraging posttransplant outcomes, and there are ongoing studies using newer-generation tyrosine-kinase inhibitors as posttransplant maintenance therapy. Here, we review the toxicities and efficacy of FLT3 inhibitors as posttransplant maintenance, recommendations on the use of FLT3 inhibitors by international consensus guidelines, and highlight key remaining questions.
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Affiliation(s)
- Amanda Blackmon
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Brian J Ball
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
- Correspondence: Brian J Ball, Division of Leukemia, Department of Hematology and HCT, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA, Email
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15
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Hematopoietic Cell Transplantation in the Treatment of Pediatric Acute Myelogenous Leukemia and Myelodysplastic Syndromes: Guidelines from the American Society of Transplantation and Cellular Therapy. Transplant Cell Ther 2022; 28:530-545. [DOI: 10.1016/j.jtct.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/20/2022]
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16
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Aydin S, Passera R, Scaldaferri M, Dellacasa CM, Poggiu M, Cattel F, Zallio F, Brunello L, Giaccone L, Dogliotti I, Busca A. Sorafenib maintenance after hematopoietic stem cell transplantation improves outcome of FLT3-ITD-mutated acute myeloid leukemia. Int J Hematol 2022; 116:883-891. [PMID: 35943684 PMCID: PMC9668769 DOI: 10.1007/s12185-022-03427-4] [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: 04/19/2022] [Revised: 07/20/2022] [Accepted: 07/20/2022] [Indexed: 11/30/2022]
Abstract
In a retrospective analysis, 21 acute myeloid leukemia patients receiving single-agent sorafenib maintenance therapy in complete remission (CR) after hematopoietic stem cell transplantation (HSCT) were compared with a control group of 22 patients without maintenance. Sorafenib was initiated a median of 3 months (IQR: 2.3–3.5) after allogeneic HSCT with a median daily dosage of 400 mg (range: 200–800) orally, and lasted a median of 11.3 months (IQR: 3.3–24.4). No significant increase in graft versus host disease or toxicity was observed. Adverse events were reversible with dose adjustment or temporary discontinuation in 19/19 cases. With a median follow-up of 34.7 months (IQR: 16.9–79.5), sorafenib maintenance significantly improved cumulative incidence of relapse (p = 0.028) as well as overall survival (OS) (p = 0.016), especially in patients undergoing allogeneic HSCT in CR1 (p < 0.001). In conclusion, sorafenib maintenance after allogeneic HSCT is safe and may improve cumulative incidence of relapse and OS in FLT3–ITD-mutated AML.
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Affiliation(s)
- Semra Aydin
- Department of Oncology, Hematology, Immuno-Oncology and Rheumatology, University Hospital of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany. .,Department of Oncology, Hematology, A.O.U. Città Della Salute e Della Scienza, Turin, Italy.
| | - Roberto Passera
- Department of Medical Sciences, A.O.U. Città Della Salute e Della Scienza, University of Torino, Turin, Italy
| | - Matilde Scaldaferri
- S.C. Clinical Pharmacology, A.O.U. Città Della Salute e Della Scienza, Turin, Italy
| | - Chiara Maria Dellacasa
- Department of Oncology, SSD Stem Cell Transplant Center, A.O.U. Città Della Salute e Della Scienza, Turin, Italy
| | - Marco Poggiu
- S.C. Clinical Pharmacology, A.O.U. Città Della Salute e Della Scienza, Turin, Italy
| | - Francesco Cattel
- S.C. Clinical Pharmacology, A.O.U. Città Della Salute e Della Scienza, Turin, Italy
| | - Francesco Zallio
- Department of Hematology, SS Antonio & Biagio and C. Arrigo Hospital, Alessandria, Italy
| | - Lucia Brunello
- Department of Hematology, SS Antonio & Biagio and C. Arrigo Hospital, Alessandria, Italy
| | - Luisa Giaccone
- Department of Oncology, SSD Stem Cell Transplant Center, A.O.U. Città Della Salute e Della Scienza, Turin, Italy
| | - Irene Dogliotti
- Department of Oncology, SSD Stem Cell Transplant Center, A.O.U. Città Della Salute e Della Scienza, Turin, Italy
| | - Alessandro Busca
- Department of Oncology, SSD Stem Cell Transplant Center, A.O.U. Città Della Salute e Della Scienza, Turin, Italy
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17
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Abstract
Hematopoietic stem cell transplantation (HSCT) is a highly effective and unique medical procedure for the treatment of most hematological malignancies. The first allogeneic transplantation was performed by E. Donnall Thomas in 1957. Since then, the field has evolved and expanded worldwide. The first successful allogenic HSCT (allo-HSCT) in China was conducted in 1981. Although the development of allo-HSCT in China lagged, China has since made considerable contributions to the process of HSCT worldwide, with more than 10,000 HSCTs performed annually. In particular, haploid HSCT (haplo-HSCT) technology represented in the Beijing Protocol has demonstrated similar efficacy to human leukocyte antigen-matched HSCT and has gradually become the pre-dominant choice for allo-HSCT in China. Currently, the number of haplo-HSCT procedures exceeds 5000 per year, and the Beijing Protocol has been greatly improved by implementing updated individualized strategies for controlling complications, relapse, and infection management. In addition, innovative haplo-HSCT technologies developed by different medical transplantation centers, such as Soochow, Zhejiang, Fujian, Chongqing, and Anhui, have emerged, providing inspiration for the refinement of global practice. This review will focus on the current activity in this field and highlight important trends that are vital in China's allo-HSCT process, examining the current viewpoint and future directions.
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18
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Abou Dalle I, El Cheikh J, Bazarbachi A. Pharmacologic Strategies for Post-Transplant Maintenance in Acute Myeloid Leukemia: It Is Time to Consider! Cancers (Basel) 2022; 14:1490. [PMID: 35326641 PMCID: PMC8946578 DOI: 10.3390/cancers14061490] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/16/2022] [Accepted: 01/16/2022] [Indexed: 11/16/2022] Open
Abstract
Patients with high-risk acute myeloid leukemia are offered allogeneic hematopoietic cell transplantation (allo-HCT) in first remission to reduce risk of relapse. However, disease recurrence remains the major reason of allo-HCT failure, occurring in around 35-45% of patients, and leading to dismal outcomes. Strategies to reduce the risk of relapse are greatly needed, especially in the early post-transplant phase where the graft-versus-leukemia (GVL) effect is not yet activated. Some practices include the use of myeloablative conditioning regimens, close monitoring of measurable residual disease and donor chimerism, rapid tapering of immunosuppression, and implementation of pre-emptive strategies as the use of donor lymphocyte infusion. However, it's time to consider prophylactic pharmacologic interventions post allo-HCT that aim at maintaining leukemic clones under control by both direct cytotoxic activity and by enhancing the GVL effect. In this current review, available data on drugs targeting epigenetic pathways like azacitidine, or actionable mutations like FLT3 and IDH1/2 inhibitors used as maintenance post allo-HCT, will be discussed.
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Affiliation(s)
| | | | - Ali Bazarbachi
- Hematology-Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Beirut 1107 2020, Lebanon; (I.A.D.); (J.E.C.)
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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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Ye Y, Yang L, Yuan X, Huang H, Luo Y. Optimization of Donor Lymphocyte Infusion for AML Relapse After Allo-HCT in the Era of New Drugs and Cell Engineering. Front Oncol 2022; 11:790299. [PMID: 35155192 PMCID: PMC8829143 DOI: 10.3389/fonc.2021.790299] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/28/2021] [Indexed: 12/19/2022] Open
Abstract
Donor lymphocyte infusion (DLI) is a key strategy for the treatment of AML relapse after allogeneic hematopoietic cell transplantation (allo-HCT) and has been used for either prophylactic, pre-emptive, or therapeutic purposes. However, the prognosis of these patients remains dismal even after DLI infusion (2-year overall survival, ~25%), and the efficacy is achieved at the cost of toxicities such as graft-versus-host (GVH) disease. Attempts to optimize DLI efficacy and safety, such as dose/timing modification and the use of cytoreduction, before DLI have been performed previously. Recently, a great number of novel targeted and immunomodulatory agents have emerged. Some of them, such as hypomethylating agents, FLT3 and Bcl-2 inhibitors, have been used in combination with DLI, aiming to enhance the graft-versus-leukemia effect. Moreover, manipulation of the DLI graft through cell selection (e.g., donor NK cells) or cell engineering (donor CAR-T cells) has shown potentially superior anti-tumor effects but less GVH effect than conventional DLI in clinical trials. This review summarizes the recent advances on the use of DLI for the prophylaxis/treatment of AML relapse and discusses future strategies which may further improve the treatment efficacy.
