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Cui Y, Mi R, Chen L, Wang L, Li D, Wei X. Case report: Venetoclax plus Azacitidine in treatment of acute undifferentiated leukemia. Hematology 2024; 29:2293494. [PMID: 38095304 DOI: 10.1080/16078454.2023.2293494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 12/02/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES Acute undifferentiated leukemia (AUL) is a clinical rare leukemia with an overall poor prognosis. Currently, there are no well-established treatment guidelines for AUL, further exploration of optimal treatment options is now required. METHODS We report an AUL patient who was complicated by a NRAS mutation and del5q was admitted to our hospital and we present the clinical features. In addition, we conducted a literature review. RESULTS The "VA" scheme combines agents Venetoclax and Azacitidine that have synergistic therapeutic effect with a tolerable safety profile. There is no previous report of the "VA" scheme employed in AUL treatment. An AUL patient who was complicated by a NRAS mutation and del5q was admitted to our hospital. The "VA" scheme was administrated, and complete remission (CR) was achieved at the end of the first cycle. The patient then underwent HLA-identical sibling allogeneic hematopoietic stem cell transplantation. DISCUSSION The "VA" scheme has been extensively used in AML treatment, but its application in AUL treatment has not yet been reported. This study is the first to report an AUL patient treated with the "VA" scheme and achieved CR. Our result preliminarily suggested the effectiveness and safety of the "VA" scheme in AUL treatment, but validation is required in more clinical samples. The "VA" scheme provides a new treatment option for AUL patients and deserves further clinical promotion.
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Affiliation(s)
- Yu Cui
- Department of Hematopathy, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, People's Republic of China
| | - Ruihua Mi
- Department of Hematopathy, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, People's Republic of China
| | - Lin Chen
- Department of Hematopathy, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, People's Republic of China
| | - Lin Wang
- Department of Hematopathy, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, People's Republic of China
| | - Dongbei Li
- Department of Hematopathy, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, People's Republic of China
| | - Xudong Wei
- Department of Hematopathy, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, People's Republic of China
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Kim M, Ahn SY, Kim T, Jung SH, Song GY, Yang DH, Lee JJ, Kim MY, Park JH, Shin MG, Ahn JS, Kim HJ, Kim DDH. Prognostic analysis according to European LeukemiaNet 2022 risk stratification for elderly patients with acute myeloid leukemia treated with decitabine. Hematology 2024; 29:2324417. [PMID: 38433437 DOI: 10.1080/16078454.2024.2324417] [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: 08/08/2023] [Accepted: 02/23/2024] [Indexed: 03/05/2024] Open
Abstract
OBJECTIVES This study aimed to evaluate the prognostic significance of the revised European LeukemiaNet (ELN)-2022 risk stratification model for 123 elderly acute myeloid leukemia (AML) patients treated with decitabine chemotherapy. RESULTS Based on the ELN-2022 risk stratification, 15 (12.2%), 51 (41.5%), and 57 (46.3%) patients were classified as having favorable, intermediate, and high-risk AML, respectively. In comparison with the ELN-2017 risk stratification, the ELN-2022 risk stratification re-assigned 26 (21.1%) and three (2.4%) patients to the adverse and favorable risk groups, respectively. Survival analysis revealed distinctive overall survival (OS) outcomes among the ELN-2022 risk groups (6-month OS rate: 73.3%, 52.9%, and 47.7% for favorable, intermediate, and adverse risk, respectively; P = 0.101), with a parallel trend observed in the event-free survival (EFS) (6-month EFS rate: 73.3%, 52.9%, and 45.6% for favorable, intermediate, and adverse risk, respectively; P = 0.049). Notably, both OS and EFS in the favorable risk group were significantly superior in comparison to that of the adverse risk group (OS: P = 0.040, EFS: P = 0.030). Although the ELN-2022 C-index (0.559) was greater than the ELN-2017 C-index (0.539), the result was not statistically significant (P = 0.059). Based on the event net reclassification index, we consistently observed significant improvements in the ELN-2022 risk stratification for overall survival (0.21 at 6 months). CONCLUSION In conclusion, the revised ELN-2022 risk stratification model may have improved the risk classification of elderly AML patients treated with hypomethylating agents compared to the ELN-2017 risk stratification model.
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Affiliation(s)
- Mihee Kim
- Hematology-Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Jeollanam-do, Republic of Korea
| | - Seo-Yeon Ahn
- Hematology-Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Jeollanam-do, Republic of Korea
| | - TaeHyung Kim
- Department of Computer Science, University of Toronto, Toronto, Canada
- The Donnelly Centre for Cellular and Biomolecular Research, University of Toronto, Toronto, Canada
| | - Sung-Hoon Jung
- Hematology-Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Jeollanam-do, Republic of Korea
| | - Ga-Young Song
- Hematology-Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Jeollanam-do, Republic of Korea
| | - Deok-Hwan Yang
- Hematology-Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Jeollanam-do, Republic of Korea
| | - Je-Jung Lee
- Hematology-Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Jeollanam-do, Republic of Korea
| | - Mi Yeon Kim
- Genomic Research Center for Hematopoietic Diseases, Chonnam National University Hwasun Hospital, Jeollanam-do, Republic of Korea
| | - Ju Heon Park
- Genomic Research Center for Hematopoietic Diseases, Chonnam National University Hwasun Hospital, Jeollanam-do, Republic of Korea
| | - Myung-Geun Shin
- Genomic Research Center for Hematopoietic Diseases, Chonnam National University Hwasun Hospital, Jeollanam-do, Republic of Korea
| | - Jae-Sook Ahn
- Hematology-Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Jeollanam-do, Republic of Korea
- Genomic Research Center for Hematopoietic Diseases, Chonnam National University Hwasun Hospital, Jeollanam-do, Republic of Korea
| | - Hyeoung-Joon Kim
- Hematology-Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Jeollanam-do, Republic of Korea
- Genomic Research Center for Hematopoietic Diseases, Chonnam National University Hwasun Hospital, Jeollanam-do, Republic of Korea
| | - Dennis Dong Hwan Kim
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
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Cui J, Chen X, Li C, Yan Q, Yuan G. Reduced duration and dosage of venetoclax is efficient in newly diagnosed patients with acute myeloid leukemia. Hematology 2024; 29:2293512. [PMID: 38095287 DOI: 10.1080/16078454.2023.2293512] [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: 06/27/2023] [Accepted: 12/02/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES The combination of Venetoclax (VEN) and Azacitidine (AZA) increases survival outcomes and yields excellent responses in patients with acute myeloid leukemia (AML). However, dose reduction (or discontinuation) is commonly encountered due to therapy-related toxicity. Thus, this study aimed to investigate the efficiency and safety of a lower dosage of venetoclax for the treatment of AML. METHODS This observational study analyzed the characteristics and outcomes of newly diagnosed AML patients who received 100 mg VEN combined with AZA for 14 days at our institution. RESULTS A total of 36 patients were enrolled, and the median age at diagnosis was 64 years. After a median follow-up of 15 (range 4-29) months, the median overall survival (OS) and progression-free survival (PFS) for the whole cohort were 17 (4-29) months and 12 (1-28) months, respectively. Meanwhile, the overall response rate (ORR) was 69.4%, and the CRc rate was 66.7% in the whole cohort. Subgroup analysis revealed that NPM1 mutations and FAB-M5 subtype were associated with higher response rates, whereas the adverse ELN risk group was predictive of an inferior response. Moreover, ASXL1, NPM1, and IDH1/2 mutations negatively impacted PFS. DISCUSSION Our study optimized the administration of venetoclax plus azacytidine for the treatment of AML patients. Response rates were favorable, with median survival in agreement with the findings of earlier reports, offering valuable insights for optimizing VEN-based regimens. CONCLUSION In summary, the VEN combination regimen is effective for the treatment of newly diagnosed AML patients in the real world despite VEN dose reductions .
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Affiliation(s)
- Jingying Cui
- School of Medicine, Wuhan University of Science and Technology, Wuhan, People's Republic of China
- Department of Hematology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, People's Republic of China
| | - Xuexing Chen
- Department of Hematology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, People's Republic of China
| | - Chunfang Li
- Department of Hematology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, People's Republic of China
| | - Qiong Yan
- Department of Hematology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, People's Republic of China
| | - Guolin Yuan
- Department of Hematology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, People's Republic of China
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He H, Wen X, Zheng H. Efficacy and safety of venetoclax-based combination therapy for previously untreated acute myeloid leukemia: a meta-analysis. Hematology 2024; 29:2343604. [PMID: 38703055 DOI: 10.1080/16078454.2024.2343604] [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: 11/26/2023] [Accepted: 03/24/2024] [Indexed: 05/06/2024] Open
Abstract
PURPOSE To explore the efficacy and safety of venetoclax-based combination therapy for older patients with newly diagnosed acute myeloid leukemia (AML). METHODS We performed a systematic review and meta-analysis of clinical trials comparing venetoclax plus hypomethylating agents (HMAs) or low-dose cytarabine (LDAC) with mono-HMAs or LDAC. The random or fixed effects model was applied to the studies based on heterogeneity. Dichotomous data were summarized using the risk ratio (RR) and 95% confidence interval (CI). Continuous variable data were reported as weighted mean differences (WMDs). RESULTS Nine studies, including a total of 1232 patients, were included in this meta-analysis. Thec complete remission (CR)/complete remission with incomplete hematological recovery (CRi) rate of the venetoclax (Ven) + azacytidine (Aza) group was significantly greater than that of the Aza monotherapy group (RR: 2.42; 95% CI: 1.85-3.15; P < 0.001). Similarly, the CR/CRi rate of the Ven + LDAC group was also significantly greater than that of the LDAC monotherapy group (RR: 2.57; 95% CI: 1.58-4.17; P = 0.00). The same results were observed for OS among these groups. However, the incidence of febrile neutropenia was greater in the Ven + Aza group than in the Ven + Decitabine (Dec) or monotherapy Aza group (RR: 0.69; 95% CI: 0.53-0.90; P = 0.006 and RR: 2.19; 95% CI: 1.58-3.03; P < 0.001, respectively). In addition, the Ven + LDAC group had significantly greater rates of constipation, diarrhea, nausea, and vomiting than the LDAC monotherapy group, with RRs and CIs of 0.61 (95% CI 0.44-0.83, P = 0.002), 1.81 (95% CI 1.22-2.67, P = 0.003), 1.39 (95% CI 1.06-1.82, P = 0.016), and 1.80 (95% CI 1.19-2.72, P = 0.005), respectively. CONCLUSION Venetoclax combined with azacitidine, decitabine, or LDAC significantly improved the CR/CRi and OS of patients with previously untreated AML. However, venetoclax plus azacitidine or LDAC was more likely to lead to increased febrile neutropenia and gastrointestinal toxicity.
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Affiliation(s)
- Hongbo He
- Leukemia Department, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, Beijing, People's Republic of China
- National Key Clinical Discipline of Pediatric Hematology, National Key Discipline of Pediatrics (Capital Medical University)
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, People's Republic of China
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, People's Republic of China
| | - Xiaojia Wen
- Leukemia Department, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, Beijing, People's Republic of China
- National Key Clinical Discipline of Pediatric Hematology, National Key Discipline of Pediatrics (Capital Medical University)
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, People's Republic of China
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, People's Republic of China
| | - Huyong Zheng
- Leukemia Department, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, Beijing, People's Republic of China
- National Key Clinical Discipline of Pediatric Hematology, National Key Discipline of Pediatrics (Capital Medical University)
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, People's Republic of China
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, People's Republic of China
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Ma J, Wang Y. Myeloid neoplasms post cytotoxic therapy: epidemiology, pathogenesis outcomes, prognostic factors, and treatment options. Ann Med 2024; 56:2329132. [PMID: 38608646 PMCID: PMC11018000 DOI: 10.1080/07853890.2024.2329132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 02/23/2024] [Indexed: 04/14/2024] Open
Abstract
Myeloid neoplasms post cytotoxic therapy (MN-pCT) are a category includes AML, MDS, and MDS/MPN arising in patients exposed to cytotoxic (DNA-damaging) therapy for an unrelated condition in 2022 version World Health Organization (WHO) classification. With improved survival of patients with tumors, the incidence of MN-pCT after chemotherapy and/or radiation therapy among patients with tumors has gradually risen. However, the outcome of MN-pCT is poorer than that of primary myeloid neoplasms. This review summarizes the current understanding based on existing research, as a foundation for further research on MN-pCT.
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Affiliation(s)
- Jing Ma
- Department of Hematology and Blood and Marrow Transplantation, Tianjin Cancer Hospital Airport Branch, Tianjin, China
- Department of Hematology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Yafei Wang
- Department of Hematology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
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Ma C, Lang H, Chen Y, Yang L, Wang C, Han L, Chen X, Ma W. Azacitidine combined with venetoclax alleviates AML-MR with TP53 mutation in SDS: a case report and literature review. Anticancer Drugs 2024; 35:548-555. [PMID: 38502829 DOI: 10.1097/cad.0000000000001594] [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: 03/21/2024]
Abstract
Shwachman-Diamond syndrome (SDS) is an autosomal recessive genetic disease, which is prone to transform into myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). TP53 mutation is a driving factor involved in the transformation of SDS into MDS/AML, and in the evolution of MDS to AML. Allogeneic hematopoietic stem cell transplantation (Allo-HSCT) is the only curable approach, however, challenge remains regarding the balance between efficacy and the high risk from treatment-related toxicity and mortality to achieve temporary disease control before transplantation to gain time and opportunities for transplantation. At present, pre-transplant bridging therapy has emerged as one of the important options with improved efficacy, reduced tumor burden, and less treatment-related toxicity. Here we reported azacitidine combined with venetoclax was used as pre-transplant bridging regimen in a TP53-mutant AML-MR case developed from SDS. He achieved complete remission with incomplete recovery and proceeded to Allo-HSCT. We hope to provide some evidence and insight for in-depth research and clinical treatment by presenting this case.
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Affiliation(s)
- Cuiping Ma
- The First Clinical Medical College of Beijing University of Traditional Chinese Medicine
| | - Haiyan Lang
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing
| | - Yuhan Chen
- Shenzhen Luohu District Hospital of Traditional Chinese Medicine, Guangdong, China
| | - Lu Yang
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing
| | - Chong Wang
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing
| | - Lizhen Han
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing
| | - Xinyi Chen
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing
| | - Wei Ma
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing
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Sun Y, Zhu G, Zhong H. Minimal residual disease monitoring in acute myeloid leukemia: Focus on MFC-MRD and treatment guidance for elderly patients. Eur J Haematol 2024; 112:870-878. [PMID: 38342613 DOI: 10.1111/ejh.14187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/25/2024] [Accepted: 01/27/2024] [Indexed: 02/13/2024]
Abstract
Acute myeloid leukemia (AML) is distinguished by clonal growth of myeloid precursor cells, which impairs normal hematopoiesis. Minimal residual disease (MRD) refers to the residual leukemia cells that persist after chemotherapy. Patients who test positive for MRD have a higher likelihood of experiencing a recurrence, regardless of the specific chemotherapy approach used. Multi-parameter flow cytometry (MFC), polymerase chain reaction (PCR), and next-generation sequencing (NGS) are commonly employed techniques for identifying MRD. In the context of AML, patients are frequently monitored for measurable residual disease via multi-parameter flow cytometry (MFC-MRD). In order to explore recent advancements in AML and MRD diagnosis, an extensive search of the PubMed database was conducted, focusing on relevant research in the past 20 years. This review aims to examine various MRD monitoring methods, the optimal time points for assessment, as well as different specimen types used. Additionally, it underscores the significance of MFC-MRD assessment in guiding the treatment of elderly AML.
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Affiliation(s)
- Yue Sun
- Department of Hematology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Gelan Zhu
- Department of Hematology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Hua Zhong
- Department of Hematology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
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Bruzzese A, Vigna E, Martino EA, Labanca C, Mendicino F, Lucia E, Olivito V, Stanzione G, Zimbo A, Lugli E, Neri A, Morabito F, Gentile M. The potential of triplet combination therapies for patients with FLT3-ITD -mutated acute myeloid leukemia. Expert Rev Hematol 2024; 17:241-253. [PMID: 38748404 DOI: 10.1080/17474086.2024.2356258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 05/13/2024] [Indexed: 05/21/2024]
Abstract
INTRODUCTION Acute myeloid leukemia (AML) encompasses a heterogeneous group of aggressive myeloid malignancies, where FMS-like tyrosine kinase 3 (FLT3) mutations are prevalent, accounting for approximately 25-30% of adult patients. The presence of this mutation is related to a dismal prognosis and high relapse rates. In the lasts years many FLT3 inhibitors have been developed. AREAS COVERED This review provides a comprehensive overview of FLT3mut AML, summarizing the state of art of current treatment and available data about combination strategies including an FLT3 inhibitor. EXPERT OPINION In addition, the review discusses the emergence of drug resistance and the need for a nuanced approaches in treating patients who are ineligible for or resistant to intensive chemotherapy. Specifically, it explores the historical context of FLT3 inhibitors (FLT3Is) and their impact on treatment outcomes, emphasizing the pivotal role of midostaurin, as well as gilteritinib and quizartinib, and providing detailed insights into ongoing trials exploring the safety and efficacy of novel triplet combinations involving FLT3Is in different AML settings.
