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Sorcini D, Stella A, Scialdone A, Sartori S, Marra A, Rossi R, De Falco F, Adamo FM, Dorillo E, Geraci C, Arcaleni R, Rompietti C, Esposito A, Moretti L, Mameli MG, Martelli MP, Falini B, Sportoletti P. FLT3-targeted therapy restores GATA1 pathway function in NPM1/FLT3-ITD mutated acute myeloid leukaemia. EJHaem 2023; 4:1100-1104. [PMID: 38024637 PMCID: PMC10660397 DOI: 10.1002/jha2.738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/05/2023] [Accepted: 06/09/2023] [Indexed: 12/01/2023]
Abstract
One-third of newly diagnosed adult acute myeloid leukaemia (AML) carry FLT3 mutations, which frequently occur together with nucleophosmin (NPM1) mutations and are associated with worse prognosis. FLT3 inhibitors are widely used in clinics with limitations due to drug resistance. AML cells carrying FLT3 mutations in both mouse models and patients present low expression of GATA1, a gene involved in haematopoietic changes preceding AML. Here, we show that FLT3 inhibition induces cellular responses and restores the GATA1 pathway and functions in NPM1/FLT3-ITD mutated AML, thus providing a new mechanism of action for this drug.
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Affiliation(s)
- D Sorcini
- Department of Medicine and SurgeryCentro di Ricerca Emato‐OncologicheUniversity of PerugiaPerugiaItaly
| | - A Stella
- Department of Medicine and SurgeryCentro di Ricerca Emato‐OncologicheUniversity of PerugiaPerugiaItaly
| | - A Scialdone
- Department of Medicine and SurgeryCentro di Ricerca Emato‐OncologicheUniversity of PerugiaPerugiaItaly
| | - S Sartori
- Department of Medicine and SurgeryCentro di Ricerca Emato‐OncologicheUniversity of PerugiaPerugiaItaly
| | - A Marra
- Department of Medicine and SurgeryCentro di Ricerca Emato‐OncologicheUniversity of PerugiaPerugiaItaly
| | - R Rossi
- Department of Medicine and SurgeryCentro di Ricerca Emato‐OncologicheUniversity of PerugiaPerugiaItaly
| | - F De Falco
- Department of Medicine and SurgeryCentro di Ricerca Emato‐OncologicheUniversity of PerugiaPerugiaItaly
| | - FM Adamo
- Department of Medicine and SurgeryCentro di Ricerca Emato‐OncologicheUniversity of PerugiaPerugiaItaly
| | - E Dorillo
- Department of Medicine and SurgeryCentro di Ricerca Emato‐OncologicheUniversity of PerugiaPerugiaItaly
| | - C Geraci
- Department of Medicine and SurgeryCentro di Ricerca Emato‐OncologicheUniversity of PerugiaPerugiaItaly
| | - R Arcaleni
- Department of Medicine and SurgeryCentro di Ricerca Emato‐OncologicheUniversity of PerugiaPerugiaItaly
| | - C Rompietti
- Department of Medicine and SurgeryCentro di Ricerca Emato‐OncologicheUniversity of PerugiaPerugiaItaly
| | - A Esposito
- Department of Medicine and SurgeryCentro di Ricerca Emato‐OncologicheUniversity of PerugiaPerugiaItaly
| | - L Moretti
- Department of Medicine and SurgeryCentro di Ricerca Emato‐OncologicheUniversity of PerugiaPerugiaItaly
| | - MG Mameli
- Department of Medicine and SurgeryCentro di Ricerca Emato‐OncologicheUniversity of PerugiaPerugiaItaly
| | - MP Martelli
- Department of Medicine and SurgeryCentro di Ricerca Emato‐OncologicheUniversity of PerugiaPerugiaItaly
| | - B Falini
- Department of Medicine and SurgeryCentro di Ricerca Emato‐OncologicheUniversity of PerugiaPerugiaItaly
| | - P Sportoletti
- Department of Medicine and SurgeryCentro di Ricerca Emato‐OncologicheUniversity of PerugiaPerugiaItaly
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Edahiro T, Ureshino H, Chishaki R, Fujino K, Mino T, Yoshida T, Fukushima N, Ichinohe T. Successful Pre- and Post-transplant Administration of Gilteritinib in a Patient with Relapsed and Refractory Acute Myeloid Leukemia Undergoing Allogeneic Peripheral Blood Stem Cell Transplantation. Intern Med 2023; 62:2243-2247. [PMID: 36450475 PMCID: PMC10465286 DOI: 10.2169/internalmedicine.1069-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 10/20/2022] [Indexed: 12/04/2022] Open
Abstract
Patients with acute myeloid leukemia (AML) harboring FMS-like tyrosine kinase 3 (FLT3)-internal tandem duplication mutation are associated with a poor survival outcome, even those receiving allogeneic stem cell transplantation (Allo-SCT). An additional treatment strategy with allo-SCT is therefore required to reduce relapse in these patients. Gilteritinib is a specific FLT3 inhibitor that has shown clinical benefit for patients with relapsed and refractory (R/R) AML harboring FLT3 mutation. We herein report a 49-year-old woman with R/R AML who was successfully treated with pre- and post-transplant gilteritinib. Post-transplant gilteritnib yielded a durable response with possible exacerbation of graft-versus-host disease.