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Affiliation(s)
- Yishan Ye
- First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China
| | - Luxin Yang
- First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China
| | - Xiaolin Yuan
- First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China
| | - He Huang
- First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China
| | - Yi Luo
- First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China
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21
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Abou Dalle I, Atoui A, Bazarbachi A. The Elephant in The Room: AML Relapse Post Allogeneic Hematopoietic Cell Transplantation. Front Oncol 2022; 11:793274. [PMID: 35047405 PMCID: PMC8761806 DOI: 10.3389/fonc.2021.793274] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 12/09/2021] [Indexed: 12/19/2022] Open
Abstract
Relapsed acute myeloid leukemia (AML) following allogeneic hematopoietic cell transplantation (allo-HCT) is an unfavorable event associated with a poor prognosis, particularly for patients with early relapses. It usually arises from resistant leukemic blasts that escaped both preparative chemotherapy regimen and the graft-versus-leukemia (GVL) effect. Independent from the choice of salvage treatment, only minority of patients can achieve durable remissions. In recent years, better understanding of the disease relapse biology post allo-HCT allowed the application of newer strategies that could induce higher rates of remission, and potential longer survival. Those strategies aim at optimizing drugs that have a direct anti-leukemia activity by targeting different oncogenic mutations, metabolism pathways or surface antigens, and concurrently enhancing the immune microenvironment to promote GVL effect. This review discusses the current treatment landscape of AML relapse post allo-HCT.
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Affiliation(s)
- Iman Abou Dalle
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Atoui
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Bazarbachi
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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22
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Al Hamed R, Labopin M, Daguindau E, Niittyvuopio R, Huynh A, Socié G, Srour M, Henri Bourhis J, Kröger N, Tholouli E, Choi G, Poiré X, Martin H, Rubio MT, Jindra P, Blaise D, Beelen D, Labussière-Wallet H, Nagler A, Bazarbachi A, Mohty M. Measurable residual disease, FLT3-ITD mutation, and disease status have independent prognostic influence on outcome of allogeneic stem cell transplantation in NPM1-mutated acute myeloid leukemia. Cancer Med 2022; 11:1068-1080. [PMID: 35048553 PMCID: PMC8855908 DOI: 10.1002/cam4.4218] [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: 07/09/2021] [Revised: 07/24/2021] [Accepted: 08/02/2021] [Indexed: 11/12/2022] Open
Abstract
Nucleophosmin‐1 (NPM1) mutations in acute myeloid leukemia (AML) confer a survival advantage in the absence of FLT3‐internal tandem duplication (FLT3‐ITD). Here, we investigated the main predictors of outcome after allogeneic hematopoietic stem cell transplantation (allo‐HCT). We identified 1572 adult (age ≥ 18 year) patients with NPM1‐mutated AML in first complete remission (CR1:78%) or second complete remission (CR2:22%) who were transplanted from matched sibling donors (30.8%) or unrelated donors (57.4%) between 2007 and 2019 at EBMT participating centers. Median follow‐up for survivors was 23.7 months. FLT3‐ITD was present in 69.3% of patients and 39.2% had detectable minimal/measurable residual disease (MRD) at transplant. In multivariate analysis, relapse incidence (RI) and leukemia‐free survival (LFS) were negatively affected by concomitant FLT3‐ITD mutation (HR 1.66 p = 0.0001, and HR 1.53, p < 0.0001, respectively), MRD positivity at transplant (HR 2.18, p < 10−5 and HR 1.71, p < 10−5, respectively), and transplant in CR2 (HR 1.36, p = 0.026, and HR 1.26, p = 0.033, respectively), but positively affected by Karnofsky score ≥90 (HR 0.74, p = 0.012, and HR 0.7, p = 0.0002, respectively). Overall survival (OS) was also negatively influenced by concomitant FLT3‐ITD (HR 1.6, p = 0.0001), MRD positivity at transplant (HR 1.61, p < 10−5), and older age (HR 1.22 per 10 years, p < 0.0001), but positively affected by matched sibling donor (unrelated donor: HR 1.35, p = 0.012; haploidentical donor: HR 1.45, p = 0.037) and Karnofsky score ≥90 (HR 0.73, p = 0.004). These results highlight the independent and significant role of FLT3‐ITD, MRD status, and disease status on posttransplant outcomes in patients with NPM1‐mutated AML allowing physicians to identify patients at risk of relapse who may benefit from posttransplant prophylactic interventions.
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Affiliation(s)
- Rama Al Hamed
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Myriam Labopin
- Department of Hematology, EBMT Paris Office, CEREST-TC, Saint Antoine Hospital, Paris, France
| | | | - Riitta Niittyvuopio
- HUCH Comprehensive Cancer Center, Stem Cell Transplantation Unit, Helsinki, Finland
| | - Anne Huynh
- CHU - Institut Universitaire du Cancer Toulouse, Oncopole, Toulouse, France
| | - Gerard Socié
- Department of Hematology - BMT, Hôpital St. Louis, Paris, France
| | - Micha Srour
- CHU de Lille, Université de Lille, Lille, France
| | - Jean Henri Bourhis
- Department of Hematology, Gustave Roussy Cancer Campus, BMT Service, Villejuif, France
| | - Nicolaus Kröger
- University Hospital Eppendorf, Bone Marrow Transplantation Centre, Hamburg, Germany
| | - Eleni Tholouli
- Clinica Haematology Department, Manchester Royal Infirmary, Manchester, UK
| | - Goda Choi
- Department of Hematology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Xavier Poiré
- Department of Haematology, Cliniques Universitaires St. Luc, Brussels, Belgium
| | - Hans Martin
- Goethe-Universitaet, Medizinische Klinik II, Hämatologie, Medizinische Onkologie, Frankfurt, Germany
| | | | - Pavel Jindra
- Department of Hematology/Oncology, Charles University Hospital, Pilsen, Czech Republic
| | - Didier Blaise
- Programme de Transplantation & Therapie Cellulaire, Centre de Recherche en Cancérologie de Marseille, Marseille, France
| | - Dietrich Beelen
- Department of Bone Marrow Transplantation, University Hospital, Essen, Germany
| | | | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Ali Bazarbachi
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Mohamad Mohty
- Department of Hematology, EBMT Paris Office, CEREST-TC, Saint Antoine Hospital, Paris, France
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23
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FLT3-inhibitor therapy for prevention and treatment of relapse after allogeneic hematopoietic cell transplantation. Int J Hematol 2022; 116:341-350. [PMID: 35460465 PMCID: PMC9392688 DOI: 10.1007/s12185-022-03352-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 02/05/2023]
Abstract
The curative potential of allogeneic hematopoietic cell transplantation (allo-HCT) for acute myeloid leukemia (AML) relies on the graft-versus-leukemia (GVL)-effect. Relapse after allo-HCT occurs in a considerable proportion of patients, and has a dismal prognosis with very limited curative potential, especially for patients with FLT-ITD-mutated AML. Since the first description of sorafenib for treatment of FLT3-ITD-mutated AML, several clinical trials have tried to determine the efficacy of FLT3 inhibitors for preventing and treating AML relapse after allo-HSCT, but many questions regarding differences among compounds and mechanisms of action remain unanswered. This review provides an overview on the established and evolving use of FLT3 inhibitors to prevent or treat relapse of AML in the context of allo-HCT, focusing on the recently discovered immunogenic potential of some FLT3 inhibitors and addressing the possible mechanisms of leukemia drug-escape.
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24
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Austin AE, Byrne M. Detecting and preventing post-hematopoietic cell transplant relapse in AML. Curr Opin Hematol 2021; 28:380-388. [PMID: 34534984 DOI: 10.1097/moh.0000000000000686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Relapsed disease is the primary cause of mortality for acute myeloid leukemia (AML) patients after allogeneic hematopoietic cell transplantation (HCT). This review outlines the most recent advances in the detection and prevention of AML relapse following allogeneic HCT. RECENT FINDINGS Conventional methods for predicting post-HCT relapse rely on the molecular and cytogenetics features present at diagnosis. These methods are slow to reflect a growing understanding of the molecular heterogeneity of AML and impact of new therapies on post-HCT outcomes. The use of measurable residual disease (MRD) techniques, including multiparameter flow cytometry and molecular testing, may improve the prognostic ability of these models and should be incorporated into post-HCT surveillance whenever possible.In the post-HCT setting, FLT3 inhibitor maintenance data indicate that effective therapies can improve post-HCT outcomes. Maintenance data with DNA methyltransferase inhibitor monotherapy is less compelling and outcomes may improve with combinations. Early interventions directed at preemptive management of MRD may further improve post-HCT outcomes. SUMMARY Post-HCT AML relapse prevention has evolved to include more sensitive measures of disease detection and novel therapies that may improve outcomes of poor-risk AML patients. Additional work is needed to maintain this progress.
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Affiliation(s)
| | - Michael Byrne
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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25
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Gorin NC. History and Development of Autologous Stem Cell Transplantation for Acute Myeloid Leukemia. Clin Hematol Int 2021; 3:83-95. [PMID: 34820613 PMCID: PMC8486970 DOI: 10.2991/chi.k.210703.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/03/2021] [Indexed: 11/23/2022] Open
Abstract
This review describes the development of cryopreservation, the birth of autologous stem cell transplantation (ASCT) and its past and present use to consolidate adult patients with acute myelogenous leukemia (AML). It summarizes the first autografts in patients in relapse, the experience of autografting in complete remission (CR), using bone marrow unpurged or purged in vitro with cyclophosphamide-derivatives, and the important shift to peripheral blood stem cells. The review also discusses the results of recent studies in favor of the use of ASCT to consolidate good- and intermediate-risk patients who reach CR with no detectable minimal residual disease, and those which support the inclusion of maintenance therapy post autograft with hypomethylating agents, anti-BCL-2, and, possibly, in the future, anti AML chimeric antigen receptor-T cells. Carefully applied to well-selected patients, ASCT may regain interest, because of its simplicity, its reduced toxicity, lower non-relapse mortality and better quality of life.