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Affiliation(s)
| | - Ernesto Vigna
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | | | | | | | - Eugenio Lucia
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | | | - Gaia Stanzione
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
- Division of Hematology, Azienda Policlinico-S. Marco, University of Catania, Catania, Italy
| | - Annamaria Zimbo
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
- UOC Laboratorio Analisi Cliniche, Biomolecolari e Genetica, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | - Elisabetta Lugli
- Ematologia Azienda USL-IRCSS Reggio Emilia, Emilia-Romagna, Italy
| | - Antonino Neri
- Scientific Directorate IRCCS of Reggio Emilia, Emilia-Romagna, Reggio Emilia, Italy
| | | | - Massimo Gentile
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
- Department of Pharmacy, Health and Nutritional Science, University of Calabria, Rende, Italy
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Zhang H, Liu J, Wu Q, Xia L. Venetoclax combined with decitabine induced tumor lysis syndrome in a young patient with acute myeloid leukemia: a case report and literature review. Anticancer Drugs 2024; 35:440-444. [PMID: 38386312 DOI: 10.1097/cad.0000000000001580] [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: 02/23/2024]
Abstract
Venetoclax, in combination with hypomethylation agents (HMAs), is a novel treatment for leukemia patients with low chemotherapy tolerance. However, it has been reported to be a risk of causing tumor lysis syndrome (TLS) in chronic lymphocytic leukemia (CLL) and elderly acute myeloid leukemia (AML) patients. Here we report a rare case of a young adult AML patient who induced TLS after receiving a combination therapy of venetoclax with decitabine (DEC). A 36-year-old male patient presented with an unexplained fever and was diagnosed with AML-M5a. The patient was first treated with a combination of antibiotics, including voriconazole 300 mg Q12h. After the infection was relieved, he was treated with 100 mg venetoclax in combination with 75 mg/m 2 DEC. However, 12 h after the first treatment, he developed diarrhea, fatigue and other symptoms, and the laboratory results were consistent with the laboratory TLS. The patient stopped chemotherapy immediately, and TLS gradually improved after receiving rehydration, diuresis, dialysis and other treatments. Finally, the patient achieved complete remission. Based on the experience of this case and related studies, we recommend the prevention of TLS should not be limited to elderly patients taking venetoclax, and it is equally important in young patients. And reduce the dosage of venetoclax when using azole antifungal drugs.
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Affiliation(s)
- Hongyong Zhang
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Nakamura N, Yamamoto N, Kondo T, Matsumoto M, Ikunari R, Sakai T, Tanaka Y, Tsunemine H, Takeda J, Kanda J, Nannya Y, Ogawa S, Takaori-Kondo A, Arima N. Sustained remission after cord blood transplantation for breast cancer with lung metastases and myelodysplastic syndrome. Int J Hematol 2024; 119:762-767. [PMID: 38523199 DOI: 10.1007/s12185-024-03762-8] [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: 12/06/2023] [Revised: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 03/26/2024]
Abstract
Allogenic hematopoietic stem cell transplantation (allo-HSCT) is not a standard therapy for solid cancer because of its high toxicity and insufficient evidence levels. However, the potential graft-versus-solid-tumor (GVT) effect of this therapy has been discussed. Many case reports have also described treatment effects of allo-HSCT in patients with hematologic malignancies and active solid tumors. A 38-year-old woman treated with fulvestrant and abemaciclib for recurrent breast cancer with multiple lung metastases was diagnosed with myelodysplastic syndrome (MDS) with increased blasts 2. She was classified as adverse risk by the 2017 European LeukemiaNet risk stratification and as very high risk by the Molecular International Prognostic Scoring System. Breast cancer treatment was interrupted and venetoclax and azacitidine therapy was started. Complete hematologic response was achieved after three cycles. However, multiple lung metastases from the breast cancer remained. The patient then underwent umbilical cord blood transplantation. She has maintained complete remission of MDS as of 1 year post-transplantation, without serious complications. Lung metastatic activity on FDG-PET/CT scan also completely disappeared by half a year post-transplantation, and this response has continued as of 1 year post-transplantation. This favorable treatment course suggests the existence of a GVT effect.
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Affiliation(s)
- Naokazu Nakamura
- Department of Hematology, Shinko Hospital, 1-4-47, Wakihamacho, Chuo-Ku, Kobe, Hyogo, 651-0072, Japan.
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Nao Yamamoto
- Department of Breast Surgery and Oncology, Shinko Hospital, Kobe, Japan
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Mayumi Matsumoto
- Department of Hematology, Shinko Hospital, 1-4-47, Wakihamacho, Chuo-Ku, Kobe, Hyogo, 651-0072, Japan
| | - Ryo Ikunari
- Department of Hematology, Shinko Hospital, 1-4-47, Wakihamacho, Chuo-Ku, Kobe, Hyogo, 651-0072, Japan
| | - Tomomi Sakai
- Department of Hematology, Shinko Hospital, 1-4-47, Wakihamacho, Chuo-Ku, Kobe, Hyogo, 651-0072, Japan
- Department of Hematology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yasuhiro Tanaka
- Department of Hematology, Shinko Hospital, 1-4-47, Wakihamacho, Chuo-Ku, Kobe, Hyogo, 651-0072, Japan
| | - Hiroko Tsunemine
- Department of Hematology, Shinko Hospital, 1-4-47, Wakihamacho, Chuo-Ku, Kobe, Hyogo, 651-0072, Japan
| | - June Takeda
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yasuhito Nannya
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Division of Hematopoietic Disease Control, Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Seishi Ogawa
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Nobuyoshi Arima
- Department of Hematology, Shinko Hospital, 1-4-47, Wakihamacho, Chuo-Ku, Kobe, Hyogo, 651-0072, Japan
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Santini V, Stahl M, Sallman DA. TP53 Mutations in Acute Leukemias and Myelodysplastic Syndromes: Insights and Treatment Updates. Am Soc Clin Oncol Educ Book 2024; 44:e432650. [PMID: 38768424 DOI: 10.1200/edbk_432650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
TP53 mutations are found in 5%-10% of de novo myelodysplastic syndrome (MDS) and AML cases. By contrast, in therapy related MDS and AML, mutations in TP53 are found in up to 30%-40% of patients. The majority of inactivating mutations observed in MDS and AML are missense mutations localized in a few prevalent hotspots. TP53 missense mutations together with truncating mutations or chromosomal loss of TP53 determine a loss-of-function effect on normal p53 function. Clonal expansion of TP53-mutant clones is observed under the selection pressure of chemotherapy or MDM2 inhibitor therapy. TP53-mutant clones are resistant to current chemotherapy, and when responses to treatment have been observed, they have correlated poorly with overall survival. The most heavily investigated and targeted agent for patients with TP53-mutant MDS and AML has been APR-246 (eprenetapopt) a p53 reactivator, in combination with azacitidine, but also in triplets with venetoclax. Despite positive results in phase II trials, a phase III trial did not confirm superior response or improved survival. Other agents, like magrolimab (anti-CD47 antibody), failed to demonstrate improved activity in TP53-mutant MDS and AML. Agents whose activity is not dependent on a functional apoptosis system like anti-CD123 antibodies or cellular therapies are in development and may hold promises. Delivering prognostic information in a dismal disease like TP53-mutated MDS and AML is particularly challenging. The physician should balance hope and realism, describing the trajectory of possible treatments and at the same time indicating the poor outcome, together with promoting adaptive coping in patients and elaborating on the nature of the disease.
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Affiliation(s)
- Valeria Santini
- MDS Unit, Hematology, DMSC, AOUC University of Florence, Florence, Italy
| | - Maximilian Stahl
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | - David A Sallman
- Department of Malignant Hematology, Moffitt Cancer Center and Research Institute, Tampa, FL
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12
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Kewan T, Stahl M, Bewersdorf JP, Zeidan AM. Treatment of Myelodysplastic Syndromes for Older Patients: Current State of Science, Challenges, and Opportunities. Curr Hematol Malig Rep 2024; 19:138-150. [PMID: 38632155 DOI: 10.1007/s11899-024-00733-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE OF REVIEW Myelodysplastic syndromes/neoplasms (MDS) represent a diverse group of pathologically distinct diseases with varying prognoses and risks of leukemia progression. This review aims to discuss current treatment options for elderly patients with MDS, focusing on patients ineligible for intensive chemotherapy or allogenic hematopoietic stem cell transplantation (HSCT). The challenges associated with treatment in this population and emerging therapeutic prospects are also explored. RECENT FINDINGS Recent advancements in molecular diagnostics have enhanced risk stratification by incorporating genetic mutations, notably through the molecular International Prognostic Scoring System (IPSS-M). Lower-risk MDS (LR-MDS) treatment ranges from observation to supportive measures and erythropoiesis-stimulating agents (ESAs), with emerging therapies like luspatercept showing promise. High-risk MDS (HR-MDS) is treated with hypomethylating agents (HMAs) or allogenic HSCT, but outcomes remain poor. Elderly MDS patients, often diagnosed after 70, pose challenges in treatment decision-making. The IPSS-M aids risk stratification, guiding therapeutic choices. For LR-MDS, supportive care, ESAs, and novel agents like luspatercept are considered. Treatment of HR-MDS involves HMAs or allogenic HSCT. Emerging treatments, including oral HMAs and novel agents targeting FLT3, and IDH 1/2 mutations, show promise. Future research should refine treatment strategies for this elderly population focusing on quality-of-life improvement.
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Affiliation(s)
- Tariq Kewan
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, and Yale Comprehensive Cancer Center, Yale University, New Haven, CT, USA
| | - Maximillian Stahl
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Jan Philipp Bewersdorf
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, and Yale Comprehensive Cancer Center, Yale University, New Haven, CT, USA.
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13
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Berton G, Sedaki B, Collomb E, Benachour S, Loschi M, Mohty B, Saillard C, Hicheri Y, Rouzaud C, Maisano V, Villetard F, Corda ED'I, Charbonnier A, Rey J, Hospital MA, Ittel A, Abbou N, Fanciullino R, Dadone-Montaudié B, Vey N, Venton G, Cluzeau T, Alary AS, Garciaz S. Poor prognosis of SRSF2 gene mutations in patients treated with VEN-AZA for newly diagnosed acute myeloid leukemia. Leuk Res 2024; 141:107500. [PMID: 38636413 DOI: 10.1016/j.leukres.2024.107500] [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: 03/04/2024] [Revised: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 04/20/2024]
Abstract
Mutations in spliceosome genes (SRSF2, SF3B1, U2AF1, ZRSR2) correlate with inferior outcomes in patients treated with intensive chemotherapy for Acute Myeloid Leukemia. However, their prognostic impact in patients treated with less intensive protocols is not well known. This study aimed to evaluate the impact of Spliceosome mutations in patients treated with Venetoclax and Azacitidine for newly diagnosed AML. 117 patients treated in 3 different hospitals were included in the analysis. 34 harbored a mutation in at least one of the spliceosome genes (splice-mut cohort). K/NRAS mutations were more frequent in the splice-mut cohort (47% vs 19%, p=0.0022). Response rates did not differ between splice-mut and splice-wt cohorts. With a median follow-up of 15 months, splice mutations were associated with a lower 18-month LFS (p=0.0045). When analyzing splice mutations separately, we found SRSF2 mutations to be associated with poorer outcomes (p=0.034 and p=0.037 for OS and LFS respectively). This negative prognostic impact remained true in our multivariate analysis. We believe this finding should warrant further studies aimed at overcoming this negative impact.
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Affiliation(s)
- Guillaume Berton
- Department of Hematology, Institut Paoli-Calmettes, Marseille, France.
| | - Bochra Sedaki
- Department of Hematology, University Hospital Centre L'Archet, Nice, France
| | - Erwann Collomb
- Department of Hematology and Cellular Therapy, La Conception Hospital, Marseille, France
| | - Sami Benachour
- Department of Hematology, University Hospital Centre L'Archet, Nice, France
| | - Michael Loschi
- Department of Hematology, University Hospital Centre L'Archet, Nice, France
| | - Bilal Mohty
- Department of Hematology, Institut Paoli-Calmettes, Marseille, France
| | - Colombe Saillard
- Department of Hematology, Institut Paoli-Calmettes, Marseille, France
| | - Yosr Hicheri
- Department of Hematology, Institut Paoli-Calmettes, Marseille, France
| | - Camille Rouzaud
- Department of Hematology, Institut Paoli-Calmettes, Marseille, France
| | - Valerio Maisano
- Department of Hematology, Institut Paoli-Calmettes, Marseille, France
| | | | | | - Aude Charbonnier
- Department of Hematology, Institut Paoli-Calmettes, Marseille, France
| | - Jerome Rey
- Department of Hematology, Institut Paoli-Calmettes, Marseille, France
| | - Marie-Anne Hospital
- Department of Hematology, Institut Paoli-Calmettes, Marseille, France; Aix-Marseille University, INSERM U1068, CNRS, Institut Paoli-Calmettes, CRCM, Marseille, France
| | - Antoine Ittel
- Department of Molecular Biology, Institut Paoli-Calmettes, Marseille, France
| | - Norman Abbou
- Department of Molecular Biology, Hôpital Nord, Marseille, France
| | - Raphaelle Fanciullino
- SMARTc: Simulation and Modeling: Adaptative Response for Therapeutics in Cancer, Marseille, France; Faculté de Pharmacie de Marseille, CRCM Inserm UMR, Marseille 1068, France; Pharmacy, Hôpital de la Conception, Marseille, France
| | | | - Norbert Vey
- Department of Hematology, Institut Paoli-Calmettes, Marseille, France; Aix-Marseille University, INSERM U1068, CNRS, Institut Paoli-Calmettes, CRCM, Marseille, France
| | - Geoffroy Venton
- Department of Hematology and Cellular Therapy, La Conception Hospital, Marseille, France
| | - Thomas Cluzeau
- Department of Hematology, University Hospital Centre L'Archet, Nice, France; INSERMU1065, C3M / Cote d'Azur University; Nice, France
| | - Anne-Sophie Alary
- Department of Molecular Biology, Institut Paoli-Calmettes, Marseille, France
| | - Sylvain Garciaz
- Department of Hematology, Institut Paoli-Calmettes, Marseille, France; Aix-Marseille University, INSERM U1068, CNRS, Institut Paoli-Calmettes, CRCM, Marseille, France
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14
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Patnaik MM, Tefferi A. Chronic myelomonocytic leukemia: 2024 update on diagnosis, risk stratification and management. Am J Hematol 2024; 99:1142-1165. [PMID: 38450850 PMCID: PMC11096042 DOI: 10.1002/ajh.27271] [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: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 03/08/2024]
Abstract
DISEASE OVERVIEW Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping features of myelodysplastic syndromes and myeloproliferative neoplasms, characterized by prominent monocytosis and an inherent risk for leukemic transformation (~15%-20% over 3-5 years). DIAGNOSIS Newly revised diagnostic criteria include sustained (>3 months) peripheral blood (PB) monocytosis (≥0.5 × 109/L; monocytes ≥10% of leukocyte count), consistent bone marrow (BM) morphology, <20% BM or PB blasts (including promonocytes), and cytogenetic or molecular evidence of clonality. Cytogenetic abnormalities occur in ~30% of patients, while >95% harbor somatic mutations: TET2 (~60%), SRSF2 (~50%), ASXL1 (~40%), RAS pathway (~30%), and others. The presence of ASXL1 and DNMT3A mutations and absence of TET2 mutations negatively impact overall survival (ASXL1WT/TET2MT genotype being favorable). RISK STRATIFICATION Several risk models serve similar purposes in identifying high-risk patients that are considered for allogeneic stem cell transplant (ASCT) earlier than later. Risk factors in the Mayo Molecular Model (MMM) include presence of truncating ASXL1 mutations, absolute monocyte count >10 × 109/L, hemoglobin <10 g/dL, platelet count <100 × 109/L, and the presence of circulating immature myeloid cells; the resulting 4-tiered risk categorization includes high (≥3 risk factors), intermediate-2 (2 risk factors), intermediate-1 (1 risk factor), and low (no risk factors); the corresponding median survivals were 16, 31, 59, and 97 months. CMML is also classified as being "myeloproliferative (MP-CMML)" or "myelodysplastic (MD-CMML)," based on the presence or absence of leukocyte count of ≥13 × 109/L. TREATMENT ASCT is the only treatment modality that secures cure or long-term survival and is appropriate for MMM high/intermediate-2 risk disease. Drug therapy is currently not disease-modifying and includes hydroxyurea and hypomethylating agents; a recent phase-3 study (DACOTA) comparing hydroxyurea and decitabine, in high-risk MP-CMML, showed similar overall survival at 23.1 versus 18.4 months, respectively, despite response rates being higher for decitabine (56% vs. 31%). UNIQUE DISEASE ASSOCIATIONS These include systemic inflammatory autoimmune diseases, leukemia cutis and lysozyme-induced nephropathy; the latter requires close monitoring of renal function during leukocytosis and is a potential indication for cytoreductive therapy.