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Affiliation(s)
- Taro Edahiro
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Japan
| | - Hiroshi Ureshino
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Japan
- Next Generation Development of Genome and Cellular Therapy Program, Research Institute for Radiation Biology and Medicine (RIRBM), Hiroshima University, Japan
| | - Ren Chishaki
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Japan
| | - Keita Fujino
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Japan
| | - Tatsuji Mino
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Japan
| | - Tetsumi Yoshida
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Japan
| | | | - Tatsuo Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Japan
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Haage TR, Schraven B, Mougiakakos D, Fischer T. How ITD Insertion Sites Orchestrate the Biology and Disease of FLT3-ITD-Mutated Acute Myeloid Leukemia. Cancers (Basel) 2023; 15:cancers15112991. [PMID: 37296951 DOI: 10.3390/cancers15112991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/25/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
Mutations of the FLT3 gene are among the most common genetic aberrations detected in AML and occur mainly as internal tandem duplications (FLT3-ITD). However, the specific sites of FLT3-ITD insertion within FLT3 show marked heterogeneity regarding both biological and clinical features. In contrast to the common assumption that ITD insertion sites (IS) are restricted to the juxtamembrane domain (JMD) of FLT3, 30% of FLT3-ITD mutations insert at the non-JMD level, thereby integrating into various segments of the tyrosine kinase subdomain 1 (TKD1). ITDs inserted within TKD1 have been shown to be associated with inferior complete remission rates as well as shorter relapse-free and overall survival. Furthermore, resistance to chemotherapy and tyrosine kinase inhibition (TKI) is linked to non-JMD IS. Although FLT3-ITD mutations in general are already recognized as a negative prognostic marker in currently used risk stratification guidelines, the even worse prognostic impact of non-JMD-inserting FLT3-ITD has not yet been particularly considered. Recently, the molecular and biological assessment of TKI resistance highlighted the pivotal role of activated WEE1 kinase in non-JMD-inserting ITDs. Overcoming therapy resistance in non-JMD FLT3-ITD-mutated AML may lead to more effective genotype- and patient-specific treatment approaches.
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Affiliation(s)
- Tobias R Haage
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke University, 39120 Magdeburg, Germany
- Gesundheitscampus Immunology, Inflammation and Infectiology (GC-I3), Medical Center, Otto-von-Guericke University, 39120 Magdeburg, Germany
| | - Burkhart Schraven
- Gesundheitscampus Immunology, Inflammation and Infectiology (GC-I3), Medical Center, Otto-von-Guericke University, 39120 Magdeburg, Germany
- Institute for Molecular and Clinical Immunology, Medical Faculty, Otto-von-Guericke University, 39120 Magdeburg, Germany
- Center of Health and Medical Prevention (CHaMP), Otto-von-Guericke University, 39106 Magdeburg, Germany
| | - Dimitrios Mougiakakos
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke University, 39120 Magdeburg, Germany
- Gesundheitscampus Immunology, Inflammation and Infectiology (GC-I3), Medical Center, Otto-von-Guericke University, 39120 Magdeburg, Germany
| | - Thomas Fischer
- Gesundheitscampus Immunology, Inflammation and Infectiology (GC-I3), Medical Center, Otto-von-Guericke University, 39120 Magdeburg, Germany
- Institute for Molecular and Clinical Immunology, Medical Faculty, Otto-von-Guericke University, 39120 Magdeburg, Germany
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Tecik M, Adan A. Therapeutic Targeting of FLT3 in Acute Myeloid Leukemia: Current Status and Novel Approaches. Onco Targets Ther 2022; 15:1449-1478. [PMID: 36474506 PMCID: PMC9719701 DOI: 10.2147/ott.s384293] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/19/2022] [Indexed: 08/13/2023] Open
Abstract
FMS-like tyrosine kinase 3 (FLT3) is mutated in approximately 30% of acute myeloid leukemia (AML) patients. The presence of FLT3-ITD (internal tandem duplication, 20-25%) mutation and, to a lesser extent, FLT3-TKD (tyrosine kinase domain, 5-10%) mutation is associated with poorer diagnosis and therapy response since the leukemic cells become hyperproliferative and resistant to apoptosis after continuous activation of FLT3 signaling. Targeting FLT3 has been the focus of many pre-clinical and clinical studies. Hence, many small-molecule FLT3 inhibitors (FLT3is) have been developed, some of which are approved such as midostaurin and gilteritinib to be used in different clinical settings, either in combination with chemotherapy or alone. However, many questions regarding the best treatment strategy remain to be answered. On the other hand, various FLT3-dependent and -independent resistance mechanisms could be evolved during FLT3i therapy which limit their clinical impact. Therefore, identifying molecular mechanisms of resistance and developing novel strategies to overcome this obstacle is a current interest in the field. In this review, recent studies of approved FLT3i and knowledge about major resistance mechanisms of clinically approved FLT3i's will be discussed together with novel treatment approaches such as designing novel FLT3i and dual FLT3i and combination strategies including approved FLT3i plus small-molecule agents targeting altered molecules in the resistant cells to abrogate resistance. Moreover, how to choose an appropriate FLT3i for the patients will be summarized based on what is currently known from available clinical data. In addition, strategies beyond FLT3i's including immunotherapeutics, small-molecule FLT3 degraders, and flavonoids will be summarized to highlight potential alternatives in FLT3-mutated AML therapy.