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Affiliation(s)
- Norbert Claude Gorin
- Department of Hematology and Cell Therapy, and EBMT Global Committee, Hopital Saint-Antoine APHP, Paris Sorbonne University, Paris, France
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26
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Wei Y, Xiong X, Li X, Lu W, He X, Jin X, Sun R, Lyu H, Yuan T, Sun T, Zhao M. Low-dose decitabine plus venetoclax is safe and effective as post-transplant maintenance therapy for high-risk acute myeloid leukemia and myelodysplastic syndrome. Cancer Sci 2021; 112:3636-3644. [PMID: 34185931 PMCID: PMC8409404 DOI: 10.1111/cas.15048] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 12/25/2022] Open
Abstract
Acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) are usually associated with poor outcomes, especially in high-risk AML/MDS. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the only curative option for patients suffering from high-risk AML/MDS. However, many patients relapse after allo-HSCT. Novel therapy to prevent relapse is urgently needed. Both the BCL-2 inhibitor venetoclax (VEN) and the hypomethylating agent decitabine (DEC) possess significant antitumor activity effects against AML/MDS. Administration of DEC has been shown to ameliorate graft-versus-host disease (GVHD) and boost the graft-versus-leukemia (GVL) effect post-transplantation. We therefore conducted a prospective study (ChiCTR1900025374) to examine the tolerability and efficacy of a maintenance therapy of low-dose decitabine (LDEC) plus VEN to prevent relapse after allo-HSCT for high-risk AML/MDS patients. Twenty patients with high-risk AML (n = 17) or high-risk MDS (n = 3) post-transplantation were recruited. Approximately day 100 post-transplantation, all patients received LDEC (15 mg/m2 for 3 d) followed by VEN (200 mg) on d 1-21. The cycle interval was 2 mo, and there was 10 cycles. The primary end points of this study were rates of overall survival (OS) and event-free survival (EFS). The secondary endpoints included adverse events (AEs), cumulative incidence of relapse (CIR), nonrelapse mortality (NRM), incidences of acute GVHD (aGVHD) and chronic GVHD (cGVHD), and incidences of viral infection after allo-HSCT. Survival outcomes were assessed using Kaplan-Meier analysis. The median follow-up was 598 (149-1072) d. Two patients relapsed, 1 died, and 1 is still alive after the second transplant. The 2-y OS and EFS rates were 85.2% and 84.7%, respectively. The median 2-y EFS time was 525 (149-1072) d, and 17 patients still had EFS and were alive at the time of this writing. The most common AEs were neutropenia, anemia, thrombocytopenia, neutropenic fever, and fatigue. Grade 2 or 3 AEs were observed in 35% (7/20) and 20% (4/20) of the patients, respectively. No grade >3 AEs were observed. aGVHD (any grade) and cGVHD (limited or extensive) occurred in 55% and 20% of patients, respectively. We conclude that LDEC + VEN can be administered safely after allo-HSCT with no evidence of an increased incidence of GVHD, and this combination decreases the relapse rate in high-risk AML/MDS patients. This novel maintenance therapy may be a promising way to prevent relapse in high-risk AML/MDS patients.
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Affiliation(s)
- Yunxiong Wei
- The First Central Clinical College of Tianjin Medical UniversityTianjinChina
| | - Xia Xiong
- The First Central Clinical College of Tianjin Medical UniversityTianjinChina
| | - Xin Li
- The First Central Clinical College of Tianjin Medical UniversityTianjinChina
| | - Wenyi Lu
- Department of HematologyTianjin First Central HospitalTianjinChina
| | - Xiaoyuan He
- Department of HematologyTianjin First Central HospitalTianjinChina
| | - Xin Jin
- Nankai University School of MedicineTianjinChina
| | - Rui Sun
- Nankai University School of MedicineTianjinChina
| | - Hairong Lyu
- Department of HematologyTianjin First Central HospitalTianjinChina
| | - Ting Yuan
- Department of HematologyTianjin First Central HospitalTianjinChina
| | - Tongtong Sun
- Department of RadiologyFirst Central Clinical CollegeTianjin Medical UniversityTianjinChina
| | - Mingfeng Zhao
- Department of HematologyTianjin First Central HospitalTianjinChina
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27
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Maintenance therapies in acute myeloid leukemia: the renaissance of an old therapeutic concept. Curr Opin Oncol 2021; 33:658-669. [PMID: 34341323 DOI: 10.1097/cco.0000000000000778] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Disease relapse remains the major cause of death in patients with acute myeloid leukemia (AML) and is driven by the persistence of leukemic cells following induction chemotherapy or allogeneic hematopoietic cell transplant (allo-HCT). Maintenance therapies to extend the duration of remission and to improve survival have been proposed for several years with mixed results but have experienced a renaissance recently. RECENT FINDINGS The oral hypomethylating agent CC-486 has been the first agent to show an overall survival (OS) benefit compared with observation in AML patients in remission following intensive chemotherapy who are not proceeding to allo-HCT. In the realm of postallo-HCT maintenance therapy, the FLT3 inhibitor sorafenib has yielded superior results in terms of OS and relapse-free survival in randomized trials compared with observation. Several open questions remain regarding patient selection, timing, duration and safety of maintenance therapies. Various targeted agents are currently tested in clinical trials and could potentially enable an even more individualized therapeutic approach. SUMMARY Maintenance therapies following intensive chemotherapy or allo-HCT offer a new therapeutic paradigm for an increasing number of AML patients and have been shown to result in an OS benefit in selected patients.
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28
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Griffin JD, Song Y, Yang H, Freimark J, Shah MV. Post-transplant maintenance therapy in patients with FLT3-mutated acute myeloid leukemia: Real-world treatment patterns and outcomes. Eur J Haematol 2021; 107:553-565. [PMID: 34289175 PMCID: PMC9292256 DOI: 10.1111/ejh.13692] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 11/29/2022]
Abstract
Objectives Maintenance therapy is one strategy to prolong survival in patients with acute myeloid leukemia (AML) following hematopoietic stem cell transplantation (HSCT). We evaluated real‐world treatment patterns and outcomes in patients with newly diagnosed FLT3‐mutated AML receiving HSCT after complete remission with first‐line chemotherapy. Methods A global, retrospective chart review to evaluate maintenance therapy and outcomes in patients with FLT3‐mutated AML after HSCT. Results Data from 1208 charts from eight countries showed that most patients (n = 765 [63.3%]) received no maintenance therapy after HSCT, 219 (18.1%) received FLT3 inhibitor maintenance therapy, and 224 (18.5%) received other types of maintenance therapy. No systematic differences were observed in healthcare resource utilization across the three groups. Clinical benefit was observed with FLT3 inhibitor maintenance over no maintenance therapy with relapse‐free survival (adjusted hazard ratio [HR] 0.57 [95% CI 0.34‐0.94], P < .05). FLT3 inhibitor and other maintenance also demonstrated overall survival benefit over no maintenance (adjusted HR 0.50 [95% CI 0.28‐0.89] and 0.46 [95% CI 0.23‐0.91], respectively; both P < .05). Conclusions Real‐world maintenance therapies after HSCT in patients with FLT3‐mutated AML were heterogeneous. While overall use of healthcare resources was not significantly increased in patients receiving maintenance therapy versus those who did not, clinical outcomes were improved.
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Affiliation(s)
| | - Yan Song
- Analysis Group, Inc., Boston, Massachusetts, USA
| | - Hongbo Yang
- Analysis Group, Inc., Boston, Massachusetts, USA
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29
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Bazzell BG, Marini BL, Benitez LL, Bixby D, Burke P, Pettit K, Perissinotti AJ. Real world use of FLT3 inhibitors for treatment of FLT3+ acute myeloid leukemia (AML): A single center, propensity-score matched, retrospective cohort study. J Oncol Pharm Pract 2021; 28:1315-1325. [PMID: 34074182 DOI: 10.1177/10781552211020815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients diagnosed with acute myeloid leukemia with a FLT3 mutation (FLT3+ AML) have historically had poor outcomes. While the addition of the FLT3 inhibitors to induction therapy has been shown to improve survival outcomes in FLT3+ AML, interactions and overlapping toxicities between FLT3 inhibitors and standard of care medications used during induction therapy (e.g. azole antifungals, anthracyclines) and logistical barriers have complicated their use. To avoid these concerns, our institution has opted to defer initiation of midostaurin until after completion of induction therapy. However, to our knowledge no study confirming the effectiveness of this strategy for real world FLT3 inhibitor use has been published. METHODS We performed a single center, propensity-score matched, retrospective cohort study characterizing efficacy and safety of our strategy for use of FLT3 inhibitors in the treatment of FLT3+ AML. The primary outcome was median event-free survival (EFS), while secondary endpoints included median overall survival (OS), overall response rate (ORR), 30-day mortality, duration of neutropenia, duration of thrombocytopenia, consolidation cycle delays, documented infections, and all-cause hospital readmission. RESULTS A total of 83 FLT3+ AML patients treated with intensive induction therapy were included in the study, of whom 48 were propensity-score matched and analyzed. Baseline characteristics were similar between the patients who received a FLT3 inhibitor after induction therapy and the historical control arm. Median EFS was not significantly different but compared favorably between the FLT3 inhibitor cohort and historical controls (not reached vs 8 months, p = 0.343) with 18-month EFS of 54% and 43% for the two cohorts, respectively. Similarly, no significant differences were noted with regard to median OS (not reached vs 28.7 months, p = 0.752), ORR (79.2% vs 79.2%), or safety outcomes between groups. CONCLUSION Compared to historical controls, addition of a FLT3 inhibitor to intensive chemotherapy post-induction may improve EFS or OS in a real world patient cohort with longer follow-up and a larger sample size. The omission of midostaurin in induction allowed for the use of an azole antifungal and the intensification of anthracycline dose may have contributed to high remission rates in both groups.