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Affiliation(s)
- Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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15
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Mangan BL, DuMontier C, Hopkins JO, Abel GA, McCurdy SR. Tailoring Therapy in Older Adults With Hematologic Malignancies. Am Soc Clin Oncol Educ Book 2024; 44:e432220. [PMID: 38788182 DOI: 10.1200/edbk_432220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Hematologic malignancies most often present in the sixth or seventh decade of life. Even so, many older adults may be unable to tolerate standard chemotherapy or require supplementary care or dose adjustments to do so. Both in community and academic centers, geriatric assessment (GA) can be used to improve the care of older adults with blood cancers. For example, hematologic oncologists can use GA to guide treatment selection, adjusting for patient frailty and goals, as well as prompt initiation of enhanced supportive care. After initial therapy, GA can improve the identification of older adults with aggressive myeloid malignancies who would benefit from hematopoietic cell transplantation (HCT), inform shared decision making, as well as allow transplanters to tailor conditioning regimen, donor selection, graft-versus-host disease prophylaxis, and pre- and post-HCT treatments. As in HCT, GA can improve the care of older patients with relapsed lymphoma or multiple myeloma eligible for chimeric antigen receptor-T therapy, identifying patients at higher risk for toxicity and providing a baseline for subsequent neurocognitive testing. Here, we review the data supporting GA for the care of older adults with blood cancers, from the community to the academic center. In addition, we explore future directions to optimize outcomes for older adults with hematologic malignancies.
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Affiliation(s)
- Brendan L Mangan
- Department of Pharmacy, University of Pennsylvania, Philadelphia, PA
| | - Clark DuMontier
- Brigham and Women's Hospital, Boston, MA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | | | - Gregory A Abel
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | - Shannon R McCurdy
- Division of Hematology-Oncology/Department of Medicine, University of Pennsylvania, Philadelphia, PA
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16
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Ionescu F, David JC, Ravichandran A, Sallman DA, Sweet K, Komrokji RS, Chan O, Kuykendall A, Padron E, Faramand R, Bejanyan N, Khimani F, Elmariah H, Pidala J, Mishra A, Perez L, Nishihori T, Lancet JE. Hypomethylating Agents and Venetoclax for Acute Myeloid Leukemia Relapsed After Hematopoietic Stem Cell Transplant. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:400-406. [PMID: 38429222 DOI: 10.1016/j.clml.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Hypomethylating agent + venetoclax is an effective frontline combination for acute myeloid leukemia, but its efficacy and safety in post-allogeneic hematopoietic cell transplant (alloHCT) relapse remain underexplored. Outcomes have been poor for this population, with no standard treatment. PATIENTS AND METHODS We retrospectively analyzed 72 Ven-naïve patients who received hypomethylating agents + venetoclax at relapse following alloHCT and aimed to evaluate the rates of complete remission with or without hematologic recovery (CR/CRi) and minimal residual disease (MRD) negativity, CR/CRi duration, and overall survival. We leveraged our larger sample to analyze the impact of cytogenetic/molecular features on the odds of CR/CRi. RESULTS CR/CRi was achieved among 32 of 67 (48%) patients, and MRD negativity was recorded among 10 of 12. NPM1 and IDH 1 or 2 mutations increased the odds of CR/CRi, as did increasing time from alloHCT to relapse. Fourteen patients subsequently received donor lymphocyte infusions or a second alloHCT. Responses lasted a median of 17.8 months (95% CI, 7.2 months to not reached), and responders had a greater median overall survival of 19.7 months (95% CI, 7.6-51.5 months) compared to 2.9 months among nonresponders (95% CI, 1.8-4.4 months; log-rank P < .01). Treatment was well tolerated, but prolonged cytopenias were common and most patients required reduction in the number of venetoclax days per cycle. CONCLUSION These data support the efficacy of this combination in the alloHCT relapse setting where we report responses among nearly half of patients, with possibly greater benefit for NPM1 and IDH 1/2-mutated cases. These responses can be durable and profound as evidenced by conversion to MRD negativity.
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Affiliation(s)
- Filip Ionescu
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Jerel C David
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL
| | | | - David A Sallman
- Department of Malignant Hematology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Kendra Sweet
- Department of Malignant Hematology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Rami S Komrokji
- Department of Malignant Hematology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Onyee Chan
- Department of Malignant Hematology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Andrew Kuykendall
- Department of Malignant Hematology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Eric Padron
- Department of Malignant Hematology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Rawan Faramand
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Nelli Bejanyan
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Farhad Khimani
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Hany Elmariah
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Joseph Pidala
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Asmita Mishra
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Lia Perez
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jeffrey E Lancet
- Department of Malignant Hematology, Moffitt Cancer Center and Research Institute, Tampa, FL.
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17
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Kelly LM, Rutter JC, Lin KH, Ling F, Duchmann M, Latour E, Arang N, Pasquer H, Ho Nhat D, Charles J, Killarney ST, Ang HX, Namor F, Culeux C, Lombard B, Loew D, Swaney DL, Krogan NJ, Brunel L, Carretero É, Verdié P, Amblard M, Fodil S, Huynh T, Sebert M, Adès L, Raffoux E, Fenouille N, Itzykson R, Lobry C, Benajiba L, Forget A, Martin AR, Wood KC, Puissant A. Targeting a lineage-specific PI3Kɣ-Akt signaling module in acute myeloid leukemia using a heterobifunctional degrader molecule. NATURE CANCER 2024:10.1038/s43018-024-00782-5. [PMID: 38816660 DOI: 10.1038/s43018-024-00782-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 05/13/2024] [Indexed: 06/01/2024]
Abstract
Dose-limiting toxicity poses a major limitation to the clinical utility of targeted cancer therapies, often arising from target engagement in nonmalignant tissues. This obstacle can be minimized by targeting cancer dependencies driven by proteins with tissue-restricted and/or tumor-restricted expression. In line with another recent report, we show here that, in acute myeloid leukemia (AML), suppression of the myeloid-restricted PIK3CG/p110γ-PIK3R5/p101 axis inhibits protein kinase B/Akt signaling and compromises AML cell fitness. Furthermore, silencing the genes encoding PIK3CG/p110γ or PIK3R5/p101 sensitizes AML cells to established AML therapies. Importantly, we find that existing small-molecule inhibitors against PIK3CG are insufficient to achieve a sustained long-term antileukemic effect. To address this concern, we developed a proteolysis-targeting chimera (PROTAC) heterobifunctional molecule that specifically degrades PIK3CG and potently suppresses AML progression alone and in combination with venetoclax in human AML cell lines, primary samples from patients with AML and syngeneic mouse models.
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Affiliation(s)
- Lois M Kelly
- INSERM UMR 944, IRSL, Saint-Louis Hospital, Paris Cité University, Paris, France
| | - Justine C Rutter
- Department of Pharmacology and Cancer Biology, Duke University, Durham, NC, USA
| | - Kevin H Lin
- Department of Pharmacology and Cancer Biology, Duke University, Durham, NC, USA
| | - Frank Ling
- INSERM UMR 944, IRSL, Saint-Louis Hospital, Paris Cité University, Paris, France
| | - Matthieu Duchmann
- INSERM UMR 944, IRSL, Saint-Louis Hospital, Paris Cité University, Paris, France
| | - Emmanuelle Latour
- INSERM UMR 944, IRSL, Saint-Louis Hospital, Paris Cité University, Paris, France
| | - Nadia Arang
- Quantitative Biosciences Institute (QBI), University of California, San Francisco, San Francisco, CA, USA
- Department of Cellular and Molecular Pharmacology, University of California San Francisco, San Francisco, CA, USA
| | - Hélène Pasquer
- INSERM UMR 944, IRSL, Saint-Louis Hospital, Paris Cité University, Paris, France
| | - Duong Ho Nhat
- INSERM UMR 944, IRSL, Saint-Louis Hospital, Paris Cité University, Paris, France
| | - Juliette Charles
- INSERM UMR 944, IRSL, Saint-Louis Hospital, Paris Cité University, Paris, France
| | - Shane T Killarney
- Department of Pharmacology and Cancer Biology, Duke University, Durham, NC, USA
| | - Hazel X Ang
- Department of Pharmacology and Cancer Biology, Duke University, Durham, NC, USA
| | - Federica Namor
- INSERM UMR 944, IRSL, Saint-Louis Hospital, Paris Cité University, Paris, France
| | - Cécile Culeux
- INSERM UMR 944, IRSL, Saint-Louis Hospital, Paris Cité University, Paris, France
| | - Bérangère Lombard
- Curie Institute, Mass Spectrometry and Proteomics Facility, PSL Research University, Paris, France
| | - Damarys Loew
- Curie Institute, Mass Spectrometry and Proteomics Facility, PSL Research University, Paris, France
| | - Danielle L Swaney
- Quantitative Biosciences Institute (QBI), University of California, San Francisco, San Francisco, CA, USA
- Department of Cellular and Molecular Pharmacology, University of California San Francisco, San Francisco, CA, USA
- Gladstone Institutes, San Francisco, California, USA
| | - Nevan J Krogan
- Quantitative Biosciences Institute (QBI), University of California, San Francisco, San Francisco, CA, USA
- Department of Cellular and Molecular Pharmacology, University of California San Francisco, San Francisco, CA, USA
- Gladstone Institutes, San Francisco, California, USA
| | - Luc Brunel
- IBMM, University of Montpellier, CNRS, ENSCM, Montpellier, France
| | - Élodie Carretero
- IBMM, University of Montpellier, CNRS, ENSCM, Montpellier, France
| | - Pascal Verdié
- IBMM, University of Montpellier, CNRS, ENSCM, Montpellier, France
| | - Muriel Amblard
- IBMM, University of Montpellier, CNRS, ENSCM, Montpellier, France
| | - Sofiane Fodil
- Department of Hematology and Immunology, Saint-Louis Hospital, AP-HP, Paris Cité University, Paris, France
| | - Tony Huynh
- Department of Hematology and Immunology, Saint-Louis Hospital, AP-HP, Paris Cité University, Paris, France
| | - Marie Sebert
- INSERM UMR 944, IRSL, Saint-Louis Hospital, Paris Cité University, Paris, France
- Department of Hematology and Immunology, Saint-Louis Hospital, AP-HP, Paris Cité University, Paris, France
| | - Lionel Adès
- INSERM UMR 944, IRSL, Saint-Louis Hospital, Paris Cité University, Paris, France
- Department of Hematology and Immunology, Saint-Louis Hospital, AP-HP, Paris Cité University, Paris, France
| | - Emmanuel Raffoux
- INSERM UMR 944, IRSL, Saint-Louis Hospital, Paris Cité University, Paris, France
- Department of Hematology and Immunology, Saint-Louis Hospital, AP-HP, Paris Cité University, Paris, France
| | - Nina Fenouille
- INSERM UMR 944, IRSL, Saint-Louis Hospital, Paris Cité University, Paris, France
| | - Raphaël Itzykson
- INSERM UMR 944, IRSL, Saint-Louis Hospital, Paris Cité University, Paris, France
- Department of Hematology and Immunology, Saint-Louis Hospital, AP-HP, Paris Cité University, Paris, France
| | - Camille Lobry
- INSERM UMR 944, IRSL, Saint-Louis Hospital, Paris Cité University, Paris, France
| | - Lina Benajiba
- INSERM UMR 944, IRSL, Saint-Louis Hospital, Paris Cité University, Paris, France
- Clinical Investigation Center, Saint-Louis Hospital, AP-HP, Paris Cité University, Paris, France
| | - Antoine Forget
- Quantitative Biosciences Institute (QBI), University of California, San Francisco, San Francisco, CA, USA
- Department of Cellular and Molecular Pharmacology, University of California San Francisco, San Francisco, CA, USA
| | - Anthony R Martin
- IBMM, University of Montpellier, CNRS, ENSCM, Montpellier, France.
| | - Kris C Wood
- Department of Pharmacology and Cancer Biology, Duke University, Durham, NC, USA.
| | - Alexandre Puissant
- INSERM UMR 944, IRSL, Saint-Louis Hospital, Paris Cité University, Paris, France.
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18
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Senapati J, Kantarjian HM, Bazinet A, Reville P, Short NJ, Daver N, Borthakur G, Bataller A, Jabbour E, DiNardo C, Haddad F, Sasaki K, Popat U, Oran B, Alousi AM, Loghavi S, Shpall E, Garcia-Manero G, Ravandi F, Kadia TM. Lower intensity therapy with cladribine/low dose cytarabine/venetoclax in older patients with acute myeloid leukemia compares favorably with intensive chemotherapy among patients undergoing allogeneic stem cell transplantation. Cancer 2024. [PMID: 38809547 DOI: 10.1002/cncr.35388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/11/2024] [Accepted: 05/08/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Allogeneic stem cell transplantation (SCT) remains the best consolidative modality in most patients with acute myeloid leukemia (AML). Along with factors directly pertaining to SCT, pretransplantation disease control, performance status, and prior treatment-related complications are important factors that affect posttransplantation survival outcomes. METHODS The authors compared the survival outcomes of patients ≥60 years of age treated on the phase 2 clinical trial of venetoclax (Ven) added to cladribine (CLAD) and low dose cytarabine (LDAC) alternating with azacitidine (CLAD/LDAC/Ven arm) (NCT03586609) who underwent allogeneic SCT in first remission to a retrospective cohort of patients ≥60 years of age who underwent SCT after intensive chemotherapy. Intensive chemotherapy was defined as the use of cytarabine >1 g/m2 and anthracyclines during induction/consolidation. RESULTS Thirty-five patients at median age of 68 years in the CLAD/LDAC/Ven arm were compared to 42 patients at a median age of 62 years in the intensive therapy arm. The 2-year relapse-free survival was superior with CLAD/LDAC/Ven versus intensive chemotherapy (88% vs. 65%; p = .03) whereas the 2-year overall survival (OS) was comparable (84% vs. 70%; p = .14). On a competing event analysis, the 2-year cumulative incidence of relapse (CIR) was significantly lower with CLAD/LDAC/Ven versus intensive chemotherapy (2.9% vs. 17.2%, Gray's p = .049) whereas nonrelapse mortality was comparable (16.2% vs. 17.1%; p = .486). CONCLUSION In conclusion, treatment with CLAD/LDAC/Ven was associated with favorable outcomes in older patients who underwent subsequent allogeneic SCT. The OS was comparable to that with intensive chemotherapy followed by allogeneic SCT, but the CIR rate was significantly lower.
