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Krenn PW, Aberger F. Targeting cancer hallmark vulnerabilities in hematologic malignancies by interfering with Hedgehog/GLI signaling. Blood 2023; 142:1945-1959. [PMID: 37595276 DOI: 10.1182/blood.2021014761] [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: 05/24/2023] [Revised: 07/14/2023] [Accepted: 08/03/2023] [Indexed: 08/20/2023] Open
Abstract
Understanding the genetic alterations, disrupted signaling pathways, and hijacked mechanisms in oncogene-transformed hematologic cells is critical for the development of effective and durable treatment strategies against liquid tumors. In this review, we focus on the specific involvement of the Hedgehog (HH)/GLI pathway in the manifestation and initiation of various cancer features in hematologic malignancies, including multiple myeloma, T- and B-cell lymphomas, and lymphoid and myeloid leukemias. By reviewing canonical and noncanonical, Smoothened-independent HH/GLI signaling and summarizing preclinical in vitro and in vivo studies in hematologic malignancies, we elucidate common molecular mechanisms by which HH/GLI signaling controls key oncogenic processes and cancer hallmarks such as cell proliferation, cancer stem cell fate, genomic instability, microenvironment remodeling, and cell survival. We also summarize current clinical trials with HH inhibitors and discuss successes and challenges, as well as opportunities for future combined therapeutic approaches. By providing a bird's eye view of the role of HH/GLI signaling in liquid tumors, we suggest that a comprehensive understanding of the general oncogenic effects of HH/GLI signaling on the formation of cancer hallmarks is essential to identify critical vulnerabilities within tumor cells and their supporting remodeled microenvironment, paving the way for the development of novel and efficient personalized combination therapies for hematologic malignancies.
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Affiliation(s)
- Peter W Krenn
- Department of Biosciences and Medical Biology, Cancer Cluster Salzburg, Paris Lodron University of Salzburg, Salzburg, Austria
| | - Fritz Aberger
- Department of Biosciences and Medical Biology, Cancer Cluster Salzburg, Paris Lodron University of Salzburg, Salzburg, Austria
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van der Kleij MBA, Guchelaar NAD, Mathijssen RHJ, Versluis J, Huitema ADR, Koolen SLW, Steeghs N. Therapeutic Drug Monitoring of Kinase Inhibitors in Oncology. Clin Pharmacokinet 2023; 62:1333-1364. [PMID: 37584840 PMCID: PMC10519871 DOI: 10.1007/s40262-023-01293-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 08/17/2023]
Abstract
Although kinase inhibitors (KI) frequently portray large interpatient variability, a 'one size fits all' regimen is still often used. In the meantime, relationships between exposure-response and exposure-toxicity have been established for several KIs, so this regimen could lead to unnecessary toxicity and suboptimal efficacy. Dose adjustments based on measured systemic pharmacokinetic levels-i.e., therapeutic drug monitoring (TDM)-could therefore improve treatment efficacy and reduce the incidence of toxicities. Therefore, the aim of this comprehensive review is to give an overview of the available evidence for TDM for the 77 FDA/EMA kinase inhibitors currently approved (as of July 1st, 2023) used in hematology and oncology. We elaborate on exposure-response and exposure-toxicity relationships for these kinase inhibitors and provide practical recommendations for TDM and discuss corresponding pharmacokinetic targets when possible.
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Affiliation(s)
- Maud B A van der Kleij
- Division of Medical Oncology, Department of Clinical Pharmacology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands.
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - Niels A D Guchelaar
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jurjen Versluis
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
- Department of Pharmacy, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Neeltje Steeghs
- Division of Medical Oncology, Department of Clinical Pharmacology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
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Update on glasdegib in acute myeloid leukemia - broadening horizons of Hedgehog pathway inhibitors. ACTA PHARMACEUTICA (ZAGREB, CROATIA) 2022; 72:9-34. [PMID: 36651529 DOI: 10.2478/acph-2022-0007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 01/20/2023]
Abstract
Numerous new emerging therapies, including oral targeted chemotherapies, have recently entered the therapeutic arsenal against acute myeloid leukemia (AML). The significant shift toward the use of these novel therapeutics, administered either alone or in combination with intensive or low-intensity chemotherapy, changes the prospects for the control of this disease, especially for elderly patients. Glasdegib, an oral Hedgehog pathway inhibitor, showed satisfactory response rates associated with moderate toxicity and less early mortality than standard induction regimens in this population. It was approved in November 2018 by the FDA and in June 2020 by the EMA for use in combination with low-dose cytarabine as a treatment of newly-diagnosed AML in patients aged ≥ 75 and/or unfit for intensive induction chemotherapy. The current paper proposes an extensive, up-to-date review of the preclinical and clinical development of glasdegib. Elements of its routine clinical use and the landscape of ongoing clinical trials are also stated.