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Affiliation(s)
- Brian G Bazzell
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine, Ann Arbor, MI, USA.,College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Bernard L Marini
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine, Ann Arbor, MI, USA.,College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Lydia L Benitez
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine, Ann Arbor, MI, USA.,College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Dale Bixby
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, Michigan Medicine, Ann Arbor, MI, USA
| | - Patrick Burke
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, Michigan Medicine, Ann Arbor, MI, USA
| | - Kristen Pettit
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, Michigan Medicine, Ann Arbor, MI, USA
| | - Anthony J Perissinotti
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine, Ann Arbor, MI, USA.,College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
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30
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Allogeneic stem cell transplantation for high-risk acute leukemia and maintenance therapy: no time to waste. Blood Adv 2021; 4:3200-3204. [PMID: 32663296 DOI: 10.1182/bloodadvances.2019000388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 06/10/2020] [Indexed: 01/01/2023] Open
Abstract
This article has a companion Counterpoint by Soiffer.
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31
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Shimony S, Yeshurun M, Wolach O, Ram R, Rozovski U, Shargian L, Zukerman T, Amit O, Bar-On Y, Krayem B, Avni B, Peretz G, Raanani P, Pasvolsky O. Post-transplantation maintenance with sorafenib or midostaurin for FLT3 positive AML patients - a multicenter retrospective observational study. Leuk Lymphoma 2021; 62:2475-2481. [PMID: 33879026 DOI: 10.1080/10428194.2021.1913145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The role of post allogeneic stem-cell transplantation (AlloSCT) FLT3 inhibition for acute myeloid leukemia in the real-world setting is unclear, especially in the era of widespread pre-transplant use of tyrosine kinase inhibitors (TKIs). In a multicenter nationwide study, we assessed 41 patients who were treated with post-transplant TKIs (sorafenib, n = 23, midostaurin, n = 18). The majority also received TKIs pre-transplant (n = 32, 79%). After a median follow up of 10 months post-transplant (range 3-53.6), 29 patients (71%) were alive and in complete remission. Similar results were seen in a subgroup analysis of pre-transplant TKI recipients (78%). In Univariate analysis, HCT-CI score < 4 and Type of TKI (sorafenib versus midostaurin) predicted longer overall survival. Seventeen patients (41%) suffered from side effects and seven patients (17%) stopped TKI therapy due to adverse events. Overall, our data suggest that post-transplant use of TKIs is safe and effective in an era of their widespread use prior to AlloSCT.
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Affiliation(s)
- Shai Shimony
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Yeshurun
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofir Wolach
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Ram
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Uri Rozovski
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liat Shargian
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tsila Zukerman
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, and Rappaport Faculty of Medicine - Technion, Haifa, Israel
| | - Odelia Amit
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yael Bar-On
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Baher Krayem
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, and Rappaport Faculty of Medicine - Technion, Haifa, Israel
| | - Batya Avni
- Institute of Hematology, Hadassah Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Galit Peretz
- Department of Hematology and Bone Marrow Transplantation, Soroka Medical center and Faculty of Medicine, Beer Sheva, Israel
| | - Pia Raanani
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oren Pasvolsky
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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32
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Assi R, Masri N, Abou Dalle I, El-Cheikh J, Bazarbachi A. Post-Transplant Maintenance Therapy for Patients with Acute Myeloid Leukemia: Current Approaches and the Need for More Trials. J Blood Med 2021; 12:21-32. [PMID: 33531851 PMCID: PMC7847363 DOI: 10.2147/jbm.s270015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/05/2021] [Indexed: 12/18/2022] Open
Abstract
Relapse rates following allogeneic stem cell transplantation for acute myeloid leukemia remain unacceptably high and a major cause of death. Maintenance therapies post-transplant administered either to patients with impending relapse or at high risk of relapse could present a strategy to improve survival and overall outcomes. With the increasing use of molecular and genomic characterization of the disease, more novel therapies became available as maintenance strategies. These options were, however, hindered by excessive toxicities, mostly hematologic, especially with the use of myeloablative conditioning regimens. Several key questions have also emerged including the efficacy of these therapies, the duration of maintenance, as well as the potential modulation of the graft and the immune microenvironment. These issues are further complicated by the paucity of well-designed prospective randomized clinical trials evaluating these agents. Future directions in this field should include better risk stratification and patient selection based on assays of minimal residual disease, as well as the incorporation of novel targets and pathways of leukemogenesis. In this article, we highlight the current evidence behind the use of post-transplant maintenance therapy, the optimal patient and disease selection, as well as the challenges faced by these strategies in an area that remains quite controversial. We will focus on therapies targeting leukemia stem cells that directly or indirectly modulate the allografted immune microenvironment and augment the graft-versus-leukemia impact.
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Affiliation(s)
- Rita Assi
- Division of Hematology-Oncology, Lebanese American University and Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Nohad Masri
- Division of Hematology-Oncology, Lebanese American University and Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Iman Abou Dalle
- Division of Hematology-Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jean El-Cheikh
- Division of Hematology-Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Bazarbachi
- Division of Hematology-Oncology, American University of Beirut Medical Center, Beirut, Lebanon
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33
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Xuan L, Liu Q. Maintenance therapy in acute myeloid leukemia after allogeneic hematopoietic stem cell transplantation. J Hematol Oncol 2021; 14:4. [PMID: 33407700 PMCID: PMC7786934 DOI: 10.1186/s13045-020-01017-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 12/02/2020] [Indexed: 02/07/2023] Open
Abstract
Relapse remains the main cause of treatment failure in acute myeloid leukemia (AML) undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT). Emerging evidence has demonstrated that AML patients might benefit from maintenance therapy post-transplantation, especially for high-risk AML patients. In this mini-review, we will summarize targeted drugs, such as hypomethylating agents, FLT3 inhibitors and isocitrate dehydrogenase inhibitors, as maintenance therapy post-transplantation in AML patients undergoing allo-HSCT.
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Affiliation(s)
- Li Xuan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
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Poiani M, Labopin M, Battipaglia G, Beelen DW, Tischer J, Finke J, Brecht A, Forcade E, Ganser A, Passweg JR, Labussiere‐Wallet H, Yakoub‐Agha I, Schäfer‐Eckart K, Kroeger N, Guffroy B, Ruggeri A, Esteve J, Nagler A, Mohty M. The impact of cytogenetic risk on the outcomes of allogeneic hematopoietic cell transplantation in patients with relapsed/refractory acute myeloid leukemia: On behalf of the acute leukemia working party (ALWP) of the European group for blood and marrow transplantation (EBMT). Am J Hematol 2021; 96:40-50. [PMID: 32944990 DOI: 10.1002/ajh.26000] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/25/2020] [Accepted: 09/14/2020] [Indexed: 11/07/2022]
Abstract
Karyotypic analysis at time of diagnosis has an important value in determining initial response to treatment, remission duration and overall survival (OS) in acute myeloid leukemia (AML). Less is known about its value before allogeneic hematopoietic cell transplantation (allo-HCT) in patients transplanted with active disease, either relapsed or primary refractory (Rel-Ref) AML. We explored the impact of cytogenetic risk (stratification according to MRC-UK) in 2089 patients with either Ref (n = 972) or Rel AML (n = 1117) transplanted during the period 2000-2017. Overall, 154 patients had a favorable risk, 1283 had an intermediate risk and 652 had an adverse cytogenetic risk. Median follow-up was 49 months. Compared to the favorable risk group, intermediate and adverse risk patients were associated with worse leukemia-free survival and OS and also with a higher incidence of relapse. In a subgroup analysis of patients in the intermediate risk group harboring Fms-like tyrosine kinase 3-internal tandem duplication (FLT3-ITD), this remained an important prognostic factor, being associated with worse outcomes. When analyzing patients according to the intensity of the conditioning regimen, no differences were observed for the main transplant outcomes. In conclusion, in patients diagnosed with AML and transplanted with active disease, karyotype remains an important prognostic factor, allowing splitting patients into different risk groups according to their cytogenetics. Similarly, FLT3-ITD mutation also remains a negative prognostic factor in this population.