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Affiliation(s)
- Jayastu Senapati
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alexandre Bazinet
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Patrick Reville
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alex Bataller
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Courtney DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Fadi Haddad
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Betul Oran
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amin M Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elizabeth Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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19
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Kobayashi T, Sato H, Miura M, Fukushi Y, Kuroki W, Ito F, Teshima K, Watanabe A, Fujishima N, Kobayashi I, Kameoka Y, Takahashi N. Overexposure to venetoclax is associated with prolonged-duration of neutropenia during venetoclax and azacitidine therapy in Japanese patients with acute myeloid leukemia. Cancer Chemother Pharmacol 2024:10.1007/s00280-024-04673-5. [PMID: 38782790 DOI: 10.1007/s00280-024-04673-5] [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: 01/22/2024] [Accepted: 05/01/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE An observational study was conducted to evaluate the pharmacokinetics of venetoclax and its impact on the efficacy and safety for Japanese patients with acute myeloid leukemia (AML) treated with venetoclax and azacitidine therapy. METHODS The association between the plasma concentration, after the first cycle of azacitidine and venetoclax therapy, and the efficacy and safety was evaluated in 33 patients with untreated or relapsed/refractory AML. RESULTS Full dose of venetoclax was administered to all patients. Venetoclax treatment was 28 day long in 82% of patients; the relative dose intensity of azacitidine was 82%. Trough concentration was significantly higher among patients with complete remission (CR) and CR with incomplete hematologic recovery (CRi) than those with the morphologic leukemia-free state and partial remission, and no response groups (P = 0.01). Median duration of grade 3 neutropenia was 28 days (range 8-46 days). Area under the concentration-time curve (AUC0-24) was significantly higher among patients with protracted grade 3 neutropenia (≥ 28 days) than those with a shorter duration (< 28 days) (P = 0.03); multivariate analysis revealed that a higher AUC0-24 was a significant predictor of a longer duration of neutropenia (odds ratio 54.3, P = 0.007). CONCLUSION Plasma concentrations of venetoclax were variable in Japanese patients with AML. Higher plasma concentrations were associated with CR/CRi and protracted grade 3 neutropenia. Therefore, it is essential to adjust the duration of venetoclax administration based on individual pharmacokinetic data to limit total drug exposure, reduce severe neutropenia, and achieve higher efficacy.
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Affiliation(s)
- Takahiro Kobayashi
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita City, Akita, Japan.
| | - Honami Sato
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita City, Akita, Japan
| | - Masatomo Miura
- Department of Pharmacokinetics, Akita University Graduate School of Medicine, Akita, Japan
| | - Yayoi Fukushi
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Wataru Kuroki
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita City, Akita, Japan
- Department of Internal Medicine, Yuri Kumiai General Hospital, Yurihonjo, Japan
| | - Fumiko Ito
- Department of Hematology, Akita City Hospital, Akita, Japan
| | - Kazuaki Teshima
- Department of Hematology, Hiraka General Hospital, Yokote, Japan
| | - Atsushi Watanabe
- Department of Hematology, Nephrology and Rheumatology, Omagari Kousei Medical Center, Daisen, Japan
| | - Naohito Fujishima
- Department of Hematology, Nephrology and Rheumatology, Noshiro Kousei Medical Center, Noshiro, Japan
| | - Isuzu Kobayashi
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita City, Akita, Japan
| | - Yoshihiro Kameoka
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita City, Akita, Japan
| | - Naoto Takahashi
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita City, Akita, Japan
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20
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Krastinaite I, Charkavliuk S, Navakauskiene R, Borutinskaite VV. Metformin as an Enhancer for the Treatment of Chemoresistant CD34+ Acute Myeloid Leukemia Cells. Genes (Basel) 2024; 15:648. [PMID: 38790277 PMCID: PMC11121461 DOI: 10.3390/genes15050648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/14/2024] [Accepted: 05/16/2024] [Indexed: 05/26/2024] Open
Abstract
Acute myeloid leukemia is the second most frequent type of leukemia in adults. Due to a high risk of development of chemoresistance to first-line chemotherapy, the survival rate of patients in a 5-year period is below 30%. One of the reasons is that the AML population is heterogeneous, with cell populations partly composed of very primitive CD34+CD38- hematopoietic stem/progenitor cells, which are often resistant to chemotherapy. First-line treatment with cytarabine and idarubicin fails to inhibit the proliferation of CD34+CD38- cells. In this study, we investigated Metformin's effect with or without first-line conventional chemotherapy, or with other drugs like venetoclax and S63845, on primitive and undifferentiated CD34+ AML cells in order to explore the potential of Metformin or S63845 to serve as adjuvant therapy for AML. We found that first-line conventional chemotherapy treatment inhibited the growth of cells and arrested the cells in the S phase of the cell cycle; however, metformin affected the accumulation of cells in the G2/M phase. We observed that CD34+ KG1a cells respond better to lower doses of cytarabine or idarubicin in combination with metformin. Also, we determined that treatment with cytarabine, venetoclax, and S63845 downregulated the strong tendency of CD34+ KG1a cells to form cell aggregates in culture due to the downregulation of leukemic stem cell markers like CD34 and CD44, as well as adhesion markers. Also, we found that idarubicin slightly upregulated myeloid differentiation markers, CD11b and CD14. Treatment with cytarabine, idarubicin, venetoclax, metformin, and S63845 upregulated some cell surface markers like HLA-DR expression, and metformin upregulated CD9, CD31, and CD105 cell surface marker expression. In conclusion, we believe that metformin has the potential to be used as an adjuvant in the treatment of resistant-to-first-line-chemotherapy AML cells. Also, we believe that the results of our study will stimulate further research and the potential use of changes in the expression of cell surface markers in the development of new therapeutic strategies.
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MESH Headings
- Humans
- Metformin/pharmacology
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/metabolism
- Leukemia, Myeloid, Acute/pathology
- Drug Resistance, Neoplasm/drug effects
- Antigens, CD34/metabolism
- Cell Line, Tumor
- Cytarabine/pharmacology
- Cell Proliferation/drug effects
- Sulfonamides/pharmacology
- Bridged Bicyclo Compounds, Heterocyclic/pharmacology
- Idarubicin/pharmacology
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Affiliation(s)
| | | | | | - Veronika Viktorija Borutinskaite
- Department of Molecular Cell Biology, Institute of Biochemistry, Life Sciences Center, Vilnius University, Sauletekio Av. 7, LT-10257 Vilnius, Lithuania; (I.K.); (S.C.); (R.N.)
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21
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Karakaslar EO, Severens JF, Sánchez-López E, van Veelen PA, Zlei M, van Dongen JJM, Otte AM, Halkes CJM, van Balen P, Veelken H, Reinders MJT, Griffioen M, van den Akker EB. A transcriptomic based deconvolution framework for assessing differentiation stages and drug responses of AML. NPJ Precis Oncol 2024; 8:105. [PMID: 38762545 PMCID: PMC11102519 DOI: 10.1038/s41698-024-00596-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 05/03/2024] [Indexed: 05/20/2024] Open
Abstract
The diagnostic spectrum for AML patients is increasingly based on genetic abnormalities due to their prognostic and predictive value. However, information on the AML blast phenotype regarding their maturational arrest has started to regain importance due to its predictive power for drug responses. Here, we deconvolute 1350 bulk RNA-seq samples from five independent AML cohorts on a single-cell healthy BM reference and demonstrate that the morphological differentiation stages (FAB) could be faithfully reconstituted using estimated cell compositions (ECCs). Moreover, we show that the ECCs reliably predict ex-vivo drug resistances as demonstrated for Venetoclax, a BCL-2 inhibitor, resistance specifically in AML with CD14+ monocyte phenotype. We validate these predictions using LUMC proteomics data by showing that BCL-2 protein abundance is split into two distinct clusters for NPM1-mutated AML at the extremes of CD14+ monocyte percentages, which could be crucial for the Venetoclax dosing patients. Our results suggest that Venetoclax resistance predictions can also be extended to AML without recurrent genetic abnormalities and possibly to MDS-related and secondary AML. Lastly, we show that CD14+ monocytic dominated Ven/Aza treated patients have significantly lower overall survival. Collectively, we propose a framework for allowing a joint mutation and maturation stage modeling that could be used as a blueprint for testing sensitivity for new agents across the various subtypes of AML.
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Affiliation(s)
- E Onur Karakaslar
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
- Pattern Recognition & Bioinformatics, Delft University of Technology, Delft, The Netherlands
- Leiden Center for Computational Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeppe F Severens
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
- Pattern Recognition & Bioinformatics, Delft University of Technology, Delft, The Netherlands
- Leiden Center for Computational Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Elena Sánchez-López
- Leiden Center for Computational Oncology, Leiden University Medical Center, Leiden, The Netherlands
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter A van Veelen
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, The Netherlands
| | - Mihaela Zlei
- Department of Flow Cytometry, Medical Laboratory, Regional Institute of Oncology, Iasi, Romania
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacques J M van Dongen
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
- Centro de Investigación del Cáncer-Instituto de Biología Molecular y Celular del Cáncer (CIC-IBMCC, USAL-CSIC-FICUS) and Department of Medicine, University of Salamanca, Salamanca, Spain
| | - Annemarie M Otte
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Peter van Balen
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hendrik Veelken
- Leiden Center for Computational Oncology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcel J T Reinders
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
- Pattern Recognition & Bioinformatics, Delft University of Technology, Delft, The Netherlands
- Leiden Center for Computational Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke Griffioen
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik B van den Akker
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands.
- Pattern Recognition & Bioinformatics, Delft University of Technology, Delft, The Netherlands.
- Leiden Center for Computational Oncology, Leiden University Medical Center, Leiden, The Netherlands.
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22
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Wang D, He J, Liu S, Zhang H, Tang D, Chen P, Yang M. Anlotinib synergizes with venetoclax to induce mitotic catastrophe in acute myeloid leukemia. Cancer Lett 2024; 593:216970. [PMID: 38763475 DOI: 10.1016/j.canlet.2024.216970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 05/21/2024]
Abstract
Venetoclax is a BCL2-targeted drug employed in treating various cancers, particularly hematologic malignancies. Venetoclax combination therapies are increasingly recognized as promising treatment strategies for acute myeloid leukemia (AML). In this study, we conducted an unbiased drug screen and identified anlotinib, a promising multi-targeted receptor tyrosine kinase inhibitor with oral activity currently utilized in the treatment of solid tumor, as a potent enhancer of venetoclax's anticancer activity in AML. Our investigation encompassed AML cell lines, primary cells, and mouse models, demonstrating effective low-dose combination therapy of anlotinib and venetoclax with minimal cytopenia or organ damage. Proteomic analysis revealed abnormal mitotic signals induced by this combination in AML cells. Mechanistically, anlotinib synergized with venetoclax by suppressing ARPP19 protein, leading to sustained activation of PP2A-B55δ. This inhibited AML cells from entering the mitotic phase, culminating in mitotic catastrophe and apoptosis. Additionally, we identified a specific synthetic lethal vulnerability in AML involving an ARPP19 mutation at S62 phosphorylation. These findings underscore the therapeutic potential of anlotinib and venetoclax combination therapy in AML, warranting further clinical investigation.
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Affiliation(s)
- Dan Wang
- Department of Pediatrics, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China; Hunan Clinical Research Center of Pediatric Cancer, Changsha, 410013, Hunan, China
| | - Jing He
- Department of Pediatrics, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China; Hunan Clinical Research Center of Pediatric Cancer, Changsha, 410013, Hunan, China
| | - Siyang Liu
- Department of Pediatrics, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China; Hunan Clinical Research Center of Pediatric Cancer, Changsha, 410013, Hunan, China
| | - Haixia Zhang
- Department of Pediatrics, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China; Hunan Clinical Research Center of Pediatric Cancer, Changsha, 410013, Hunan, China
| | - Daolin Tang
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Pan Chen
- Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410031, Hunan, China.
| | - Minghua Yang
- Department of Pediatrics, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China; Hunan Clinical Research Center of Pediatric Cancer, Changsha, 410013, Hunan, China.
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23
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Carnie CJ, Götz MJ, Palma-Chaundler CS, Weickert P, Wanders A, Serrano-Benitez A, Li HY, Gupta V, Awwad SW, Blum CJ, Sczaniecka-Clift M, Cordes J, Zagnoli-Vieira G, D'Alessandro G, Richards SL, Gueorguieva N, Lam S, Beli P, Stingele J, Jackson SP. Decitabine cytotoxicity is promoted by dCMP deaminase DCTD and mitigated by SUMO-dependent E3 ligase TOPORS. EMBO J 2024:10.1038/s44318-024-00108-2. [PMID: 38760575 DOI: 10.1038/s44318-024-00108-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 03/15/2024] [Accepted: 04/16/2024] [Indexed: 05/19/2024] Open
Abstract
The nucleoside analogue decitabine (or 5-aza-dC) is used to treat several haematological cancers. Upon its triphosphorylation and incorporation into DNA, 5-aza-dC induces covalent DNA methyltransferase 1 DNA-protein crosslinks (DNMT1-DPCs), leading to DNA hypomethylation. However, 5-aza-dC's clinical outcomes vary, and relapse is common. Using genome-scale CRISPR/Cas9 screens, we map factors determining 5-aza-dC sensitivity. Unexpectedly, we find that loss of the dCMP deaminase DCTD causes 5-aza-dC resistance, suggesting that 5-aza-dUMP generation is cytotoxic. Combining results from a subsequent genetic screen in DCTD-deficient cells with the identification of the DNMT1-DPC-proximal proteome, we uncover the ubiquitin and SUMO1 E3 ligase, TOPORS, as a new DPC repair factor. TOPORS is recruited to SUMOylated DNMT1-DPCs and promotes their degradation. Our study suggests that 5-aza-dC-induced DPCs cause cytotoxicity when DPC repair is compromised, while cytotoxicity in wild-type cells arises from perturbed nucleotide metabolism, potentially laying the foundations for future identification of predictive biomarkers for decitabine treatment.
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Affiliation(s)
- Christopher J Carnie
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK.
- The Gurdon Institute and Department of Biochemistry, University of Cambridge, Cambridge, UK.
| | - Maximilian J Götz
- Gene Center and Department of Biochemistry, Ludwig-Maximilians-Universität München, Munich, Germany
| | | | - Pedro Weickert
- Gene Center and Department of Biochemistry, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Amy Wanders
- The Gurdon Institute and Department of Biochemistry, University of Cambridge, Cambridge, UK
| | - Almudena Serrano-Benitez
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
- The Gurdon Institute and Department of Biochemistry, University of Cambridge, Cambridge, UK
| | - Hao-Yi Li
- Gene Center and Department of Biochemistry, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Vipul Gupta
- The Gurdon Institute and Department of Biochemistry, University of Cambridge, Cambridge, UK
| | - Samah W Awwad
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
- The Gurdon Institute and Department of Biochemistry, University of Cambridge, Cambridge, UK
| | | | | | - Jacqueline Cordes
- Gene Center and Department of Biochemistry, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Guido Zagnoli-Vieira
- The Gurdon Institute and Department of Biochemistry, University of Cambridge, Cambridge, UK
| | - Giuseppina D'Alessandro
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
- The Gurdon Institute and Department of Biochemistry, University of Cambridge, Cambridge, UK
| | - Sean L Richards
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - Nadia Gueorguieva
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
- The Gurdon Institute and Department of Biochemistry, University of Cambridge, Cambridge, UK
| | - Simon Lam
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
- The Gurdon Institute and Department of Biochemistry, University of Cambridge, Cambridge, UK
| | - Petra Beli
- Institute of Molecular Biology (IMB), Mainz, Germany
- Institute of Developmental Biology and Neurobiology (IDN), Johannes Gutenberg-Universität, Mainz, Germany
| | - Julian Stingele
- Gene Center and Department of Biochemistry, Ludwig-Maximilians-Universität München, Munich, Germany.
| | - Stephen P Jackson
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK.
- The Gurdon Institute and Department of Biochemistry, University of Cambridge, Cambridge, UK.
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24
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Corradi G, Forte D, Cristiano G, Polimeno A, Ciciarello M, Salvestrini V, Bandini L, Robustelli V, Ottaviani E, Cavo M, Ocadlikova D, Curti A. Ex vivo characterization of acute myeloid leukemia patients undergoing hypomethylating agents and venetoclax regimen reveals a venetoclax-specific effect on non-suppressive regulatory T cells and bona fide PD-1 +TIM3 + exhausted CD8 + T cells. Front Immunol 2024; 15:1386517. [PMID: 38812504 PMCID: PMC11133521 DOI: 10.3389/fimmu.2024.1386517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/30/2024] [Indexed: 05/31/2024] Open
Abstract
Acute myeloid leukemia (AML) is an aggressive heterogeneous disease characterized by several alterations of the immune system prompting disease progression and treatment response. The therapies available for AML can affect lymphocyte function, limiting the efficacy of immunotherapy while hindering leukemia-specific immune reactions. Recently, the treatment based on Venetoclax (VEN), a specific B-cell lymphoma 2 (BCL-2) inhibitor, in combination with hypomethylating agents (HMAs) or low-dose cytarabine, has emerged as a promising clinical strategy in AML. To better understand the immunological effect of VEN treatment, we characterized the phenotype and immune checkpoint (IC) receptors' expression on CD4+ and CD8+ T cells from AML patients after the first and second cycle of HMA in combination with VEN. HMA and VEN treatment significantly increased the percentage of naïve CD8+ T cells and TIM-3+ CD4+ and CD8+ T cells and reduced cytokine-secreting non-suppressive T regulatory cells (Tregs). Of note, a comparison between AML patients treated with HMA only and HMA in combination with VEN revealed the specific contribution of VEN in modulating the immune cell repertoire. Indeed, the reduction of cytokine-secreting non-suppressive Tregs, the increased TIM-3 expression on CD8+ T cells, and the reduced co-expression of PD-1 and TIM-3 on both CD4+ and CD8+ T cells are all VEN-specific. Collectively, our study shed light on immune modulation induced by VEN treatment, providing the rationale for a novel therapeutic combination of VEN and IC inhibitors in AML patients.
