Dose intensity for induction in acute myeloid leukemia: what, when, and for whom?

Effectiveness of nirmatrelvir/ritonavir in hospitalized haematological malignancy patients with mild-to-moderate COVID-19: A retrospective study

Patients with haematological malignancies (HMs) are highly vulnerable to COVID-19 due to their immunocompromised status, which leads to prolonged viral clearance and severe outcomes. Nirmatrelvir/ritonavir has shown efficacy in reducing severity and mortality in high-risk COVID-19 outpatients, but its effectiveness in hospitalized HM patients remains unclear. We conducted a retrospective study to assess the effectiveness of nirmatrelvir/ritonavir on mortality and viral clearance in hospitalized HM patients with mild-to-moderate COVID-19 during China's first COVID-19 surge. Mortality rate and viral clearance time were the primary end-points. Cox proportional hazards models were used to detect factors associated with mortality and viral clearance. A total of 116 HM patients, with a median age of 47.2 years, hospitalized for a minimum of 5 days with mild-to-moderate COVID-19, were included in this study. There was no difference in the 90-day mortality rate between HM patients treated with nirmatrelvir/ritonavir within 5 days and those not treated (4.9% vs. 5.3%, p = 1.000). Nirmatrelvir/ritonavir use within 5 days reduced the time to viral clearance (hazard ratio [HR] = 1.59, 95% confidence interval [CI] 1.04-2.42). Nirmatrelvir/ritonavir use within 5 days in hospitalized HM patients with mild-to-moderate COVID-19 does not reduce mortality but accelerates viral clearance.

Effect of NPM1 Mutation Subtype and Co-Mutation Patterns on the Outcomes of Acute Myeloid Leukemia

INTRODUCTION

NPM1 mutated AML without FLT3-ITD is considered "favorable" per the recent ELN 2022 criteria. However, our center has been challenged with treatment-refractory patients, prompting a search for additional prognostic factors.

METHODS

We reviewed records of NPM1 AML patients from 2015 to 2024. Factors associated with event-free survival (EFS) and overall survival (OS) were evaluated using Cox regression.

RESULTS

Among 141 patients with NPM1 AML, subtype A was the most common (N = 99), followed by subtype D (N = 10), subtype B (N = 6), subtype G/I/J/K/R (N = 3/5/3/2/1) and other subtypes (N = 12). Ninety patients received chemotherapy (chemo), 41 received hypomethylating agent +/- venetoclax (HMA/ven) and 10 did not receive specific anti-AML therapy. At 12 months, EFS for subtypes A, D, B, G/I/J/K/R, and other subtypes were 49%, 58%, 50%, 49%, and 31%, and OS were 71%, 79%, 50%, 44%, and 56%, respectively. Fifty patients had allogeneic stem cell transplants: 33 in CR1 and 17 in CR2+. EFS at 12 months post-HSCT was 72%. On multivariable analysis, co-mutation with KRAS (HR: 2.69, 95% CI: 1.20-6.00) or TET2 (HR: 1.99, 95% CI: 1.22-3.26) was associated with worse EFS. For each 50 k/mm3 increase in WBC at diagnosis, the risk of relapse or death increased by 21%. For OS, co-mutation with IDH1/IDH2 (HR: 0.40, 95% CI: 0.21-0.74) was associated with better OS, whereas co-mutation with SRSF2 (HR: 2.70, 95% CI: 1.35-5.40) was associated with worse OS.

CONCLUSION

We did not find a statistically significant difference in EFS and OS among the NPM1 subtypes. However, our results showed that the prognoses of NPM1 AML can be influenced by other co-occurring mutations. A larger study is needed to confirm our findings.

Dual targeting of CXC chemokine receptor 4 and multidrug resistance protein 1 by ZIN056 effectively combat daunorubicin resistance in acute myeloid leukemia cells