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Affiliation(s)
- Monica Poiani
- Hematology Department, Hôpital Saint Antoine Service d'Hématologie et Thérapie Cellulaire Paris France
- Clinica di Ematologia, AOU Ospedali Riuniti Ancona Italy
| | - Myriam Labopin
- Hematology Department, Hôpital Saint Antoine Service d'Hématologie et Thérapie Cellulaire Paris France
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Centre de Recherche Saint‐Antoine (CRSA) Paris France
- EBMT Paris study office Paris France
| | - Giorgia Battipaglia
- Hematology Department, Hôpital Saint Antoine Service d'Hématologie et Thérapie Cellulaire Paris France
- Federico II University, Hematology Department Naples Italy
| | - Dietrich W. Beelen
- Department of Bone Marrow Transplantation, West German Cancer Center University Hospital of Essen Essen Germany
| | | | - Jürgen Finke
- Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine University of Freiburg Freiburg Germany
| | - Arne Brecht
- Deutsche Klinik fuer Diagnostik, KMT Zentrum Wiesbaden Germany
| | | | - Arnold Ganser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation Hannover Medical School Hannover Germany
| | | | | | | | | | - Nicolaus Kroeger
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | | | | | - Jordi Esteve
- Hospital Clinic, Dept. of Hematology, IDIBAPS Barcelona Spain
| | - Arnon Nagler
- EBMT Paris study office Paris France
- Hematology Division and Bone Marrow Transplantation Chaim Sheba Medical Center Tel‐Hashomer Israel
| | - Mohamad Mohty
- Hematology Department, Hôpital Saint Antoine Service d'Hématologie et Thérapie Cellulaire Paris France
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Centre de Recherche Saint‐Antoine (CRSA) Paris France
- EBMT Paris study office Paris France
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35
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Relapse of acute myeloid leukemia after allogeneic hematopoietic cell transplantation: clinical features and outcomes. Bone Marrow Transplant 2020; 56:1126-1133. [PMID: 33268829 DOI: 10.1038/s41409-020-01163-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/10/2020] [Accepted: 11/17/2020] [Indexed: 12/13/2022]
Abstract
Posttransplant relapse represents the greatest obstacle to the success of allogeneic hematopoietic cell transplantation (HCT) for patients with acute myeloid leukemia (AML). This study investigated clinical features and outcomes of posttransplant relapse of AML based on data for 1265 patients with AML suffering relapse after allogeneic HCT conducted during complete remission (CR). Relapse occurred at a median of 6.1 months. The incidence rate of relapse peaked at 29.0 per 100 patient-years during the first 3-6 months period post transplant, after which the rate declined over time, and after 3 years remained consistently at less than 1 per 100 patient-years. The probability of overall survival (OS) after posttransplant relapse was 19% at 2 years, with 68% of deaths being attributed to leukemia. The interval from transplantation to relapse was identified as the strongest indicator for OS. Donor lymphocyte infusion (DLI) and second allogeneic HCT (HCT2) were administered to 152 (12%) and 481 (38%) patients, respectively. Landmark analyses showed some signs of survival benefit when these procedures were performed during CR, but no benefit was gained when performed during non-CR. Our findings clarify clinical features of posttransplant relapse of AML, and indicate the urgent need for developing effective bridging to cellular therapies.
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Antar AI, Otrock ZK, Abou Dalle I, El-Cheikh J, Bazarbachi A. Pharmacologic Therapies to Prevent Relapse of Acute Myeloid Leukemia After Allogeneic Hematopoietic Stem Cell Transplantation. Front Oncol 2020; 10:596134. [PMID: 33224890 PMCID: PMC7667262 DOI: 10.3389/fonc.2020.596134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/09/2020] [Indexed: 12/29/2022] Open
Abstract
Relapse is the main cause of mortality in patients with acute myeloid leukemia (AML) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Adverse cytogenetic or molecular risk factors, as well as refractory disease or persistent measurable residual disease (MRD) at the time of transplantation are associated with an increased risk of recurrence. Salvage therapy for AML relapse after allo-HSCT is often limited to chemotherapy, donor lymphocyte infusions and/or second transplants and is rarely successful. Effective post-transplant preventive intervention in high risk AML may be crucial. The most frequent and promising approach is the use of post-transplant maintenance with hypomethylating agents or with FLT3 tyrosine kinase inhibitors when the target is present. Moreover, IDH1/IDH2 inhibitors and BCL-2 inhibitors in combination with other strategies are promising approaches in the maintenance setting. Here we summarize the current knowledge about the preemptive and prophylactic use of pharmacologic agents after allo-HSCT to prevent relapse of AML.
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Affiliation(s)
- Ahmad I. Antar
- Almoosa Specialist Hospital, Department of Internal Medicine, Division of Hematology-Oncology, Al-Ahsa, Saudi Arabia
- Department of Hematology and Oncology, Hammoud Hospital University Medical Center, Saida, Lebanon
| | - Zaher K. Otrock
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Iman Abou Dalle
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jean El-Cheikh
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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37
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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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38
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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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Xuan L, Wang Y, Huang F, Fan Z, Xu Y, Sun J, Xu N, Deng L, Li X, Liang X, Luo X, Shi P, Liu H, Wang Z, Jiang L, Yu C, Zhou X, Lin R, Chen Y, Tu S, Huang X, Liu Q. Sorafenib maintenance in patients with FLT3-ITD acute myeloid leukaemia undergoing allogeneic haematopoietic stem-cell transplantation: an open-label, multicentre, randomised phase 3 trial. Lancet Oncol 2020; 21:1201-1212. [PMID: 32791048 DOI: 10.1016/s1470-2045(20)30455-1] [Citation(s) in RCA: 184] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Findings of retrospective studies suggest that sorafenib maintenance post-transplantation might reduce relapse in patients with FLT3 internal tandem duplication (FLT3-ITD) acute myeloid leukaemia undergoing allogeneic haematopoietic stem-cell transplantation. We investigated the efficacy and tolerability of sorafenib maintenance post-transplantation in this population. METHODS We did an open-label, randomised phase 3 trial at seven hospitals in China. Eligible patients (aged 18-60 years) had FLT3-ITD acute myeloid leukaemia, were undergoing allogeneic haematopoietic stem-cell transplantation, had an Eastern Cooperative Oncology Group performance status of 0-2, had composite complete remission before and after transplantation, and had haematopoietic recovery within 60 days post-transplantation. Patients were randomly assigned (1:1) to sorafenib maintenance (400 mg orally twice daily) or non-maintenance (control) at 30-60 days post-transplantation. Randomisation was done with permuted blocks (block size four) and implemented through an interactive web-based randomisation system. The primary endpoint was the 1-year cumulative incidence of relapse in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT02474290; the trial is complete. FINDINGS Between June 20, 2015, and July 21, 2018, 202 patients were enrolled and randomly assigned to sorafenib maintenance (n=100) or control (n=102). Median follow-up post-transplantation was 21·3 months (IQR 15·0-37·0). The 1-year cumulative incidence of relapse was 7·0% (95% CI 3·1-13·1) in the sorafenib group and 24·5% (16·6-33·2) in the control group (hazard ratio 0·25, 95% CI 0·11-0·57; p=0·0010). Within 210 days post-transplantation, the most common grade 3 and 4 adverse events were infections (25 [25%] of 100 patients in the sorafenib group vs 24 [24%] of 102 in the control group), acute graft-versus-host-disease (GVHD; 23 [23%] of 100 vs 21 [21%] of 102), chronic GVHD (18 [18%] of 99 vs 17 [17%] of 99), and haematological toxicity (15 [15%] of 100 vs seven [7%] of 102). There were no treatment-related deaths. INTERPRETATION Sorafenib maintenance post-transplantation can reduce relapse and is well tolerated in patients with FLT3-ITD acute myeloid leukaemia undergoing allogeneic haematopoietic stem-cell transplantation. This strategy could be a suitable therapeutic option for patients with FLT3-ITD acute myeloid leukaemia. FUNDING None.
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Affiliation(s)
- Li Xuan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yu Wang
- Department of Hematology, Peking University People's Hospital, Beijing, China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhiping Fan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yajing Xu
- Department of Hematology, Xiangya Hospital, Central South University, Changsha, China
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Na Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Lan Deng
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Xudong Li
- Department of Hematology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xinquan Liang
- Department of Hematology, First People's Hospital of Chenzhou, Chenzhou, China
| | - Xiaodan Luo
- Department of Hematology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Pengcheng Shi
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hui Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhixiang Wang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ling Jiang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Chunzi Yu
- Department of Hematology, Peking University People's Hospital, Beijing, China
| | - Xuan Zhou
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ren Lin
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yan Chen
- Department of Hematology, Xiangya Hospital, Central South University, Changsha, China
| | - Sanfang Tu
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaojun Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Hematology, Peking University People's Hospital, Beijing, China
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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40
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Shi J, Cao L, Luo Y, Zhao Y, Tan Y, Yu J, Lai X, Zhu Y, Hu Y, He J, Sun J, Zheng W, Wei G, Huang H. Maintenance sorafenib is superior to prophylactic donor lymphocyte infusion at improving the prognosis of acute myeloid leukemia with FMS-like tyrosine kinase 3 internal tandem duplication after allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2020; 56:293-296. [PMID: 32753705 DOI: 10.1038/s41409-020-01015-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 07/15/2020] [Accepted: 07/24/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Jimin Shi
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, China.,Stem Cell Institute, Zhejiang University, Hangzhou, China
| | - Liqin Cao
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, China.,Stem Cell Institute, Zhejiang University, Hangzhou, China
| | - Yi Luo
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, China.,Stem Cell Institute, Zhejiang University, Hangzhou, China
| | - Yanmin Zhao
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, China.,Stem Cell Institute, Zhejiang University, Hangzhou, China
| | - Yamin Tan
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, China.,Stem Cell Institute, Zhejiang University, Hangzhou, China
| | - Jian Yu
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, China.,Stem Cell Institute, Zhejiang University, Hangzhou, China
| | - Xiaoyu Lai
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, China.,Stem Cell Institute, Zhejiang University, Hangzhou, China
| | - Yuanyuan Zhu
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, China.,Stem Cell Institute, Zhejiang University, Hangzhou, China
| | - Yongxian Hu
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, China.,Stem Cell Institute, Zhejiang University, Hangzhou, China
| | - Jingsong He
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, China.,Stem Cell Institute, Zhejiang University, Hangzhou, China
| | - Jie Sun
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, China.,Stem Cell Institute, Zhejiang University, Hangzhou, China
| | - Weiyan Zheng
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, China.,Stem Cell Institute, Zhejiang University, Hangzhou, China
| | - Guoqing Wei
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, China.,Stem Cell Institute, Zhejiang University, Hangzhou, China
| | - He Huang
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China. .,Institute of Hematology, Zhejiang University, Hangzhou, China. .,Zhejiang Province Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, China. .,Stem Cell Institute, Zhejiang University, Hangzhou, China.