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Affiliation(s)
- Giulia Corradi
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
- Department of Oncology Hematology, Pescara Hospital, Pescara, Italy
| | - Dorian Forte
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Gianluca Cristiano
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
| | - Andrea Polimeno
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
| | - Marilena Ciciarello
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
- Consiglio Nazionale delle Ricerche (CNR) Institute of Molecular Genetics “Luigi Luca Cavalli-Sforza”, Unit of Bologna, Bologna, Italy
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Valentina Salvestrini
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
| | - Lorenza Bandini
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
| | - Valentina Robustelli
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
| | - Emanuela Ottaviani
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
| | - Michele Cavo
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Darina Ocadlikova
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
| | - Antonio Curti
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
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25
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Shi X, Feng M, Nakada D. Metabolic dependencies of acute myeloid leukemia stem cells. Int J Hematol 2024:10.1007/s12185-024-03789-x. [PMID: 38750343 DOI: 10.1007/s12185-024-03789-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/26/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024]
Abstract
Acute myeloid leukemia (AML) is a heterogeneous hematologic malignancy primarily driven by an immature population of AML cells termed leukemia stem cells (LSCs) that are implicated in AML development, chemoresistance, and relapse. An emerging area of research in AML focuses on identifying and targeting the aberrant metabolism in LSCs. Dysregulated metabolism is involved in sustaining functional properties of LSCs, impeding myeloid differentiation, and evading programmed cell death, both in the process of leukemogenesis and in response to chemotherapy. This review discusses recent discoveries regarding the aberrant metabolic processes of AML LSCs that have begun to change the therapeutic landscape of AML.
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Affiliation(s)
- Xiangguo Shi
- Department of Molecular & Human Genetics, Baylor College of Medicine, Houston, TX, 77030, USA.
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, PA, USA.
| | - Mengdie Feng
- Department of Molecular & Human Genetics, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Daisuke Nakada
- Department of Molecular & Human Genetics, Baylor College of Medicine, Houston, TX, 77030, USA.
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26
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Kitahara M, Sumi M, Kazumoto H, Shishido T, Ueki T, Hiroshima Y, Kamei K, Kobayashi H. Disseminated Infection by Scedosporium/Lomentospora during Induction Therapy for Acute Myeloid Leukemia Complicated by Nontuberculous Mycobacteria. Intern Med 2024; 63:1465-1471. [PMID: 37839883 DOI: 10.2169/internalmedicine.2159-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
Scedosporium/Lomentospora infections are rare and are associated with a high mortality rate in immunocompromised patients. A 69-year-old man with nontuberculous mycobacteria (NTM) died during induction chemotherapy for acute myeloid leukemia because of multiple organ failure due to pneumonia. During an autopsy, Lomentospora prolificans was detected using a fungal gene analysis of the blood, lungs, spleen, kidneys, and intestines, and Scedosporium aurantiacum was detected in the lungs. NTM disease may predispose patients to Scedosporium/Lomentospora infections. Physicians should consider Scedosporium/Lomentospora spp. as an invasive fungal infection that occurs during myelosuppression, particularly when NTM is a complication.
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MESH Headings
- Humans
- Aged
- Leukemia, Myeloid, Acute/complications
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/microbiology
- Male
- Scedosporium/isolation & purification
- Mycobacterium Infections, Nontuberculous/drug therapy
- Mycobacterium Infections, Nontuberculous/diagnosis
- Mycobacterium Infections, Nontuberculous/complications
- Mycobacterium Infections, Nontuberculous/microbiology
- Fatal Outcome
- Induction Chemotherapy
- Immunocompromised Host
- Nontuberculous Mycobacteria/isolation & purification
- Mycoses/diagnosis
- Mycoses/microbiology
- Mycoses/drug therapy
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Affiliation(s)
- Mari Kitahara
- Department of Hematology, Nagano Red Cross Hospital, Japan
| | - Masahiko Sumi
- Department of Hematology, Nagano Red Cross Hospital, Japan
| | | | | | | | - Yuki Hiroshima
- Department of Hematology, Nagano Red Cross Hospital, Japan
| | - Katsuhiko Kamei
- Department of Medical Mycology Research Center, Chiba University, Japan
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27
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Rodems BJ, Sharma S, Baker CD, Kaszuba CM, Ito T, Liesveld JL, Calvi LM, Becker MW, Jordan CT, Ashton JM, Bajaj J. Temporal Single Cell Analysis of Leukemia Microenvironment Identifies Taurine-Taurine Transporter Axis as a Key Regulator of Myeloid Leukemia. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.11.593633. [PMID: 38798540 PMCID: PMC11118281 DOI: 10.1101/2024.05.11.593633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Signals from the microenvironment are known to be critical for development, sustaining adult stem cells, and for oncogenic progression. While candidate niche-driven signals that can promote cancer progression have been identified 1-6 , concerted efforts to comprehensively map microenvironmental ligands for cancer stem cell specific surface receptors have been lacking. Here, we use temporal single cell RNA-sequencing to identify molecular cues from the bone marrow stromal niche that engage leukemia stem cells (LSC) during oncogenic progression. We integrate these data with our RNA-seq analysis of human LSCs from distinct aggressive myeloid cancer subtypes and our CRISPR based in vivo LSC dependency map 7 to develop a temporal receptor-ligand interactome essential for disease progression. These analyses identify the taurine transporter (TauT)-taurine axis as a critical dependency of myeloid malignancies. We show that taurine production is restricted to the osteolineage population during cancer initiation and expansion. Inhibiting taurine synthesis in osteolineage cells impairs LSC growth and survival. Our experiments with the TauT genetic loss of function murine model indicate that its loss significantly impairs the progression of aggressive myeloid leukemias in vivo by downregulating glycolysis. Further, TauT inhibition using a small molecule strongly impairs the growth and survival of patient derived myeloid leukemia cells. Finally, we show that TauT inhibition can synergize with the clinically approved oxidative phosphorylation inhibitor venetoclax 8, 9 to block the growth of primary human leukemia cells. Given that aggressive myeloid leukemias continue to be refractory to current therapies and have poor prognosis, our work indicates targeting the taurine transporter may be of therapeutic significance. Collectively, our data establishes a temporal landscape of stromal signals during cancer progression and identifies taurine-taurine transporter signaling as an important new regulator of myeloid malignancies.
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28
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Zhang S, Lou S, Bian W, Liu J, Wang R, Wang Y, Zhao Y, Zou X, Jin D, Liang Y, Sun J, Liu L. Selective eradication of venetoclax-resistant monocytic acute myeloid leukemia with iron oxide nanozymes. Biochem Biophys Res Commun 2024; 719:150117. [PMID: 38761635 DOI: 10.1016/j.bbrc.2024.150117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 04/23/2024] [Accepted: 05/13/2024] [Indexed: 05/20/2024]
Abstract
The clinical treatment of human acute myeloid leukemia (AML) is rapidly progressing from chemotherapy to targeted therapies led by the BCL-2 inhibitor venetoclax (VEN). Despite its unprecedented success, VEN still encounters clinical resistance. Thus, uncovering the biological vulnerability of VEN-resistant AML disease and identifying effective therapies to treat them are urgently needed. We have previously demonstrated that iron oxide nanozymes (IONE) are capable of overcoming chemoresistance in AML. The current study reports a new activity of IONE in overcoming VEN resistance. Specifically, we revealed an aberrant redox balance with excessive intracellular reactive oxygen species (ROS) in VEN-resistant monocytic AML. Treatment with IONE potently induced ROS-dependent cell death in monocytic AML in both cell lines and primary AML models. In primary AML with developmental heterogeneity containing primitive and monocytic subpopulations, IONE selectively eradicated the VEN-resistant ROS-high monocytic subpopulation, successfully resolving the challenge of developmental heterogeneity faced by VEN. Overall, our study revealed an aberrant redox balance as a therapeutic target for monocytic AML and identified a candidate IONE that could selectively and potently eradicate VEN-resistant monocytic disease.
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Affiliation(s)
- Shaoqi Zhang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, China; Liangzhu Laboratory, Zhejiang University, Hangzhou, 311121, China
| | - Shang Lou
- Liangzhu Laboratory, Zhejiang University, Hangzhou, 311121, China
| | - Wei Bian
- Liangzhu Laboratory, Zhejiang University, Hangzhou, 311121, China
| | - Jun Liu
- Liangzhu Laboratory, Zhejiang University, Hangzhou, 311121, China
| | - Rong Wang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, China; Liangzhu Laboratory, Zhejiang University, Hangzhou, 311121, China
| | - Yanan Wang
- Liangzhu Laboratory, Zhejiang University, Hangzhou, 311121, China
| | - Yin Zhao
- Liangzhu Laboratory, Zhejiang University, Hangzhou, 311121, China
| | - Xiaoqing Zou
- Liangzhu Laboratory, Zhejiang University, Hangzhou, 311121, China
| | - Diange Jin
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, China; Liangzhu Laboratory, Zhejiang University, Hangzhou, 311121, China
| | - Yue Liang
- Liangzhu Laboratory, Zhejiang University, Hangzhou, 311121, China
| | - Jie Sun
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, China.
| | - Lina Liu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, China; Liangzhu Laboratory, Zhejiang University, Hangzhou, 311121, China.
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29
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Nagasaki J, Nishimoto M, Koh H, Okamura H, Nakamae M, Sakatoku K, Ido K, Kuno M, Makuuchi Y, Takakuwa T, Nakashima Y, Hino M, Nakamae H. T cells with high BCL-2 expression induced by venetoclax impact anti-leukemic immunity "graft-versus-leukemia effects". Blood Cancer J 2024; 14:79. [PMID: 38744860 PMCID: PMC11094022 DOI: 10.1038/s41408-024-01064-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 05/16/2024] Open
Affiliation(s)
- Joji Nagasaki
- Department of Hematology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
- Department of Tumor Microenvironment, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Mitsutaka Nishimoto
- Department of Hematology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan.
| | - Hideo Koh
- Department of Hematology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
- Department of Preventive Medicine and Environmental Health, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Okamura
- Department of Hematology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
- Department of Laboratory Medicine and Medical Informatics, Osaka Metropolitan University, Osaka, Japan
| | - Mika Nakamae
- Department of Hematology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
- Department of Laboratory Medicine and Medical Informatics, Osaka Metropolitan University, Osaka, Japan
| | - Kazuki Sakatoku
- Department of Hematology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Kentaro Ido
- Department of Hematology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
- Department of Laboratory Medicine and Medical Informatics, Osaka Metropolitan University, Osaka, Japan
| | - Masatomo Kuno
- Department of Hematology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yosuke Makuuchi
- Department of Hematology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Teruhito Takakuwa
- Department of Hematology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yasuhiro Nakashima
- Department of Hematology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Masayuki Hino
- Department of Hematology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hirohisa Nakamae
- Department of Hematology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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30
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Coltoff A, Kuykendall A. Emerging drug profile: JAK inhibitors. Leuk Lymphoma 2024:1-12. [PMID: 38739701 DOI: 10.1080/10428194.2024.2353434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 05/05/2024] [Indexed: 05/16/2024]
Abstract
Dysregulated JAK/STAT hyperactivity is essential to the pathogenesis of myelofibrosis, and JAK inhibitors are the first-line treatment option for many patients. There are four FDA-approved JAK inhibitors for patients with myelofibrosis. Single-agent JAK inhibition can improve splenomegaly, symptom burden, cytopenias, and possibly survival in patients with myelofibrosis. Despite their efficacy, JAK inhibitors produce variable or short-lived responses, in part due to the large network of cooperating signaling pathways and downstream targets of JAK/STAT, which mediates upfront or acquired resistance to JAK inhibitors. Synergistic inhibition of JAK/STAT accessory pathways can increase the rates and duration of response for patients with myelofibrosis. Two recently reported, placebo-controlled phase III trials of novel agents added to JAK inhibition met their primary endpoint, and additional late-stage studies are ongoing. This paper will review role of dysregulated JAK/STAT signaling, biological plausible additional therapeutic targets and the recent advancements in combination strategies with JAK inhibitors for myelofibrosis.
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Affiliation(s)
- Alexander Coltoff
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, USA
| | - Andrew Kuykendall
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA
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31
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Diepstraten ST, Yuan Y, La Marca JE, Young S, Chang C, Whelan L, Ross AM, Fischer KC, Pomilio G, Morris R, Georgiou A, Litalien V, Brown FC, Roberts AW, Strasser A, Wei AH, Kelly GL. Putting the STING back into BH3-mimetic drugs for TP53-mutant blood cancers. Cancer Cell 2024; 42:850-868.e9. [PMID: 38670091 DOI: 10.1016/j.ccell.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 01/06/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024]
Abstract
TP53-mutant blood cancers remain a clinical challenge. BH3-mimetic drugs inhibit BCL-2 pro-survival proteins, inducing cancer cell apoptosis. Despite acting downstream of p53, functional p53 is required for maximal cancer cell killing by BH3-mimetics through an unknown mechanism. Here, we report p53 is activated following BH3-mimetic induced mitochondrial outer membrane permeabilization, leading to BH3-only protein induction and thereby potentiating the pro-apoptotic signal. TP53-deficient lymphomas lack this feedforward loop, providing opportunities for survival and disease relapse after BH3-mimetic treatment. The therapeutic barrier imposed by defects in TP53 can be overcome by direct activation of the cGAS/STING pathway, which promotes apoptosis of blood cancer cells through p53-independent BH3-only protein upregulation. Combining clinically relevant STING agonists with BH3-mimetic drugs efficiently kills TRP53/TP53-mutant mouse B lymphoma, human NK/T lymphoma, and acute myeloid leukemia cells. This represents a promising therapy regime that can be fast-tracked to tackle TP53-mutant blood cancers in the clinic.
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Affiliation(s)
- Sarah T Diepstraten
- Blood Cells and Blood Cancer Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia.
| | - Yin Yuan
- Blood Cells and Blood Cancer Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia; Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC 3050, Australia
| | - John E La Marca
- Blood Cells and Blood Cancer Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia; Genome Engineering and Cancer Modelling Program, Olivia Newton-John Cancer Research Institute, Heidelberg, VIC 3084, Australia; School of Cancer Medicine, La Trobe University, Melbourne, VIC 3086, Australia
| | - Savannah Young
- Blood Cells and Blood Cancer Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia
| | - Catherine Chang
- Blood Cells and Blood Cancer Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia
| | - Lauren Whelan
- Blood Cells and Blood Cancer Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia
| | - Aisling M Ross
- Blood Cells and Blood Cancer Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; School of Medicine, Bernal Institute, Limerick Digital Cancer Research Centre & Health Research Institute, University of Limerick, Limerick, Ireland
| | - Karla C Fischer
- Blood Cells and Blood Cancer Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia
| | - Giovanna Pomilio
- Blood Cells and Blood Cancer Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia
| | - Rhiannon Morris
- Blood Cells and Blood Cancer Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia
| | - Angela Georgiou
- Blood Cells and Blood Cancer Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia
| | - Veronique Litalien
- Blood Cells and Blood Cancer Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia
| | - Fiona C Brown
- Blood Cells and Blood Cancer Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia; Australian Centre for Blood Diseases, Monash University, Melbourne, VIC 3004, Australia
| | - Andrew W Roberts
- Blood Cells and Blood Cancer Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia; Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC 3050, Australia
| | - Andreas Strasser
- Blood Cells and Blood Cancer Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia
| | - Andrew H Wei
- Blood Cells and Blood Cancer Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia; Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC 3050, Australia
| | - Gemma L Kelly
- Blood Cells and Blood Cancer Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia.