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Jiang X, Jiang L, Cheng J, Chen F, Ni J, Yin C, Wang Q, Wang Z, Fang D, Yi Z, Yu G, Zhong Q, Carter BZ, Meng F. Inhibition of EZH2 by chidamide exerts antileukemia activity and increases chemosensitivity through Smo/Gli-1 pathway in acute myeloid leukemia. J Transl Med 2021; 19:117. [PMID: 33743723 PMCID: PMC7981995 DOI: 10.1186/s12967-021-02789-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 03/15/2021] [Indexed: 12/17/2022] Open
Abstract
Background Epigenetic dysregulation plays important roles in leukemogenesis and the progression of acute myeloid leukemia (AML). Histone acetyltransferases (HATs) and histone deacetylases (HDACs) reciprocally regulate the acetylation and deacetylation of nuclear histones. Aberrant activation of HDACs results in uncontrolled proliferation and blockade of differentiation, and HDAC inhibition has been investigated as epigenetic therapeutic strategy against AML. Methods Cell growth was assessed with CCK-8 assay, and apoptosis was evaluated by flow cytometry in AML cell lines and CD45 + and CD34 + CD38- cells from patient samples after staining with Annexin V-fluorescein isothiocyanate (FITC)/propidium iodide (PI). EZH2 was silenced with short hairpin RNA (shRNA) or overexpressed by lentiviral transfection. Changes in signaling pathways were detected by western blotting. The effect of chidamide or EZH2-specific shRNA (shEZH2) in combination with adriamycin was studied in vivo in leukemia-bearing nude mouse models. Results In this study, we investigated the antileukemia effects of HDAC inhibitor chidamide and its combinatorial activity with cytotoxic agent adriamycin in AML cells. We demonstrated that chidamide suppressed the levels of EZH2, H3K27me3 and DNMT3A, exerted potential antileukemia activity and increased the sensitivity to adriamycin through disruption of Smo/Gli-1 pathway and downstream signaling target p-AKT in AML cells and stem/progenitor cells. In addition to decreasing the levels of H3K27me3 and DNMT3A, inhibition of EZH2 either pharmacologically by chidamide or genetically by shEZH2 suppressed the activity of Smo/Gli-1 pathway and increased the antileukemia activity of adriamycin against AML in vitro and in vivo. Conclusions Inhibition of EZH2 by chidamide has antileukemia activity and increases the chemosensitivity to adriamycin through Smo/Gli-1 pathway in AML cells (Fig. 5). These findings support the rational combination of HDAC inhibitors and chemotherapy for the treatment of AML. Supplementary Information The online version contains supplementary material available at 10.1186/s12967-021-02789-3.
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Affiliation(s)
- Xuejie Jiang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China.
| | - Ling Jiang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Jiaying Cheng
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Fang Chen
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Jinle Ni
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Changxin Yin
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Qiang Wang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Zhixiang Wang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Dan Fang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Zhengshan Yi
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Guopan Yu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Qingxiu Zhong
- Department of Hematology, Kanghua Hospital, Dongguan, 523080, Guangdong, China
| | - Bing Z Carter
- Section of Molecular Hematology and Therapy, Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Fanyi Meng
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China. .,Department of Hematology, Kanghua Hospital, Dongguan, 523080, Guangdong, China.
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Hu Y, Charaan M, van Oostrum I, Heeg B, Bell T. The cost-effectiveness of glasdegib in combination with low-dose cytarabine, for the treatment of newly diagnosed acute myeloid leukemia in adult patients who are not eligible to receive intensive induction chemotherapy in Canada. J Med Econ 2021; 24:150-161. [PMID: 33461352 DOI: 10.1080/13696998.2021.1875743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AIM The clinical efficacy and safety of DAURISMO (glasdegib) combined with low-dose cytarabine (LDAC) were demonstrated in the BRIGHT AML 1003 study among newly diagnosed acute myeloid leukemia patients who are not eligible to receive intensive chemotherapy. This study aims to evaluate its cost-effectiveness versus LDAC alone and azacitidine from a Canadian payer perspective. MATERIALS AND METHODS A partitioned-survival model was developed with three health states: progression-free survival (PFS), relapse/progression and death. Clinical inputs were obtained from the BRIGHT AML 1003 study for glasdegib and LDAC, and from the two trial publications and indirect treatment comparison for azacitidine. Drug acquisition/administration, disease management, adverse event and end-of-life costs were considered. All costs were measured in Canadian dollars. Cost-effectiveness of glasdegib + LDAC was assessed against LDAC alone in main population, and against azacitidine by bone marrow blasts (BMB). A weighted average ICER was calculated to represent the current treatment use of Canadian clinical practice. The reference-case analysis was conducted probabilistically, and numerous probabilistic scenario analyses were conducted. RESULTS The incremental cost-effectiveness ratios (ICERs) compared to LDAC alone was CAD $177,065 (a mean gain of 0.41 QALYs and an incremental cost of CAD $72,695), to azacitidine in 20-30% and >30% BMB group were CAD $178,201 (a mean gain of 0.34 QALYs and an incremental cost of CAD $59,889) and dominant (a mean gain of 0.28 QALYs while reducing costs by CAD $7,856) respectively, resulting in a weighted average ICER of CAD $81,310 per QALY. LIMITATIONS AND CONCLUSIONS Though uncertainties remain with the generated PFS curve, the derived azacitidine curves, administration and vial wastage, the model has been built under the best available evidence and relied on clinical opinions where there were data gaps. The weighted average ICER suggests that glasdegib + LDAC is cost-effective at a CAD $100,000 willingness-to-pay threshold.
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Affiliation(s)
- Yannan Hu
- Ingress-Health, Rotterdam, the Netherlands
| | | | | | - Bart Heeg
- Ingress-Health, Rotterdam, the Netherlands
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