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41
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Miyamoto K, Minami Y. Cutting Edge Molecular Therapy for Acute Myeloid Leukemia. Int J Mol Sci 2020; 21:ijms21145114. [PMID: 32698349 PMCID: PMC7404220 DOI: 10.3390/ijms21145114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/09/2020] [Accepted: 07/14/2020] [Indexed: 12/31/2022] Open
Abstract
Recently, whole exome sequencing for acute myeloid leukemia (AML) has been performed by a next-generation sequencer in several studies. It has been revealed that a few gene mutations are identified per AML patient. Some of these mutations are actionable mutations that affect the response to an approved targeted treatment that is available for off-label treatment or that is available in clinical trials. The era of precision medicine for AML has arrived, and it is extremely important to detect actionable mutations relevant to treatment decision-making. However, the percentage of actionable mutations found in AML is about 50% at present, and therapeutic development is also needed for AML patients without actionable mutations. In contrast, the newly approved drugs are less toxic than conventional intensive chemotherapy and can be combined with low-intensity treatments. These combination therapies can contribute to the improvement of prognosis, especially in elderly AML patients who account for more than half of all AML patients. Thus, the treatment strategy for leukemia is changing drastically and showing rapid progress. In this review, we present the latest information regarding the recent development of treatment for AML.
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MESH Headings
- Animals
- Antineoplastic Agents/pharmacology
- Antineoplastic Agents/therapeutic use
- Combined Modality Therapy/methods
- Drug Approval
- Epigenesis, Genetic/drug effects
- Humans
- Immunotherapy, Adoptive/methods
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/immunology
- Leukemia, Myeloid, Acute/metabolism
- Leukemia, Myeloid, Acute/therapy
- Molecular Targeted Therapy/methods
- Mutation/drug effects
- Precision Medicine/methods
- Signal Transduction/drug effects
- Small Molecule Libraries/pharmacology
- Small Molecule Libraries/therapeutic use
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Affiliation(s)
| | - Yosuke Minami
- Correspondence: ; Tel.: +81-4-7133-1111; Fax: +81-7133-6502
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42
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Burchert A, Bug G, Fritz LV, Finke J, Stelljes M, Röllig C, Wollmer E, Wäsch R, Bornhäuser M, Berg T, Lang F, Ehninger G, Serve H, Zeiser R, Wagner EM, Kröger N, Wolschke C, Schleuning M, Götze KS, Schmid C, Crysandt M, Eßeling E, Wolf D, Wang Y, Böhm A, Thiede C, Haferlach T, Michel C, Bethge W, Wündisch T, Brandts C, Harnisch S, Wittenberg M, Hoeffkes HG, Rospleszcz S, Burchardt A, Neubauer A, Brugger M, Strauch K, Schade-Brittinger C, Metzelder SK. Sorafenib Maintenance After Allogeneic Hematopoietic Stem Cell Transplantation for Acute Myeloid Leukemia With FLT3-Internal Tandem Duplication Mutation (SORMAIN). J Clin Oncol 2020; 38:2993-3002. [PMID: 32673171 DOI: 10.1200/jco.19.03345] [Citation(s) in RCA: 285] [Impact Index Per Article: 71.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Despite undergoing allogeneic hematopoietic stem cell transplantation (HCT), patients with acute myeloid leukemia (AML) with internal tandem duplication mutation in the FMS-like tyrosine kinase 3 gene (FLT3-ITD) have a poor prognosis, frequently relapse, and die as a result of AML. It is currently unknown whether a maintenance therapy using FLT3 inhibitors, such as the multitargeted tyrosine kinase inhibitor sorafenib, improves outcome after HCT. PATIENTS AND METHODS In a randomized, placebo-controlled, double-blind phase II trial (SORMAIN; German Clinical Trials Register: DRKS00000591), 83 adult patients with FLT3-ITD-positive AML in complete hematologic remission after HCT were randomly assigned to receive for 24 months either the multitargeted and FLT3-kinase inhibitor sorafenib (n = 43) or placebo (n = 40 placebo). Relapse-free survival (RFS) was the primary endpoint of this trial. Relapse was defined as relapse or death, whatever occurred first. RESULTS With a median follow-up of 41.8 months, the hazard ratio (HR) for relapse or death in the sorafenib group versus placebo group was 0.39 (95% CI, 0.18 to 0.85; log-rank P = .013). The 24-month RFS probability was 53.3% (95% CI, 0.36 to 0.68) with placebo versus 85.0% (95% CI, 0.70 to 0.93) with sorafenib (HR, 0.256; 95% CI, 0.10 to 0.65; log-rank P = .002). Exploratory data show that patients with undetectable minimal residual disease (MRD) before HCT and those with detectable MRD after HCT derive the strongest benefit from sorafenib. CONCLUSION Sorafenib maintenance therapy reduces the risk of relapse and death after HCT for FLT3-ITD-positive AML.
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Affiliation(s)
- Andreas Burchert
- Department of Internal Medicine, Hematology, Oncology and Immunology, Philipps University Marburg and University Hospital Gießen and Marburg, Campus Marburg, Marburg, Germany
| | - Gesine Bug
- Department of Medicine 2, Hematology and Oncology, Goethe University Frankfurt, Frankfurt, Germany
| | - Lea V Fritz
- Department of Internal Medicine, Hematology, Oncology and Immunology, Philipps University Marburg and University Hospital Gießen and Marburg, Campus Marburg, Marburg, Germany
| | - Jürgen Finke
- Department of Internal Medicine I, Hematology, Oncology and Stem Cell Transplantation, Freiburg University Medical Center, Freiburg, Germany
| | - Matthias Stelljes
- Department of Medicine A/Hematology and Oncology, University of Muenster, Münster, Germany
| | - Christoph Röllig
- Medical Department I, University Hospital Carl Gustav Carus, Technische Universitat Dresden, Germany
| | - Ellen Wollmer
- Department of Internal Medicine, Hematology, Oncology and Immunology, Philipps University Marburg and University Hospital Gießen and Marburg, Campus Marburg, Marburg, Germany
| | - Ralph Wäsch
- Department of Internal Medicine I, Hematology, Oncology and Stem Cell Transplantation, Freiburg University Medical Center, Freiburg, Germany
| | - Martin Bornhäuser
- Medical Department I, University Hospital Carl Gustav Carus, Technische Universitat Dresden, Germany
| | - Tobias Berg
- Department of Medicine 2, Hematology and Oncology, Goethe University Frankfurt, Frankfurt, Germany
| | - Fabian Lang
- Department of Medicine 2, Hematology and Oncology, Goethe University Frankfurt, Frankfurt, Germany
| | - Gerhard Ehninger
- Medical Department I, University Hospital Carl Gustav Carus, Technische Universitat Dresden, Germany
| | - Hubert Serve
- Department of Medicine 2, Hematology and Oncology, Goethe University Frankfurt, Frankfurt, Germany
| | - Robert Zeiser
- Department of Internal Medicine I, Hematology, Oncology and Stem Cell Transplantation, Freiburg University Medical Center, Freiburg, Germany
| | - Eva-Maria Wagner
- Medical Department III, Hematology, Medical Oncology and Pneumology, University Mainz, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Katharina S Götze
- Department of Medicine III, Technical University of Munich, Munich, Germany
| | - Christoph Schmid
- Department of Hematology and Oncology, University Hospital Augsburg, Augsburg, Germany
| | - Martina Crysandt
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen University, Aachen, Germany
| | - Eva Eßeling
- Department of Medicine A/Hematology and Oncology, University of Muenster, Münster, Germany
| | - Dominik Wolf
- Department of Hematology and Oncology, University Hospital Bonn, Bonn, Germany; and Department of Hematology and Oncology, Innsbruck Medical University, Innsbruck, Austria
| | - Ying Wang
- Department of Internal Medicine, Hematology, Oncology and Immunology, Philipps University Marburg and University Hospital Gießen and Marburg, Campus Marburg, Marburg, Germany
| | - Alexandra Böhm
- Department of Hematology/Oncology/Stem Cell Transplantation, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Christian Thiede
- Medical Department I, University Hospital Carl Gustav Carus, Technische Universitat Dresden, Germany
| | | | - Christian Michel
- Department of Internal Medicine, Hematology, Oncology and Immunology, Philipps University Marburg and University Hospital Gießen and Marburg, Campus Marburg, Marburg, Germany
| | | | - Thomas Wündisch
- Department of Internal Medicine, Hematology, Oncology and Immunology, Philipps University Marburg and University Hospital Gießen and Marburg, Campus Marburg, Marburg, Germany
| | - Christian Brandts
- Department of Medicine 2, Hematology and Oncology, Goethe University Frankfurt, Frankfurt, Germany
| | - Susanne Harnisch
- Coordinating Center for Clinical Trials, Philipps University Marburg, Marburg, Germany
| | - Michael Wittenberg
- Coordinating Center for Clinical Trials, Philipps University Marburg, Marburg, Germany
| | - Heinz-Gert Hoeffkes