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32
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Gener-Ricos G, Rodriguez-Sevilla JJ, Urrutia S, Bataller A, Bazinet A, Garcia-Manero G. Advances in the management of higher-risk myelodysplastic syndromes: future prospects. Leuk Lymphoma 2024:1-12. [PMID: 38712556 DOI: 10.1080/10428194.2024.2344061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 04/12/2024] [Indexed: 05/08/2024]
Abstract
Higher-risk myelodysplastic syndromes (HR-MDS) are defined using a number of prognostic scoring systems that include the degree of cytopenias, percentage of blasts, cytogenetic alterations, and more recently genomic data. HR-MDS encompasses characteristics such as progressive cytopenias, increased bone marrow blasts, unfavorable cytogenetics, and an adverse mutational profile. Survival is generally poor, and patients require therapy to improve outcomes. Hypomethylating agents (HMAs), such as azacitidine, decitabine, and more recently, oral decitabine/cedazuridine, are the only approved therapies for HR-MDS. These are often continued until loss of response, progression, or unacceptable toxicity. Combinations including an HMA plus other drugs have been investigated but have not demonstrated better outcomes compared to single-agent HMA. Moreover, in a disease of high genomic complexity such as HR-MDS, therapy targeting specific genomic abnormalities is of interest. This review will examine the biological underpinnings of HR-MDS, its therapeutic landscape in the frontline and relapsed settings, as well as the impact of hematopoietic stem cell transplantation, the only known curative intervention for this disease.
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Affiliation(s)
- Georgina Gener-Ricos
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Samuel Urrutia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alex Bataller
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alexandre Bazinet
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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33
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Noronha N, Durette C, Cahuzac M, E Silva B, Courtois J, Humeau J, Sauvat A, Hardy MP, Vincent K, Laverdure JP, Lanoix J, Baron F, Thibault P, Perreault C, Ehx G. Autophagy degrades immunogenic endogenous retroelements induced by 5-azacytidine in acute myeloid leukemia. Leukemia 2024; 38:1019-1031. [PMID: 38627586 DOI: 10.1038/s41375-024-02250-6] [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: 12/22/2022] [Revised: 04/02/2024] [Accepted: 04/08/2024] [Indexed: 05/08/2024]
Abstract
The hypomethylating agent 5-azacytidine (AZA) is the first-line treatment for AML patients unfit for intensive chemotherapy. The effect of AZA results in part from T-cell cytotoxic responses against MHC-I-associated peptides (MAPs) deriving from hypermethylated genomic regions such as cancer-testis antigens (CTAs), or endogenous retroelements (EREs). However, evidence supporting higher ERE MAPs presentation after AZA treatment is lacking. Therefore, using proteogenomics, we examined the impact of AZA on the repertoire of MAPs and their source transcripts. AZA-treated AML upregulated both CTA and ERE transcripts, but only CTA MAPs were presented at greater levels. Upregulated ERE transcripts triggered innate immune responses against double-stranded RNAs but were degraded by autophagy, and not processed into MAPs. Autophagy resulted from the formation of protein aggregates caused by AZA-dependent inhibition of DNMT2. Autophagy inhibition had an additive effect with AZA on AML cell proliferation and survival, increased ERE levels, increased pro-inflammatory responses, and generated immunogenic tumor-specific ERE-derived MAPs. Finally, autophagy was associated with a lower abundance of CD8+ T-cell markers in AML patients expressing high levels of EREs. This work demonstrates that AZA-induced EREs are degraded by autophagy and shows that inhibiting autophagy can improve the immune recognition of AML blasts in treated patients.
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MESH Headings
- Humans
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/immunology
- Leukemia, Myeloid, Acute/pathology
- Azacitidine/pharmacology
- Autophagy/drug effects
- Antimetabolites, Antineoplastic/pharmacology
- Antimetabolites, Antineoplastic/therapeutic use
- DNA Methylation/drug effects
- Cell Proliferation
- Antigens, Neoplasm/genetics
- Antigens, Neoplasm/immunology
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Affiliation(s)
| | | | | | - Bianca E Silva
- GIGA Institute, Laboratory of Hematology, University of Liege, Liege, Belgium
| | - Justine Courtois
- GIGA Institute, Laboratory of Hematology, University of Liege, Liege, Belgium
| | | | - Allan Sauvat
- Equipe labellisée par la Ligue contre le Cancer, Université de Paris, Sorbonne Université, Inserm U1138, Institut Universitaire de France, Paris, France
| | | | | | | | - Joël Lanoix
- IRIC, Université de Montréal, Montreal, QC, Canada
| | - Frédéric Baron
- GIGA Institute, Laboratory of Hematology, University of Liege, Liege, Belgium
| | | | | | - Gregory Ehx
- IRIC, Université de Montréal, Montreal, QC, Canada.
- GIGA Institute, Laboratory of Hematology, University of Liege, Liege, Belgium.
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34
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Wang L, Song J, Xiao X, Li D, Liu T, He X. Comparison of venetoclax and ivosidenib/enasidenib for unfit newly diagnosed patients with acute myeloid leukemia and IDH1/2 mutation: a network meta-analysis. J Chemother 2024; 36:202-207. [PMID: 37599456 DOI: 10.1080/1120009x.2023.2247200] [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: 03/24/2023] [Revised: 06/28/2023] [Accepted: 07/20/2023] [Indexed: 08/22/2023]
Abstract
Because of lacking of head-to-head comparison between venetoclax and IDH1/IDH2 inhibitors (ivosidenib/enasidenib) for newly diagnosed unfit patients with acute myeloid leukemia (AML), the optimal option for these patients still remains undefined. We searched relevant published reports. Three RCTs with 180 IDH1 mutant and 165 IDH2 mutant patients were identified. Indirect comparison of OS using fixed effects network meta-analysis (NMA) models indicated venetoclax plus azacitidine (Ven-Aza) significantly improved survival than enasidenib plus azacitidine (Ena-Aza) (HR:0.30, p = 0.005) for those newly diagnosed patients with AML and IDH2 Mutation. And, for those IDH2 mutation patients, Ven-Aza also had the highest probability of 98.3% (OS analysis) and 84.0% (CR/CRi analysis) to be the best intervention among these first-line treatment regimens (Ven-Aza, Ena-Aza and Aza). And, there was a favorable trend towards Ven-Aza in survival analysis (HR:0.69, p = 0.42), when compared to ivosidenib plus azacitidine (Ivo-Aza) for those newly diagnosed patients with AML and IDH1 Mutation. For those IDH1 Mutation, venetoclax plus azacitidine (Ven-Aza) had the highest probability of 65.8% (OS analysis) and 73.0% (CR/CRi analysis) to be the best intervention among these first-line treatment regimens (Ven-Aza, ivosidenib plus azacitidine (Ivo-Aza) and azacitidine (Aza)). In conclusion, venetoclax plus azacitidine could be a good option for unfit newly diagnosed patients with acute myeloid leukemia and IDH1/2 mutation. Considering our limits (only trial data-based network meta-analysis et al.), future trials directly comparing these regimens are warranted.
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Affiliation(s)
- Lida Wang
- Department of E.N.T, Weifang People's Hospital, Weifang, China
| | - Jiwu Song
- Department of Stomatology, Weifang People's Hospital, Weifang, Shandong, China
| | - Xiangming Xiao
- Department of General Surgery, Weifang People's Hospital, Weifang, China
| | - Dianfang Li
- Department of Hematology, Weifang People's Hospital, Weifang, Shandong, China
| | - Tianmeng Liu
- Weifang Medical University, Weifang People's Hospital, Weifang, Shandong, China
| | - Xiaopo He
- Department of Oral and Maxillofacial Surgery, Weifang People's Hospital, Weifang, China
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35
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Uy GL, DeAngelo DJ, Lozier JN, Fisher DM, Jonas BA, Magnani JL, Becker PS, Lazarus HM, Winkler IG. Targeting hematologic malignancies by inhibiting E-selectin: A sweet spot for AML therapy? Blood Rev 2024; 65:101184. [PMID: 38493006 PMCID: PMC11051645 DOI: 10.1016/j.blre.2024.101184] [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: 12/18/2023] [Revised: 02/06/2024] [Accepted: 02/26/2024] [Indexed: 03/18/2024]
Abstract
E-selectin, a cytoadhesive glycoprotein, is expressed on venular endothelial cells and mediates leukocyte localization to inflamed endothelium, the first step in inflammatory cell extravasation into tissue. Constitutive marrow endothelial E-selectin expression also supports bone marrow hematopoiesis via NF-κB-mediated signaling. Correspondingly, E-selectin interaction with E-selectin ligand (sialyl Lewisx) on acute myeloid leukemia (AML) cells leads to chemotherapy resistance in vivo. Uproleselan (GMI-1271) is a carbohydrate analog of sialyl Lewisx that blocks E-selectin binding. A Phase 2 trial of MEC chemotherapy combined with uproleselan for relapsed/refractory AML showed a median overall survival of 8.8 months and low (2%) rates of severe oral mucositis. Clinical trials seek to confirm activity in AML and mitigation of neutrophil-mediated adverse events (mucositis and diarrhea) after intensive chemotherapy. In this review we summarize E-selectin biology and the rationale for uproleselan in combination with other therapies for hematologic malignancies. We also describe uproleselan pharmacology and ongoing clinical trials.
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Affiliation(s)
- Geoffrey L Uy
- Division of Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel J DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | | | - Brian A Jonas
- Department of Internal Medicine, Division of Malignant Hematology/Cellular Therapy and Transplantation, University of California Davis, Davis, CA, USA
| | | | - Pamela S Becker
- Leukemia Division, Department of Hematology and Hematopoietic Cell Transplantation, Department of Hematologic Malignancies Translational Science, City of Hope National Medical Center, Duarte, CA, USA
| | - Hillard M Lazarus
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Ingrid G Winkler
- Mater Research Institute - The University of Queensland, Translational Research Institute, Brisbane, Woolloongabba, QLD, Australia
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36
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Rong C, Yang F, Chen Y, Wang M, Ai C, Luo Y, Gao P, Weng Y, Huang X, Gu M, Huang W, Xia Y. Low‑dose venetoclax combined with azacitidine in older and frail patients with newly diagnosed acute myeloid leukaemia. Oncol Lett 2024; 27:228. [PMID: 38586209 PMCID: PMC10996028 DOI: 10.3892/ol.2024.14362] [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: 10/31/2023] [Accepted: 02/14/2024] [Indexed: 04/09/2024] Open
Abstract
In the present study, the aim was to evaluate the clinical efficacy and safety of low-dose venetoclax combined with azacitidine for the treatment of older and frail patients with newly diagnosed acute myeloid leukaemia (AML). Data of 26 older patients with newly diagnosed AML admitted to Yuyao People's Hospital (Yuyao, China) between January 2021 and May 2023 were retrospectively analysed. The treatment regimens were as follows: Subcutaneous injection of 100 mg azacitidine on days 1-5 and 100 mg oral venetoclax on days 3-16 or 200 mg oral venetoclax on days 3-30. The median age of the 26 patients was 73 years. After the first course of treatment, the complete remission (CR) and CR with incomplete haematological recovery rate was 84.6%, and the objective response rate was 96.2%. The most common adverse events noted during treatment were haematological adverse events including grade 3/4 granulocytosis (57.7%), febrile neutropenia (30.8%), pulmonary infection (32.0%), thrombocytopenia (42.3%) and anaemia (42.3%). A total of 13 (50.0%) patients did not require platelet (PLT) infusion during treatment. The main non-haematological adverse reactions included gastrointestinal reactions such as nausea, vomiting and diarrhoea. Patients were followed up until December 2023, with a median follow-up time of 9.5 months (range, 1.9-26.0 months). Of the 26 patients, nine (34.6%) patients experienced relapse, with a mean recurrence time of 5.9 months. In conclusion, preliminary results indicated that low-dose venetoclax combined with azacitidine is effective and safe for the treatment of older and frail patients with newly diagnosed AML, providing a new treatment option for these patients.
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Affiliation(s)
- Chunmeng Rong
- Department of Hematopathology, Yuyao People's Hospital, Yuyao, Zhejiang 315400, P.R. China
| | - Fang Yang
- Department of Hematopathology, Yuyao People's Hospital, Yuyao, Zhejiang 315400, P.R. China
| | - Yalu Chen
- Department of Hematopathology, Yuyao People's Hospital, Yuyao, Zhejiang 315400, P.R. China
| | - Ming Wang
- Department of Hematopathology, Yuyao People's Hospital, Yuyao, Zhejiang 315400, P.R. China
| | - Cheng Ai
- Department of Hematopathology, Yuyao People's Hospital, Yuyao, Zhejiang 315400, P.R. China
| | - Yuqing Luo
- Department of Hematopathology, Yuyao People's Hospital, Yuyao, Zhejiang 315400, P.R. China
| | - Panpan Gao
- Department of Hematopathology, Yuyao People's Hospital, Yuyao, Zhejiang 315400, P.R. China
| | - Yiqin Weng
- Department of Hematopathology, Yuyao People's Hospital, Yuyao, Zhejiang 315400, P.R. China
| | - Xiaguang Huang
- Department of Hematopathology, Yuyao People's Hospital, Yuyao, Zhejiang 315400, P.R. China
| | - Meier Gu
- Department of Hematopathology, Yuyao People's Hospital, Yuyao, Zhejiang 315400, P.R. China
| | - Weiping Huang
- Clinical Laboratory Department, Yuyao People's Hospital, Yuyao, Zhejiang 315400, P.R. China
| | - Yongming Xia
- Department of Hematopathology, Yuyao People's Hospital, Yuyao, Zhejiang 315400, P.R. China
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37
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Fowler-Shorten DJ, Hellmich C, Markham M, Bowles KM, Rushworth SA. BCL-2 inhibition in haematological malignancies: Clinical application and complications. Blood Rev 2024; 65:101195. [PMID: 38523032 DOI: 10.1016/j.blre.2024.101195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/19/2024] [Accepted: 03/20/2024] [Indexed: 03/26/2024]
Abstract
B-cell lymphoma-2 (BCL-2) family proteins are fundamental regulators of the intrinsic apoptotic pathway which modulate cellular fate. In many haematological malignancies, overexpression of anti-apoptotic factors (BCL-2, BCL-XL and MCL-1) circumvent apoptosis. To address this cancer hallmark, a concerted effort has been made to induce apoptosis by inhibiting BCL-2 family proteins. A series of highly selective BCL-2 homology 3 (BH3) domain mimetics are in clinical use and in ongoing clinical trials for acute myeloid leukaemia (AML), chronic myeloid leukaemia (CML), chronic lymphocytic leukaemia (CLL), and multiple myeloma (MM). These inhibitors serve as promising candidates, both as single agents or in combination therapy to improve patient outcomes. In other diseases such as follicular lymphoma, efficacy has been notably limited. There are also clinical problems with BCL-2 family inhibition, including drug resistance, disease relapse, tumour lysis syndrome, and clinically relevant cytopenias. Here, we provide a balanced view on both the clinical benefits of BCL-2 inhibition as well as the associated challenges.
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Affiliation(s)
- Dominic J Fowler-Shorten
- Centre for Metabolic Health, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7UQ, UK
| | - Charlotte Hellmich
- Centre for Metabolic Health, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7UQ, UK; Department of Haematology, Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich NR4 7UY, UK
| | - Matthew Markham
- Centre for Metabolic Health, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7UQ, UK
| | - Kristian M Bowles
- Centre for Metabolic Health, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7UQ, UK; Department of Haematology, Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich NR4 7UY, UK
| | - Stuart A Rushworth
- Centre for Metabolic Health, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7UQ, UK.
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38
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Tauveron-Jalenques U, Lambert J. [Decitabine-cedazuridine as first line in acute myeloid leukaemia ineligible for conventional induction chemotherapy]. Bull Cancer 2024; 111:435-436. [PMID: 38582741 DOI: 10.1016/j.bulcan.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/10/2024] [Accepted: 01/13/2024] [Indexed: 04/08/2024]
Affiliation(s)
- Urbain Tauveron-Jalenques
- Service de thérapie cellulaire et d'hématologie clinique adulte, CHU de Clermont-Ferrand, site Estaing, 63100 Clermont-Ferrand, France
| | - Juliette Lambert
- Service d'hématologie, centre hospitalier de Versailles, 78150 Le Chesnay-Rocquencourt, France.