Drug resistance, associated with the overexpression of CXC chemokine receptor CXCR4 and multidrug resistance protein 1 (MDR1) remains a significant barrier to effective therapy in Acute Myeloid Leukemia (AML). Targeting both CXCR4 and MDR1 could potentially enhance treatment efficacy in resistance. In silico computational screening of the Zinc natural product library using Discovery Studio Visualizer, Protein-Ligand Interaction Profiler, GROMACS, and GMX_MMPBSA techniques were used. THP-1, and SKM-1 cells were used for in vitro analysis. Flow cytometry was employed for target analysis and apoptosis enumerations. The virtual screening identified ZIN056 with favorable binding affinities of - 10.6 kcal/mol and - 9.1 kcal/mol for CXCR4 and MDR1, respectively. MD simulations demonstrated stable binding interactions, with Root Mean Square Deviation values around 0.2 nm for both proteins. The ΔG binding calculations further confirmed values of - 30.09 kcal/mol for CXCR4 and - 34.47 kcal/mol for MDR1, indicating energetically favorable binding. The compound inhibited the THP-1 and SKM-1 cell proliferation with GI50 values of 250.6 nM, and 346.7 nM, respectively. ZIN056 decreased CXCR-4 expression and MDR1-induced positive population (MDR1+) in THP-1 and SKM-1 cells. ZIN056 inhibited the proliferation of the regular and MDR1+ AML cells, while Daunorubicin exhibited a tenfold resistance in controlling MDR1+ AML cell proliferation. ZIN056-induced apoptosis in MDR1 + AML cells, whereas Daunorubicin failed to promote apoptosis in these cells. The findings suggest that dual targeting of CXCR4 and MDR1 using ZIN056 may offer a promising strategy to overcome drug resistance in AML and provide a foundation for further development of dual inhibitors for AML patients.

Hematopoietic cell transplantation for older acute myeloid leukemia patients in first complete remission: results of a randomized phase III study

Given the selection of elderly patients with AML in first complete remission (CR1) the advantage of consolidation with allogeneic hematopoietic cell transplantation (HCT) over chemotherapy is still unclear. Newly diagnosed AML patients in CR1 aged 60-75 years were registered and a donor search initiated. After one consolidation cycle, patients with a matched donor were randomized to HCT with fludarabine/low-dose total body irradiation and cyclosporine/mycophenolate mofetil immunosuppression or conventional non-HCT. Primary outcome was restricted mean leukemia-free survival (RM-LFS) up to 5 years. Between 2010 and 2017, 245 patients (median age 67 years) were registered at CR1. After one consolidation, 26.9% of patients failed inclusion criteria. Of the 179 (73%) patients still on study, 75.4% had an HLA identical donor. Ten ineligible patients were excluded, and 125 randomized to HCT (N=83) or non-HCT (N=42). The primary outcome RM-LFS up to 5 years was 24.5 months (95% confidence interval [CI]: 18.9-30.1) in the HCT and 15.6 months (95% CI: 10.4-20.8) in the non-HCT arm (P=0.022) due to a decrease in cumulative relapse incidence from 91.1% (95% CI: 80.7-100.0) after non-HCT to 37.8% (95% CI: 27.2-48.4) after HCT (P<0.0001). The secondary endpoints RM-OS up to 5 years was 27.8 months (95% CI:22.3-33.2) in the HCT as compared to 28.6 months (95% CI: 22.2-35.0) in the non-HCT arm; non-relapse mortality at 5 years was 33.4% (95% CI: 23.0-43.9) with HCT and 0% without. In older patients with AML in CR1 5-year RM-LFS is better with HCT than with non-HCT consolidation treatment. The long-term RM-LFS benefit did not translate into a better RM-OS during the study period.

Venetoclax plus D-CAG (decitabine, cytarabine, aclarubicin, G-CSF) for elderly or unfit patients with newly diagnosed acute myeloid leukemia: a multicenter, prospective study

Induction regimens with satisfactory remission rates are limited for patients with acute myeloid leukemia (AML) who are elderly or ineligible for intensive chemotherapy. This study is a single-arm, multicenter, prospective phase I/II study (registered with the Chinese Clinical Trial Registry as ChiCTR 2200059694 on May 8, 2022), aiming to evaluate the efficacy and safety of venetoclax plus decitabine, cytarabine, aclarubicin, and granulocyte colony-stimulating factor (VD-CAG) for newly diagnosed AML patients who are elderly or ineligible for intensive chemotherapy. The primary endpoint was composite complete remission (CRc) after 1 cycle of induction chemotherapy. The secondary endpoints were measurable residual disease (MRD) by flow cytometry and adverse events. Forty patients(n = 40) received 1 cycle of the VD-CAG regimen for induction chemotherapy. The median age of the patients was 64 (55-81) years, and 10 patients (25%) had secondary AML. Our results showed that 1 cycle of VD-CAG had a high overall response rate of 97.5% and CRc of 95%, and all 10 patients with secondary AML achieved CRc. Moreover, the patients who achieved CRc had deep remission, with MRD-negativity of 71.1% and 54.2% by flow cytometry and molecular assessment, respectively. In addition, blood cell recovery was quick, with a median time to absolute neutrophil count ≥ 1.0 × 109/L and platelet count ≥ 100 × 109/L at 19 days and 15.5 days, respectively. In conclusion, VD-CAG demonstrates high efficacy as an induction treatment for elderly or unfit patients with newly diagnosed AML, and it could be an alternative upfront therapy for this subpopulation, Trials with large-scale subjects are needed for further validation, especially for secondary AML.