- Tumorklinik (Medizinische Onkologie, Palliativmedizin, Hämatologie und Hämostasiologie), Klinikum Fulda, Fulda, Germany
| | - Susanne Rospleszcz
- Chair of Genetic Epidemiology, Institut für Medizinische Informationsverarbeitung Biometrie und Epidemiologie, Faculty of Medicine, Ludwigs Maximilian Universität München and Institute of Genetic Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany
| | - Alexander Burchardt
- Department of Internal Medicine, Hematology, Oncology and Immunology, University Hospital Gießen and Marburg, Campus Gießen, Gießen, Germany
| | - Andreas Neubauer
- Department of Internal Medicine, Hematology, Oncology and Immunology, Philipps University Marburg and University Hospital Gießen and Marburg, Campus Marburg, Marburg, Germany
| | - Markus Brugger
- Institut für Medizinische Informationsverarbeitung Biometrie und Epidemiologie, Faculty of Medicine, Ludwigs Maximilian Universität München and Institute of Genetic Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany and Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Konstantin Strauch
- Institut für Medizinische Informationsverarbeitung Biometrie und Epidemiologie, Faculty of Medicine, Ludwigs Maximilian Universität München and Institute of Genetic Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany and Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Johannes Gutenberg University, Mainz, Germany.,Institute of Medical Biometry and Epidemiology, Philipps University Marburg, Marburg, Germany
| | | | - Stephan K Metzelder
- Department of Internal Medicine, Hematology, Oncology and Immunology, Philipps University Marburg and University Hospital Gießen and Marburg, Campus Marburg, Marburg, Germany
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Soiffer RJ. Maintenance therapy for high-risk acute leukemia after allogeneic hematopoietic cell transplantation: wait a minute. Blood Adv 2020; 4:3205-3208. [PMID: 32663295 PMCID: PMC7362380 DOI: 10.1182/bloodadvances.2019000389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 03/02/2020] [Indexed: 01/06/2023] Open
Abstract
This article has a companion Point by Scott.
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Affiliation(s)
- Robert J Soiffer
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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44
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Bataller A, Oñate G, Diaz-Beyá M, Guijarro F, Garrido A, Vives S, Tormo M, Arnan M, Salamero O, Sampol A, Coll R, Vall-Llovera F, Oliver-Caldés A, López-Guerra M, Pratcorona M, Zamora L, Villamon E, Roué G, Blanco A, Nomdedeu JF, Colomer D, Brunet S, Sierra J, Esteve J. Acute myeloid leukemia with NPM1 mutation and favorable European LeukemiaNet category: outcome after preemptive intervention based on measurable residual disease. Br J Haematol 2020; 191:52-61. [PMID: 32510599 DOI: 10.1111/bjh.16857] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/18/2020] [Indexed: 01/22/2023]
Abstract
In the European LeukemiaNet favourable risk category, allogeneic haematopoietic stem cell transplantation (alloSCT) is not indicated in first complete remission for patients with acute myeloid leukaemia (AML) with NPM1 mutations (ELNfav NPM1 AML), although a proportion of these patients will relapse. Given the prognostic importance of measurable residual disease (MRD), CETLAM-12 considered a pre-emptive intervention in patients with molecular failure (MF). We analyzed 110 ELNfav NPM1 AML patients achieving complete remission (CR) after induction chemotherapy. Two-year cumulative incidence of relapse (CIR), overall survival (OS) and leukaemia-free survival (LFS) were 17%, 81·5% and 82%, respectively. Forty-six patients required additional therapy for MF (n = 33) or haematological relapse (HemR; n = 13), resulting in a molecular LFS (molLFS) and a cumulative incidence of MF at two years of 61% and 38% respectively. Two-year OS for these 46 patients was 66%, with a different outcome between patients with MF (86%) and HemR (42%) (P = 0·002). Quantitative NPM1 detection at different timepoints was predictive of molLFS; an MRD ratio (NPM1mut/ABL1 × 100) cut-off of 0·05 after first consolidation identified two cohorts with a two-year molLFS of 77% and 40% for patients below and above 0·05, respectively. In conclusion, MRD-based pre-emptive intervention resulted in a favourable outcome for ELNfav NPM1 AML patients.
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Affiliation(s)
- Alex Bataller
- Hematology Department, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Guadalupe Oñate
- Hematology Department, Hospital de la Santa Creu i Sant Pau, UAB, Barcelona, Spain
| | - Marina Diaz-Beyá
- Hematology Department, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Francesca Guijarro
- Hematology Department, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Ana Garrido
- Hematology Department, Hospital de la Santa Creu i Sant Pau, UAB, Barcelona, Spain
| | - Susana Vives
- Hematology Department, ICO - Hospital Germans Trias i Pujol, Badalona, Spain
| | - Mar Tormo
- Hematology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Montserrat Arnan
- Hematology Department, ICO - Hospital Duran i Reynals, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Olga Salamero
- Hematology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Antònia Sampol
- Hematology Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Rosa Coll
- Hematology Department, ICO - Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - Ferran Vall-Llovera
- Hematology Department, Hospital Universitari Mútua de Terrassa, Terrassa, Spain
| | - Aina Oliver-Caldés
- Hematology Department, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Mònica López-Guerra
- Hematopathology Section, Hospital Clínic, IDIBAPS, CIBERONC, UB, Barcelona, Spain
| | - Marta Pratcorona
- Hematology Department, Hospital de la Santa Creu i Sant Pau, UAB, Barcelona, Spain
| | - Lurdes Zamora
- Hematology Department, ICO - Hospital Germans Trias i Pujol, Badalona, Spain
| | - Eva Villamon
- Hematology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Gaël Roué
- Hematology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Adoración Blanco
- Hematology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Josep F Nomdedeu
- Hematology Department, Hospital de la Santa Creu i Sant Pau, UAB, Barcelona, Spain
| | - Dolors Colomer
- Hematopathology Section, Hospital Clínic, IDIBAPS, CIBERONC, UB, Barcelona, Spain
| | - Salut Brunet
- Hematology Department, Hospital de la Santa Creu i Sant Pau, UAB, Barcelona, Spain
| | - Jorge Sierra
- Hematology Department, Hospital de la Santa Creu i Sant Pau, UAB, Barcelona, Spain
| | - Jordi Esteve
- Hematology Department, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
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Bazarbachi A, Bug G, Baron F, Brissot E, Ciceri F, Dalle IA, Döhner H, Esteve J, Floisand Y, Giebel S, Gilleece M, Gorin NC, Jabbour E, Aljurf M, Kantarjian H, Kharfan-Dabaja M, Labopin M, Lanza F, Malard F, Peric Z, Prebet T, Ravandi F, Ruggeri A, Sanz J, Schmid C, Shouval R, Spyridonidis A, Versluis J, Vey N, Savani BN, Nagler A, Mohty M. Clinical practice recommendation on hematopoietic stem cell transplantation for acute myeloid leukemia patients with FLT3-internal tandem duplication: a position statement from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation. Haematologica 2020; 105:1507-1516. [PMID: 32241850 PMCID: PMC7271578 DOI: 10.3324/haematol.2019.243410] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/19/2020] [Indexed: 12/13/2022] Open
Abstract
The FMS-like tyrosine kinase 3 (FLT3) gene is mutated in 25-30% of patients with acute myeloid leukemia (AML). Because of the poor prognosis associated with FLT3-internal tandem duplication mutated AML, allogeneic hematopoietic stem-cell transplantation (SCT) was commonly performed in first complete remission. Remarkable progress has been made in frontline treatments with the incorporation of FLT3 inhibitors and the development of highly sensitive minimal/measurable residual disease assays. Similarly, recent progress in allogeneic hematopoietic SCT includes improvement of transplant techniques, the use of haploidentical donors in patients lacking an HLA matched donor, and the introduction of FLT3 inhibitors as post-transplant maintenance therapy. Nevertheless, current transplant strategies vary between centers and differ in terms of transplant indications based on the internal tandem duplication allelic ratio and concomitant nucleophos-min-1 mutation, as well as in terms of post-transplant maintenance/consolidation. This review generated by international leukemia or transplant experts, mostly from the European Society for Blood and Marrow Transplantation, attempts to develop a position statement on best approaches for allogeneic hematopoietic SCT for AML with FLT3-internal tandem duplication including indications for and modalities of such transplants and on the potential optimization of post-transplant maintenance with FLT inhibitors.