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39
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Stelljes M, Middeke JM, Bug G, Wagner-Drouet EM, Müller LP, Schmid C, Krause SW, Bethge W, Jost E, Platzbecker U, Klein SA, Schubert J, Niederland J, Kaufmann M, Schäfer-Eckart K, Schaich M, Baldauf H, Stölzel F, Petzold C, Röllig C, Alakel N, Steffen B, Hauptrock B, Schliemann C, Sockel K, Lang F, Kriege O, Schaffrath J, Reicherts C, Berdel WE, Serve H, Ehninger G, Schmidt AH, Bornhäuser M, Mikesch JH, Schetelig J. Remission induction versus immediate allogeneic haematopoietic stem cell transplantation for patients with relapsed or poor responsive acute myeloid leukaemia (ASAP): a randomised, open-label, phase 3, non-inferiority trial. Lancet Haematol 2024; 11:e324-e335. [PMID: 38583455 DOI: 10.1016/s2352-3026(24)00065-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Whether high-dose cytarabine-based salvage chemotherapy, administered to induce complete remission in patients with poor responsive or relapsed acute myeloid leukaemia scheduled for allogeneic haematopoietic stem-cell transplantation (HSCT) after intensive conditioning confers a survival advantage, is unclear. METHODS To test salvage chemotherapy before allogeneic HSCT, patients aged between 18 and 75 years with non-favourable-risk acute myeloid leukaemia not in complete remission after first induction or untreated first relapse were randomly assigned 1:1 to remission induction with high-dose cytarabine (3 g/m2 intravenously, 1 g/m2 intravenously for patients >60 years or with a substantial comorbidity) twice daily on days 1-3 plus mitoxantrone (10 mg/m2 intravenously) on days 3-5 or immediate allogeneic HSCT for the disease control group. Block randomisation with variable block lengths was used and patients were stratified by age, acute myeloid leukaemia risk, and disease status. The study was open label. The primary endpoint was treatment success, defined as complete remission on day 56 after allogeneic HSCT, with the aim to show non-inferiority for disease control compared with remission induction with a non-inferiority-margin of 5% and one-sided type 1 error of 2·5%. The primary endpoint was analysed in both the intention-to-treat (ITT) population and in the per-protocol population. The trial is completed and was registered at ClinicalTrials.gov, NCT02461537. FINDINGS 281 patients were enrolled between Sept 17, 2015, and Jan 12, 2022. Of 140 patients randomly assigned to disease control, 135 (96%) proceeded to allogeneic HSCT, 97 (69%) after watchful waiting only. Of 141 patients randomly assigned to remission induction, 134 (95%) received salvage chemotherapy and 128 (91%) patients subsequently proceeded to allogeneic HSCT. In the ITT population, treatment success was observed in 116 (83%) of 140 patients in the disease control group versus 112 (79%) of 141 patients with remission induction (test for non-inferiority, p=0·036). Among per-protocol treated patients, treatment success was observed in 116 (84%) of 138 patients with disease control versus 109 (81%) of 134 patients in the remission induction group (test for non-inferiority, p=0·047). The difference in treatment success between disease control and remission induction was estimated as 3·4% (95% CI -5·8 to 12·6) for the ITT population and 2·7% (-6·3 to 11·8) for the per-protocol population. Fewer patients with disease control compared with remission induction had non-haematological adverse events grade 3 or worse (30 [21%] of 140 patients vs 86 [61%] of 141 patients, χ2 test p<0·0001). Between randomisation and the start of conditioning, with disease control two patients died from progressive acute myeloid leukaemia and zero from treatment-related complications, and with remission induction two patients died from progressive acute myeloid leukaemia and two from treatment-related complications. Between randomisation and allogeneic HSCT, patients with disease control spent a median of 27 days less in hospital than those with remission induction, ie, the median time in hospital was 15 days (range 7-64) versus 42 days (27-121, U test p<0·0001), respectively. INTERPRETATION Non-inferiority of disease control could not be shown at the 2·5% significance level. The rate of treatment success was also not statistically better for patients with remission induction. Watchful waiting and immediate transplantation could be an alternative for fit patients with poor response or relapsed acute myeloid leukaemia who have a stem cell donor available. More randomised controlled intention-to-transplant trials are needed to define the optimal treatment before transplantation for patients with active acute myeloid leukaemia. FUNDING DKMS and the Gert and Susanna Mayer Stiftung Foundation.
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Affiliation(s)
| | | | - Gesine Bug
- Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | - Lutz P Müller
- University Hospital, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Christoph Schmid
- Faculty of Medicine, Augsburg University Hospital, Augsburg, Germany
| | | | | | - Edgar Jost
- University Hospital Aachen & Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, Aachen, Germany
| | | | | | | | - Judith Niederland
- Helios Klinikum Berlin-Buch, Klinik für Hämatologie und Zelltherapie, Berlin, Germany
| | | | | | | | | | - Friedrich Stölzel
- University Hospital TU Dresden, Dresden, Germany; University Hospital Schleswig-Holstein, Kiel, Germany
| | | | | | - Nael Alakel
- University Hospital TU Dresden, Dresden, Germany
| | - Björn Steffen
- Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | | | - Katja Sockel
- University Hospital TU Dresden, Dresden, Germany
| | - Fabian Lang
- Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | - Judith Schaffrath
- University Hospital, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | | | | | - Hubert Serve
- Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Gerhard Ehninger
- University Hospital TU Dresden, Dresden, Germany; Cellex Cell Professionals, Cologne, Germany
| | | | - Martin Bornhäuser
- University Hospital TU Dresden, Dresden, Germany; National Center for Tumor Diseases, Dresden, Germany
| | | | - Johannes Schetelig
- University Hospital TU Dresden, Dresden, Germany; DKMS gemeinnützige GmbH, Tübingen und Dresden, Germany.
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40
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Law AD, Mattsson JI. Transplant without salvage: cut out the middleman. Lancet Haematol 2024; 11:e310-e311. [PMID: 38583456 DOI: 10.1016/s2352-3026(24)00072-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 04/09/2024]
Affiliation(s)
- Arjun Datt Law
- Hans Messner Allogeneic Blood and Marrow Transplant Program, Princess Maragaret Cancer Centre, Toronto, ON M5G 2M9, Canada; Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jonas Ingemar Mattsson
- Hans Messner Allogeneic Blood and Marrow Transplant Program, Princess Maragaret Cancer Centre, Toronto, ON M5G 2M9, Canada; Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Gloria and Seymour Epstein Chair in Cell Therapy and Transplantation, Toronto, ON, Canada.
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41
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Garcia-Manero G, Kazmierczak M, Wierzbowska A, Fong CY, Keng MK, Ballinari G, Scarci F, Adès L. Pracinostat combined with azacitidine in newly diagnosed adult acute myeloid leukemia (AML) patients unfit for standard induction chemotherapy: PRIMULA phase III study. Leuk Res 2024; 140:107480. [PMID: 38499457 DOI: 10.1016/j.leukres.2024.107480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/09/2024] [Indexed: 03/20/2024]
Abstract
Non-intensive therapies such as the hypomethylating agent (HMA) azacitidine (AZA) have been used in patients with AML ineligible for intensive induction chemotherapy (IC) or stem cell transplant due to advanced age, comorbidities, and/or risk factors. However, response rates and survival remain dismal. Pre-clinical studies indicate the epigenetic combination of HMAs and HDAC inhibitors induce re-expression of silenced genes synergistically. The activity of pracinostat, an oral pan-HDAC inhibitor, has been shown in xenograft tumor models of AML and promising efficacy was seen in a Phase 2 study. This Phase 3 study (NCT03151408) evaluated the efficacy/safety of pracinostat administered with AZA in adult patients with newly diagnosed AML ineligible to receive IC. Patients were randomized to either pracinostat plus AZA or placebo/AZA and stratified by cytogenetic risk and ECOG status. As planned, an interim analysis was performed when 232/390 events (deaths) occurred. A total of 406 patients were randomized (203/group) at the time of the analysis. Median overall survival was 9.95 months for both treatment groups (p=0.8275). There was no significant difference between treatments in secondary efficacy endpoints, reflecting a lack of clinical response. This study did not show a benefit of adding pracinostat to AZA in elderly patients unfit for IC.
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Affiliation(s)
| | - Maciej Kazmierczak
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Agnieszka Wierzbowska
- Department of Hematology, Medical University of Lodz, Lodz, Poland; Provincial Multispecialized Oncology and Traumatology Center, Lodz, Poland
| | - Chun Yew Fong
- Austin Health, Olivia Newton John Cancer Wellness Centre, Victoria, Australia
| | | | | | | | - Lionel Adès
- Hôpital Saint Louis AP-HP, and Paris cité University and INSERM U944, Paris, France
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42
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Niscola P, Gianfelici V, Giovannini M, Piccioni D, Mazzone C, Fabritiis PD. Very long-term efficacy of venetoclax combined with hypomethylating agents in two AML elderly: is it the time for treatment discontinuation strategies? Ann Hematol 2024; 103:1787-1788. [PMID: 38459155 DOI: 10.1007/s00277-024-05700-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/05/2024] [Indexed: 03/10/2024]
Affiliation(s)
- Pasquale Niscola
- Hematology Unit, Sant 'Eugenio Hospital of Rome, ASL Roma 2, Rome, Italy.
| | | | - Marco Giovannini
- Hematology Unit, Sant 'Eugenio Hospital of Rome, ASL Roma 2, Rome, Italy
| | - Daniela Piccioni
- Hematology Unit, Sant 'Eugenio Hospital of Rome, ASL Roma 2, Rome, Italy
| | - Carla Mazzone
- Hematology Unit, Sant 'Eugenio Hospital of Rome, ASL Roma 2, Rome, Italy
| | - Paolo de Fabritiis
- Hematology Unit, Sant 'Eugenio Hospital of Rome, ASL Roma 2, Rome, Italy
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43
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Manda S, Anz BM, Benton C, Broun ER, Yimer HA, Renshaw JS, Geils G, Berdeja J, Cruz J, Melear JM, Fanning S, Fletcher L, Li Y, Duan Y, Werner ME, Potluri J, Pai MV, Donnellan WB. A phase 3b study of venetoclax and azacitidine or decitabine in an outpatient setting in patients with acute myeloid leukemia. Hematol Oncol 2024; 42:e3274. [PMID: 38711253 DOI: 10.1002/hon.3274] [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: 01/31/2024] [Revised: 04/09/2024] [Accepted: 04/13/2024] [Indexed: 05/08/2024]
Abstract
Venetoclax, a highly selective BCL-2 inhibitor, combined with hypomethylating agents (HMAs) azacitidine or decitabine, is approved for the treatment of newly diagnosed acute myeloid leukemia (ND AML) in patients who are ineligible to receive intensive chemotherapy. Previous clinical studies initiated venetoclax plus HMA in an inpatient setting owing to concerns of tumor lysis syndrome (TLS). This study (NCT03941964) evaluated the efficacy and safety of venetoclax plus HMA in a United States community-based outpatient setting in patients with ND AML (N = 60) who were treatment naïve for AML, ineligible to receive intensive chemotherapy, had no evidence of spontaneous TLS at screening, and were deemed as appropriate candidates for outpatient initiation of venetoclax plus HMA by the investigator. Patients received venetoclax in combination with azacitidine (75 mg/m2) or decitabine (20 mg/m2) for up to 6 cycles during the study. With a median time on study of 18.3 weeks, the best response rate of composite complete remission was 66.7%, and the overall post-baseline red blood cell (RBC) and platelet transfusion independence rate was 55.0%, consistent with results of studies in which treatment was initiated in an inpatient setting. Key adverse events included nausea, anemia, thrombocytopenia, neutropenia, and white blood cell count decrease of any grade (≥50% of patients). The observed safety profile was generally consistent with that of venetoclax plus HMA observed in inpatient AML studies. With close monitoring, 2 cases of TLS were identified, appropriately managed, and the patients were able to continue study treatment. CLINICAL TRIALS REGISTRATION: This study is registered at ClinicalTrials.gov. The registration identification number is NCT03941964.
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Affiliation(s)
- Sudhir Manda
- Arizona Oncology, The US Oncology Network, Tucson, Arizona, USA
| | | | - Christopher Benton
- Rocky Mountain Cancer Centers, The US Oncology Network, Englewood, Colorado, USA
| | | | | | - John S Renshaw
- Texas Oncology - San Antonio Medical Center, The US Oncology Network, San Antonio, Texas, USA
| | - George Geils
- Charleston Oncology, Charleston, South Carolina, USA
| | - Jesus Berdeja
- Sarah Cannon Research Institute and Tennessee Oncology, Nashville, Tennessee, USA
| | - Jose Cruz
- Methodist Physicians Texas Transplant Specialists, San Antonio, Texas, USA
| | - Jason M Melear
- Texas Oncology - Austin Midtown, The US Oncology Network, Austin, Texas, USA
| | - Suzanne Fanning
- Prisma Health Cancer Institute, Greenville, South Carolina, USA
| | - Luke Fletcher
- Willamette Valley Cancer Institute and US Oncology Research Center, Eugene, Oregon, USA
| | - Yukun Li
- AbbVie, Inc, North Chicago, Illinois, USA
| | | | | | | | | | - William B Donnellan
- Sarah Cannon Research Institute and Tennessee Oncology, Nashville, Tennessee, USA
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44
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Noguera-Castells A, Campillo-Marcos I, Davalos V, García-Prieto CA, Valcárcel D, Molero A, Palomo L, Gattermann N, Wulfert M, Chaparro-González L, Solé F, Cabezón M, Jiménez-Lorenzo MJ, Xicoy B, Zamora L, De Stefano A, Casalin I, Finelli C, Follo MY, Esteller M. DNA methylation profiling of myelodysplastic syndromes and clinical response to azacitidine: A multicentre retrospective study. Br J Haematol 2024; 204:1838-1843. [PMID: 38471524 DOI: 10.1111/bjh.19392] [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: 12/21/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/14/2024]
Abstract
Real-world data have revealed that a substantial portion of patients with myelodysplastic syndromes (MDS) does not respond to epigenetic therapy with hypomethylating agents (HMAs). The cellular and molecular reasons for this resistance to the demethylating agent and biomarkers that would be able to predict the treatment refractoriness are largely unknown. In this study, we shed light on this enigma by characterizing the epigenomic profiles of patients with MDS treated with azacitidine. Our approach provides a comprehensive view of the evolving DNA methylation architecture of the disease and holds great potential for advancing our understanding of MDS treatment responses to HMAs.
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Affiliation(s)
- Aleix Noguera-Castells
- Cancer Epigenetics Group, Josep Carreras Leukaemia Research Institute (IJC), Barcelona, Catalonia, Spain
- Department of Biosciences, Faculty of Science, Technology and Engineering, University of Vic - Central University of Catalonia (UVic-UCC), Vic, Barcelona, Catalonia, Spain
- Centro de Investigacion Biomedica en Red Cancer (CIBERONC), Madrid, Spain
| | - Ignacio Campillo-Marcos
- Cancer Epigenetics Group, Josep Carreras Leukaemia Research Institute (IJC), Barcelona, Catalonia, Spain
- Centro de Investigacion Biomedica en Red Cancer (CIBERONC), Madrid, Spain
| | - Veronica Davalos
- Cancer Epigenetics Group, Josep Carreras Leukaemia Research Institute (IJC), Barcelona, Catalonia, Spain
| | - Carlos A García-Prieto
- Cancer Epigenetics Group, Josep Carreras Leukaemia Research Institute (IJC), Barcelona, Catalonia, Spain
- Life Sciences Department, Barcelona Supercomputing Center (BSC), Barcelona, Catalonia, Spain
| | - David Valcárcel
- Department of Hematology, Experimental Hematology Unit, Vall d'Hebron Institute of Oncology (VHIO), University Hospital Vall d'Hebron, Barcelona, Spain
| | - Antonieta Molero
- Department of Hematology, Experimental Hematology Unit, Vall d'Hebron Institute of Oncology (VHIO), University Hospital Vall d'Hebron, Barcelona, Spain
| | - Laura Palomo
- Department of Hematology, Experimental Hematology Unit, Vall d'Hebron Institute of Oncology (VHIO), University Hospital Vall d'Hebron, Barcelona, Spain
| | - Norbert Gattermann
- Department of Hematology, Oncology and Clinical Immunology, University Cancer Center, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Michael Wulfert
- Department of Hematology, Oncology and Clinical Immunology, University Cancer Center, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Lorea Chaparro-González
- Myelodysplastic Syndromes Research Group, Josep Carreras Leukaemia Research Institute (IJC), Barcelona, Catalonia, Spain
| | - Francesc Solé
- Myelodysplastic Syndromes Research Group, Josep Carreras Leukaemia Research Institute (IJC), Barcelona, Catalonia, Spain
| | - Marta Cabezón
- Department of Hematology, ICO-IJC-Hospital Germans Trias i Pujol, UAB, Badalona, Catalonia, Spain
- Myeloid neoplasms Research Group, Josep Carreras Leukaemia Research Institute (IJC), Barcelona, Catalonia, Spain
| | - María J Jiménez-Lorenzo
- Department of Hematology, ICO-IJC-Hospital Germans Trias i Pujol, UAB, Badalona, Catalonia, Spain
- Myeloid neoplasms Research Group, Josep Carreras Leukaemia Research Institute (IJC), Barcelona, Catalonia, Spain
| | - Blanca Xicoy
- Department of Hematology, ICO-IJC-Hospital Germans Trias i Pujol, UAB, Badalona, Catalonia, Spain
- Myeloid neoplasms Research Group, Josep Carreras Leukaemia Research Institute (IJC), Barcelona, Catalonia, Spain
| | - Lurdes Zamora
- Department of Hematology, ICO-IJC-Hospital Germans Trias i Pujol, UAB, Badalona, Catalonia, Spain
- Myeloid neoplasms Research Group, Josep Carreras Leukaemia Research Institute (IJC), Barcelona, Catalonia, Spain
| | - Alessia De Stefano
- Cellular Signalling Laboratory, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Irene Casalin
- Cellular Signalling Laboratory, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Carlo Finelli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Institute of Hematology "Seràgnoli", Bologna, Italy
| | - Matilde Y Follo
- Cellular Signalling Laboratory, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Manel Esteller
- Cancer Epigenetics Group, Josep Carreras Leukaemia Research Institute (IJC), Barcelona, Catalonia, Spain
- Centro de Investigacion Biomedica en Red Cancer (CIBERONC), Madrid, Spain
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Catalonia, Spain
- Physiological Sciences Department, School of Medicine and Health Sciences, University of Barcelona (UB), Barcelona, Catalonia, Spain
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45
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Forsberg M, Konopleva M. AML treatment: conventional chemotherapy and emerging novel agents. Trends Pharmacol Sci 2024; 45:430-448. [PMID: 38643058 DOI: 10.1016/j.tips.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 03/25/2024] [Accepted: 03/25/2024] [Indexed: 04/22/2024]
Abstract
Acute myeloid leukemia (AML) is driven by complex mutations and cytogenetic abnormalities with profound tumoral heterogeneity, making it challenging to treat. Ten years ago, the 5-year survival rate of patients with AML was only 29% with conventional chemotherapy and stem cell transplantation. All attempts to improve conventional therapy over the previous 40 years had failed. Now, new genomic, immunological, and molecular insights have led to a renaissance in AML therapy. Improvements to standard chemotherapy and a wave of new targeted therapies have been developed. However, how best to incorporate these advances into frontline therapy and sequence them in relapse is not firmly established. In this review, we highlight current treatments of AML, targeted agents, and pioneering attempts to synthesize these developments into a rational standard of care (SoC).