Transplant versus no transplant in myelodysplastic syndrome and acute myeloid leukemia with TP53 mutation; a referral center experience

A remarkably high rate of post-transplant relapse in patients with TP53-mutated myelodysplastic syndrome/acute myeloid leukemia (MDS/AML) calls to question the utility of allogeneic stem cell transplant (HSCT). We, therefore, performed a retrospective analysis to compare the outcomes between HSCT (N = 38) versus non-HSCT (N = 45) approaches. Patients in the HSCT cohort were younger (median age 63 vs. 72) while patients in the non-HSCT cohort more commonly had complex karyotype with chromosome 17 aberrancy and 5q deletion (p < .01). A total of 69 TP53 variants including 64 pathogenic variants, and 5 variants of undetermined significance were detected. Nine patients (4 in HSCT and 5 in non-HSCT) had multi-hit TP53 variants. After induction: 57.9% versus 56.6% in the HSCT versus non-HSCT cohort achieved morphologic complete remission. Median time to HSCT was 6 months and median follow-up was 15.1 months for HSCT and 5.7 months for non-HSCT. Median disease-free survival (DFS) and overall survival (OS) were 11.7 and 15.9 months for HSCT, and 4.1 and 5.7 months for non-HSCT cohorts, respectively. Non-relapse mortality at 12 months was 22% versus 44% for HSCT versus non-HSCT. In the HSCT cohort, the rate of grade II-IV acute and chronic graft-versus-host disease (GVHD) was 55% and 18%, respectively. None of the patients from the non-HSCT cohort were alive while four patients from the HSCT cohort were alive, in remission, and without GVHD (GRFS) at the time of abstraction. Better treatment strategies for patients with TP53-mutated MDS/AML remain an area of unmet clinical need.

Different treatment strategies versus a common standard arm (CSA) in patients with newly diagnosed AML over the age of 60 years: a randomized German inter-group study

A randomized inter-group trial comparing more intensive treatment strategies to a common standard arm 3 + 7 (CSA) was conducted in patients with non-M3 AML. Untreated patients ≥ 60 years were allocated to the CSA (n = 132) or to the study group arms (n = 1154) of the AMLCG (TAD/HAM versus HAM/HAM ± G-CSF followed by TAD and maintenance) and the OSHO (intermediate-dose ara-C/mitoxantrone followed by ara-C/mitoxantrone). Median age of the 1147 eligible patients was 69 (range 60-87) years. CR/CRi status at 90 days was not significantly different between the CSA (54% (95%CI: 45-64)) and the study group arms (53% (95%CI: 47-60) and 59% (95%CI: 58-63)). The five-year event-free survival (EFS) probability (primary endpoint) was 6.2% (95%CI: 2.7-14.0) in the CSA, 7.6% (95%CI: 4.5-12.8) in study group A and 11.1% (95%CI: 9.0-13.7) in B. The 5-year OS was 17.2% (95%CI: 11.0-26.9), 17.0% (95%CI: 2.0-23.9), and 19.5% (95%CI: 16.7-22.8) in CSA, study group A and B, respectively. Neither study group differed significantly from the CSA regarding EFS, OS, or relapse-free survival. In multivariate analyses, allocation to the treatment strategy was not significantly associated with the time-to-event endpoints. The evaluation of more intensive treatment strategies did not show clinically relevant outcome differences when compared to CSA.

The Class IIA Histone Deacetylase (HDAC) Inhibitor TMP269 Downregulates Ribosomal Proteins and Has Anti-Proliferative and Pro-Apoptotic Effects on AML Cells

Acute myeloid leukemia (AML) is a hematopoietic malignancy characterized by altered myeloid progenitor cell proliferation and differentiation. As in many other cancers, epigenetic transcriptional repressors such as histone deacetylases (HDACs) are dysregulated in AML. Here, we investigated (1) HDAC gene expression in AML patients and in different AML cell lines and (2) the effect of treating AML cells with the specific class IIA HDAC inhibitor TMP269, by applying proteomic and comparative bioinformatic analyses. We also analyzed cell proliferation, apoptosis, and the cell-killing capacities of TMP269 in combination with venetoclax compared to azacitidine plus venetoclax, by flow cytometry. Our results demonstrate significantly overexpressed class I and class II HDAC genes in AML patients, a phenotype which is conserved in AML cell lines. In AML MOLM-13 cells, TMP269 treatment downregulated a set of ribosomal proteins which are overexpressed in AML patients at the transcriptional level. TMP269 showed anti-proliferative effects and induced additive apoptotic effects in combination with venetoclax. We conclude that TMP269 exerts anti-leukemic activity when combined with venetoclax and has potential as a therapeutic drug in AML.