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Affiliation(s)
- Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Department of Anatomy, Cell Biology, and Physiological Sciences, American University of Beirut, Beirut, Lebanon
| | - Gesine Bug
- Department of Medicine 2, Hematology and Oncology, University Hospital, Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | - Eolia Brissot
- Sorbonne Universités, UPMC University of Paris 06, INSERM, Centre de Recherche Saint-Antoine (CRSA), Hematology Department, AP-HP, Saint Antoine Hospital, Paris, France
| | - Fabio Ciceri
- Vita-Salute San Raffaele University of Milan, Milan, ItalyHematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Iman Abou Dalle
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hartmut Döhner
- Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany
| | - Jordi Esteve
- Hematology Department, Hospital Clínic of Barcelona, IDIBAPS, University of Barcelona, Barcellona, Spain
| | - Yngvar Floisand
- Department of Hematology, Oslo University Hospital - Rikshospitalet, Oslo, Norway
- Center for Cancer Cell Reprogramming, Institute for Cancer Research, Oslo University Hospital, Montebello, Oslo, Norway
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Oncohematology, Maria Sklodowska-Curie Institute - Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Maria Gilleece
- Department of Haematology, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Norbert-Claude Gorin
- Department of Hematology and Cell Therapy, European Society for Blood and Marrow Transplantation, Paris Office, Hopital Saint-Antoine, Paris, France
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mahmoud Aljurf
- Department of Hematology King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mohamed Kharfan-Dabaja
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapies Program, Mayo Clinic, Jacksonville, FL, USA
| | - Myriam Labopin
- Acute Leukemia Working Party, Paris Study Office, European Society for Blood and Marrow Transplantation, Paris, France
- Sorbonne Universités, UPMC University of Paris 06, INSERM, Centre de Recherche Saint-Antoine (CRSA), Hematology Department, AP-HP, Saint Antoine Hospital, Paris, France
| | | | - Florent Malard
- Sorbonne Universités, UPMC University of Paris 06, INSERM, Centre de Recherche Saint-Antoine (CRSA), Hematology Department, AP-HP, Saint Antoine Hospital, Paris, France
| | - Zinaida Peric
- University Hospital Center Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Thomas Prebet
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Annalisa Ruggeri
- Department of Pediatric Hematology and Oncology, IRCCS Bambino Gesù Children's Hospital, Roma, ItalyEurocord, Hôpital Saint Louis, Paris, France
| | - Jaime Sanz
- Hematology Department, Hospital Universitari i Politecnic La Fe. Instituto de Investigación Sanitaria La Fe, Valencia, CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Christoph Schmid
- Department of Hematology and Oncology, Augsburg University Hospital, Augsburg, Germany
| | - Roni Shouval
- Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Jurjen Versluis
- Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Norbert Vey
- Department of Hematology, Institut Paoli-Calmettes, Marseille, France
| | - Bipin N Savani
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arnon Nagler
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Israel
| | - Mohamad Mohty
- Sorbonne Universités, UPMC University of Paris 06, INSERM, Centre de Recherche Saint-Antoine (CRSA), Hematology Department, AP-HP, Saint Antoine Hospital, Paris, France
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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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47
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Culos KA, Gatwood KS, Byrne M. Maintenance Strategies After Hematopoietic Cell Transplantation. Pharmacotherapy 2020; 40:727-740. [PMID: 32343426 DOI: 10.1002/phar.2407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Hematopoietic cell transplantation (HCT) is an essential component of potentially curative therapy for patients with hematologic malignancies. High-dose chemotherapy with autologous (auto) stem cell rescue is used to overcome chemoresistance in multiple myeloma, non-Hodgkin lymphoma, and Hodgkin lymphoma. Alternatively, poor-risk acute leukemias rely on the graft versus leukemia effect of allogeneic (allo) products. Long-term remissions are feasible with both auto- and allo-HCT; however, disease relapse is the leading cause of death after HCT for many patients. In recognition of this, novel therapies are being investigated in the upfront, relapsed/refractory, and post-HCT maintenance settings to deepen response and maintain disease control. To date, the most robust data to support this approach are in multiple myeloma, where post-transplant maintenance therapy has improved clinical outcomes. In Hodgkin lymphoma, patients with high-risk features may benefit from post-auto-HCT vedotin (BV) regardless of pre-HCT BV exposure. Apart from mantle cell lymphoma, where rituximab maintenance is generally accepted, post-auto-HCT maintenance in other forms of NHL is less established. In patients who undergo allo-HCT, the utilization of maintenance therapy is an important component of improving post-HCT outcomes, however, an individualized approach that considers patient factors such as residual toxicity from HCT, an immature graft with poor graft function, infection, and graft-versus-host disease create a complex environment for aggressive interventions. Initiation of directed agents in patients with identified mutations prior to allo-HCT, including FLT3 in acute myeloid leukemia and Philadelphia chromosome in acute lymphoid leukemia have generally improved post-HCT outcomes. Ongoing studies are exploring the safety and efficacy of additional maintenance strategies post-allo-HCT in an effort to further improve post-HCT outcomes.
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Affiliation(s)
- Kathryn A Culos
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Katie S Gatwood
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael Byrne
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Sudasena D, Balanescu DV, Donisan T, Hassan S, Palaskas N, Kim P, Karimzad K, Lopez-Mattei J, Arain S, Gould KL, Iliescu C. Fulminant Vascular and Cardiac Toxicity Associated with Tyrosine Kinase Inhibitor Sorafenib. Cardiovasc Toxicol 2020; 19:382-387. [PMID: 30543051 DOI: 10.1007/s12012-018-9499-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The use of vascular endothelial growth factor inhibitors such as sorafenib is limited by a risk of severe cardiovascular toxicity. A 28-year-old man with acute myeloid leukemia treated with prednisone, tacrolimus, and sorafenib following stem cell transplantation presented with severe bilateral lower extremity claudication. The patient was discharged against medical advice prior to finalizing a cardiovascular evaluation, but returned 1 week later with signs suggestive of septic shock. Laboratory tests revealed troponin I of 12.63 ng/mL, BNP of 1690 pg/mL, and negative infectious workup. Electrocardiogram showed sinus tachycardia and new pathologic Q waves in the anterior leads. Coronary angiography revealed severe multivessel coronary artery disease. Peripheral angiography revealed severely diseased left anterior and posterior tibial arteries, tibioperoneal trunk, and peroneal artery, and subtotal occlusion of the right posterior tibial artery. Multiple coronary and peripheral drug-eluting stents were implanted. An intra-aortic balloon pump was placed. Cardiac magnetic resonance imaging revealed chronic left ventricular infarction with some viability, 17% ejection fraction, and left ventricular mural thrombi. The patient opted for medical management. Persistent symptoms 9 months later led to repeat angiography, showing total occlusion of the second obtuse marginal artery due to in-stent restenosis with proximal stent fracture, and chronic total occlusion of the right internal iliac artery extending to the pudendal branch. Cardiac positron emission tomography/computed tomography viability study demonstrated viable myocardium, deeming revascularization appropriate. Symptom resolution was obtained with no recurrences. Sorafenib-associated vasculopathy may follow a fulminant course. Multimodality cardiovascular imaging is essential for optimal management.
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Affiliation(s)
- Daryl Sudasena
- Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Dinu Valentin Balanescu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, 1451, 77030, Houston, TX, USA
| | - Teodora Donisan
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, 1451, 77030, Houston, TX, USA
| | - Saamir Hassan
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, 1451, 77030, Houston, TX, USA
| | - Nicolas Palaskas
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, 1451, 77030, Houston, TX, USA
| | - Peter Kim
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, 1451, 77030, Houston, TX, USA
| | - Kaveh Karimzad
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, 1451, 77030, Houston, TX, USA
| | - Juan Lopez-Mattei
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, 1451, 77030, Houston, TX, USA
| | - Salman Arain
- Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - K Lance Gould
- Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Cezar Iliescu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, 1451, 77030, Houston, TX, USA.
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Lam SS, Leung AY. Overcoming Resistance to FLT3 Inhibitors in the Treatment of FLT3-Mutated AML. Int J Mol Sci 2020; 21:E1537. [PMID: 32102366 PMCID: PMC7073218 DOI: 10.3390/ijms21041537] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 02/21/2020] [Accepted: 02/21/2020] [Indexed: 01/13/2023] Open
Abstract
Acute myeloid leukaemia (AML) carrying internal tandem duplication (ITD) of Fms-Like Tyrosine kinase 3 (FLT3) gene is associated with high risk of relapse and poor clinical outcome upon treatment with conventional chemotherapy. FLT3 inhibitors have been approved for the treatment of this AML subtype but leukaemia relapse remains to be a major cause of treatment failure. Mechanisms of drug resistance have been proposed, including evolution of resistant leukaemic clones; adaptive cellular mechanisms and a protective leukaemic microenvironment. These models have provided important leads that may inform design of clinical trials. Clinically, FLT3 inhibitors in combination with conventional chemotherapy as induction treatment for fit patients; with low-intensity treatment as salvage treatment or induction for unfit patients as well as maintenance treatment with FLT3 inhibitors post HSCT hold promise to improve survival in this AML subtype.
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Affiliation(s)
| | - Anskar Y.H. Leung
- Division of Haematology, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China;
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50
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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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