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Affiliation(s)
- Mark Forsberg
- Montefiore Einstein Cancer Center, Department of Oncology, 1300 Morris Park Avenue, Bronx, NY 10461, USA
| | - Marina Konopleva
- Montefiore Einstein Cancer Center, Department of Oncology, 1300 Morris Park Avenue, Bronx, NY 10461, USA.
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46
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Olesinski EA, Bhatia KS, Wang C, Pioso MS, Lin XX, Mamdouh AM, Ng SX, Sandhu V, Jasdanwala SS, Yilma B, Bohl S, Ryan JA, Malani D, Luskin MR, Kallioniemi O, Porkka K, Adamia S, Chng WJ, Osato M, Weinstock DM, Garcia JS, Letai A, Bhatt S. Acquired Multidrug Resistance in AML Is Caused by Low Apoptotic Priming in Relapsed Myeloblasts. Blood Cancer Discov 2024; 5:180-201. [PMID: 38442309 PMCID: PMC11061585 DOI: 10.1158/2643-3230.bcd-24-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/05/2023] [Accepted: 12/19/2023] [Indexed: 03/07/2024] Open
Abstract
In many cancers, mortality is associated with the emergence of relapse with multidrug resistance (MDR). Thus far, the investigation of cancer relapse mechanisms has largely focused on acquired genetic mutations. Using acute myeloid leukemia (AML) patient-derived xenografts (PDX), we systematically elucidated a basis of MDR and identified drug sensitivity in relapsed AML. We derived pharmacologic sensitivity for 22 AML PDX models using dynamic BH3 profiling (DBP), together with genomics and transcriptomics. Using in vivo acquired resistant PDXs, we found that resistance to unrelated, narrowly targeted agents in distinct PDXs was accompanied by broad resistance to drugs with disparate mechanisms. Moreover, baseline mitochondrial apoptotic priming was consistently reduced regardless of the class of drug-inducing selection. By applying DBP, we identified drugs showing effective in vivo activity in resistant models. This study implies evasion of apoptosis drives drug resistance and demonstrates the feasibility of the DBP approach to identify active drugs for patients with relapsed AML. SIGNIFICANCE Acquired resistance to targeted therapy remains challenging in AML. We found that reduction in mitochondrial priming and common transcriptomic signatures was a conserved mechanism of acquired resistance across different drug classes in vivo. Drugs active in vivo can be identified even in the multidrug resistant state by DBP.
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MESH Headings
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/pathology
- Leukemia, Myeloid, Acute/genetics
- Humans
- Apoptosis/drug effects
- Animals
- Mice
- Drug Resistance, Neoplasm/drug effects
- Drug Resistance, Neoplasm/genetics
- Drug Resistance, Multiple/genetics
- Drug Resistance, Multiple/drug effects
- Xenograft Model Antitumor Assays
- Granulocyte Precursor Cells/drug effects
- Granulocyte Precursor Cells/pathology
- Antineoplastic Agents/pharmacology
- Antineoplastic Agents/therapeutic use
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Affiliation(s)
- Elyse A. Olesinski
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | | | - Chuqi Wang
- Department of Pharmacy, National University of Singapore, Singapore
| | - Marissa S. Pioso
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Xiao Xian Lin
- Department of Pharmacy, National University of Singapore, Singapore
| | - Ahmed M. Mamdouh
- Department of Pharmacy, National University of Singapore, Singapore
| | - Shu Xuan Ng
- Department of Pharmacy, National University of Singapore, Singapore
| | - Vedant Sandhu
- Department of Pharmacy, National University of Singapore, Singapore
| | | | - Binyam Yilma
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Stephan Bohl
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jeremy A. Ryan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Disha Malani
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Marlise R. Luskin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Olli Kallioniemi
- Institute for Molecular Medicine Finland FIMM, Hi-Life, University of Helsinki, Helsinki, Finland
- Science for Life Laboratory, Department of Oncology and Pathology, Karolinska Institute, Solna, Sweden
| | - Kimmo Porkka
- Hematology Research Unit Helsinki, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Department of Hematology, HUS, Helsinki, Finland
| | - Sophia Adamia
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Wee Joo Chng
- Cancer Science Institute of Singapore, National University of Singapore, Centre for Translational Medicine, Singapore
| | - Motomi Osato
- Cancer Science Institute of Singapore, National University of Singapore, Centre for Translational Medicine, Singapore
| | - David M. Weinstock
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jacqueline S. Garcia
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anthony Letai
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Shruti Bhatt
- Department of Pharmacy, National University of Singapore, Singapore
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47
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Fruchtman H, Avigan ZM, Waksal JA, Brennan N, Mascarenhas JO. Management of isocitrate dehydrogenase 1/2 mutated acute myeloid leukemia. Leukemia 2024; 38:927-935. [PMID: 38600315 DOI: 10.1038/s41375-024-02246-2] [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: 01/04/2024] [Revised: 04/01/2024] [Accepted: 04/04/2024] [Indexed: 04/12/2024]
Abstract
The emergence of next generation sequencing and widespread use of mutational profiling in acute myeloid leukemia (AML) has broadened our understanding of the heterogeneous molecular basis of the disease. Since genetic sequencing has become a standard practice, several driver mutations have been identified. Accordingly, novel targeted therapeutic agents have been developed and are now approved for the treatment of subsets of patients that carry mutations in FLT3, IDH1, and IDH2 [1, 2]. The emergence of these novel agents in AML offers patients a new modality of therapy, and shifts treatment paradigms toward individualized medicine. In this review, we outline the role of IDH mutations in malignant transformation, focus in on a novel group of targeted therapeutic agents directed toward IDH1- and IDH2-mutant AML, and explore their impact on prognosis in patients with AML.
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Affiliation(s)
| | - Zachary M Avigan
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Julian A Waksal
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - John O Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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48
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Maeda T, Najima Y, Kamiyama Y, Nakao S, Ozaki Y, Nishio H, Tsuchihashi K, Ichihara E, Miumra Y, Endo M, Maruyama D, Yoshinami T, Susumu N, Takekuma M, Motohashi T, Ito M, Baba E, Ochi N, Kubo T, Uchino K, Kimura T, Tamura S, Nishimoto H, Kato Y, Sato A, Takano T, Yano S. Effectiveness and safety of primary prophylaxis with G-CSF after induction therapy for acute myeloid leukemia: a systematic review and meta-analysis of the clinical practice guidelines for the use of G-CSF 2022 from the Japan society of clinical oncology. Int J Clin Oncol 2024; 29:535-544. [PMID: 38494578 PMCID: PMC11043120 DOI: 10.1007/s10147-023-02465-0] [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: 09/07/2023] [Accepted: 12/14/2023] [Indexed: 03/19/2024]
Abstract
Although granulocyte colony-stimulating factor (G-CSF) reduces the incidence, duration, and severity of neutropenia, its prophylactic use for acute myeloid leukemia (AML) remains controversial due to a theoretically increased risk of relapse. The present study investigated the effects of G-CSF as primary prophylaxis for AML with remission induction therapy. A detailed literature search for related studies was performed using PubMed, Ichushi-Web, and the Cochrane Library. Data were independently extracted and assessed by two reviewers. A qualitative analysis of pooled data was conducted, and the risk ratio with corresponding confidence intervals was calculated in the meta-analysis and summarized. Sixteen studies were included in the qualitative analysis, nine of which were examined in the meta-analysis. Although G-CSF significantly shortened the duration of neutropenia, primary prophylaxis with G-CSF did not correlate with infection-related mortality. Moreover, primary prophylaxis with G-CSF did not affect disease progression/recurrence, overall survival, or adverse events, such as musculoskeletal pain. However, evidence to support or discourage the use of G-CSF as primary prophylaxis for adult AML patients with induction therapy remains limited. Therefore, the use of G-CSF as primary prophylaxis can be considered for adult AML patients with remission induction therapy who are at a high risk of infectious complications.
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Affiliation(s)
- Tomoya Maeda
- Department of Hemato-Oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan.
| | - Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-Ku, Tokyo, 113-8677, Japan
| | - Yutaro Kamiyama
- Division of Clinical Oncology and Hematology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Shinji Nakao
- Department of Hematology, Faculty of Medicine, Institute of Medical Pharmaceutical and Health Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Yukinori Ozaki
- Department of Breast Medical Oncology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8850, Japan
| | - Hiroshi Nishio
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Kenji Tsuchihashi
- Department of Hematology, Oncology and Cardiovascular Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Eiki Ichihara
- Center for Clinical Oncology, Okayama University Hospital, 2-5-1 Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Yuji Miumra
- Department of Medical Oncology, Toranomon Hospital, 2-2-2 Toranomon, Minato-Ku, Tokyo, 105-8470, Japan
| | - Makoto Endo
- Department of Orthopedic Surgery, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Dai Maruyama
- Department of Hematology Oncology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8850, Japan
| | - Tatsuhiro Yoshinami
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, 565-0871, Japan
| | - Nobuyuki Susumu
- Department of Obstetrics and Gynecology, International University of Health and Welfare Narita Hospital, 4-3 Kozunomori, Narita, Chiba, 286-8686, Japan
| | - Munetaka Takekuma
- Department of Gynecology, Shizuoka Cancer Center Hospital, Sunto-Gun, Shizuoka, 411-8777, Japan
| | - Takashi Motohashi
- Department of Obstetrics and Gynecology, Tokyo Women's Medical University Hospital, 8-1 Kawada-Cho, Shinjyuku-Ku, Tokyo, 162-8666, Japan
| | - Mamoru Ito
- Department of Hematology, Oncology and Cardiovascular Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Eishi Baba
- Department of Oncology and Social Medicine, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Nobuaki Ochi
- Department of General Internal Medicine 4, Kawasaki Medical School, 2-6-1 Nakasange, Kita-Ku, Okayama, 700-8505, Japan
| | - Toshio Kubo
- Department of Allergy and Respiratory Medicine, Okayama University Hospital, 2-5-1 Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Keita Uchino
- Department of Medical Oncology, NTT Medical Center Tokyo, 5-9-22 Higashi-Gotanda, Shinagawa-Ku, Tokyo, 141-8625, Japan
| | - Takahiro Kimura
- Department of Urology, The Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Shinobu Tamura
- Department of Hematology/Oncology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Hitomi Nishimoto
- Department of Nursing, Okayama University Hospital, 2-5-1 Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Yasuhisa Kato
- Department of Drug Information, Faculty of Pharmaceutical Sciences, Shonan University of Medical Sciences, 16-48 Kamishinano, Totsuka-Ku, Yokohama, Kanagawa, 224-0806, Japan
| | - Atsushi Sato
- Department of Medical Oncology, Hirosaki University Graduate School of Medicine, 5 Zaifu-Cho, Hirosaki, Aomori, 036-8562, Japan
| | - Toshimi Takano
- Department of Breast Medical Oncology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8850, Japan
| | - Shingo Yano
- Division of Clinical Oncology and Hematology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
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49
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Haider SMW, Zehra M, Shah NN, Sotomayor EM, Swoboda DM. A comprehensive case study on successful multimodal therapy in philadelphia chromosome-positive acute myeloid leukemia with NPM1 and IDH2 mutations. Leuk Res Rep 2024; 21:100461. [PMID: 38736691 PMCID: PMC11081792 DOI: 10.1016/j.lrr.2024.100461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 05/14/2024] Open
Abstract
A 67-year-old female came to Tampa General Hospital with Philadelphia chromosome-positive (Ph+) acute myeloid leukemia (AML) featuring an intriguing combination of mutations, including NPM1 and IDH2 mutations. Novel combination therapy with azacitidine, venetoclax and ponatinib allowed her to successfully achieve a complete response (CR) and undergo an allogeneic hematopoietic stem cell transplant (HSCT). This case report provides an overview of her clinical course, emphasizing the significance of integrated therapy and the challenges associated with balancing treatment for AML. It also underscores the importance of a multidisciplinary approach and careful monitoring of patients with complex hematologic conditions.
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Affiliation(s)
| | - Mehwish Zehra
- Indus Hospital And Health Network, Karachi, Sindh, Pakistan
| | - Nikesh N Shah
- Tampa General Hospital Cancer Institute, Tampa, FL, USA
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50
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Sackstein P, Williams A, Zemel R, Marks JA, Renteria AS, Rivero G. Transplant Eligible and Ineligible Elderly Patients with AML-A Genomic Approach and Next Generation Questions. Biomedicines 2024; 12:975. [PMID: 38790937 PMCID: PMC11117792 DOI: 10.3390/biomedicines12050975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/15/2024] [Accepted: 04/16/2024] [Indexed: 05/26/2024] Open
Abstract
The management of elderly patients diagnosed with acute myelogenous leukemia (AML) is complicated by high relapse risk and comorbidities that often preclude access to allogeneic hematopoietic cellular transplantation (allo-HCT). In recent years, fast-paced FDA drug approval has reshaped the therapeutic landscape, with modest, albeit promising improvement in survival. Still, AML outcomes in elderly patients remain unacceptably unfavorable highlighting the need for better understanding of disease biology and tailored strategies. In this review, we discuss recent modifications suggested by European Leukemia Network 2022 (ELN-2022) risk stratification and review recent aging cell biology advances with the discussion of four AML cases. While an older age, >60 years, does not constitute an absolute contraindication for allo-HCT, the careful patient selection based on a detailed and multidisciplinary risk stratification cannot be overemphasized.
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Affiliation(s)
- Paul Sackstein
- Lombardi Cancer Institute, School of Medicine, Georgetown University, Washington, DC 20007, USA; (P.S.); (R.Z.); (J.A.M.)
| | - Alexis Williams
- Department of Medicine, New York University, New York, NY 10016, USA;
| | - Rachel Zemel
- Lombardi Cancer Institute, School of Medicine, Georgetown University, Washington, DC 20007, USA; (P.S.); (R.Z.); (J.A.M.)
| | - Jennifer A. Marks
- Lombardi Cancer Institute, School of Medicine, Georgetown University, Washington, DC 20007, USA; (P.S.); (R.Z.); (J.A.M.)
| | - Anne S. Renteria
- Lombardi Cancer Institute, School of Medicine, Georgetown University, Washington, DC 20007, USA; (P.S.); (R.Z.); (J.A.M.)
| | - Gustavo Rivero
- Lombardi Cancer Institute, School of Medicine, Georgetown University, Washington, DC 20007, USA; (P.S.); (R.Z.); (J.A.M.)
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