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Affiliation(s)
- Melisa Tecik
- Bioengineering Program, Graduate School of Engineering and Science, Abdullah Gul University, Kayseri, Turkey
| | - Aysun Adan
- Department of Molecular Biology and Genetics, Faculty of Life and Natural Sciences, Abdullah Gul University, Kayseri, Turkey
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Blackmon A, Aldoss I, Ball BJ. FLT3 Inhibitors as Maintenance Therapy after Allogeneic Stem-Cell Transplantation. Blood Lymphat Cancer 2022; 12:137-147. [PMID: 36097605 PMCID: PMC9464008 DOI: 10.2147/blctt.s281252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/19/2022] [Indexed: 11/23/2022] Open
Abstract
Mutations in the FLT3 gene are associated with poor prognosis in patients with AML, even after consolidation with allogeneic hematopoietic cell transplantation (alloHCT) in first remission. Treatment failure in FLT3-mutated AML is largely driven by excessive risk of relapse compared to other genetic subtypes, including in patients post-alloHCT. As a result, there is substantial interest in studying posttransplant maintenance therapy in FLT3-mutated AML as an approach to optimize disease control and improve long-term outcomes. Clinical trials utilizing posttransplant FLT3 inhibitors, such as sorafenib and midostaurin, have shown feasibility, safety, and encouraging posttransplant outcomes, and there are ongoing studies using newer-generation tyrosine-kinase inhibitors as posttransplant maintenance therapy. Here, we review the toxicities and efficacy of FLT3 inhibitors as posttransplant maintenance, recommendations on the use of FLT3 inhibitors by international consensus guidelines, and highlight key remaining questions.
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Affiliation(s)
- Amanda Blackmon
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Brian J Ball
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
- Correspondence: Brian J Ball, Division of Leukemia, Department of Hematology and HCT, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA, Email
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Perl AE, Larson RA, Podoltsev NA, Strickland S, Wang ES, Atallah E, Schiller GJ, Martinelli G, Neubauer A, Sierra J, Montesinos P, Récher C, Yoon SS, Hosono N, Onozawa M, Chiba S, Kim HJ, Hasabou N, Lu Q, Tiu R, Levis MJ. Follow-up of patients with R/R FLT3-mutation-positive AML treated with gilteritinib in the phase 3 ADMIRAL trial. Blood 2022; 139:3366-3375. [PMID: 35081255 PMCID: PMC9197557 DOI: 10.1182/blood.2021011583] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 12/16/2021] [Indexed: 11/20/2022] Open
Abstract
The phase 3 ADMIRAL (NCT02421939; Study ID: 2215-CL-0301) trial showed superior overall survival in patients with relapsed/refractory FLT3-mutation-positive acute myeloid leukemia (AML) randomized 2:1 to receive the oral FMS-like tyrosine kinase 3 inhibitor gilteritinib vs those randomized to receive salvage chemotherapy (SC). Here we provide a follow-up of the ADMIRAL trial 2 years after the primary analysis to clarify the long-term treatment effects and safety of gilteritinib in these patients with AML. At the time of this analysis, the median survival follow-up was 37.1 months, with deaths in 203 of 247 and 97 of 124 patients in the gilteritinib and SC arms, respectively; 16 gilteritinib-treated patients remained on treatment. The median overall survival for the gilteritinib and SC arms was 9.3 and 5.6 months, respectively (hazard ratio, 0.665; 95% confidence interval [CI], 0.518, 0.853; two-sided P = .0013); 2-year estimated survival rates were 20.6% (95% CI, 15.8, 26.0) and 14.2% (95% CI, 8.3, 21.6). The gilteritinib-arm 2-year cumulative incidence of relapse after composite complete remission was 75.7%, with few relapses occurring after 18 months. Overall, 49 of 247 patients in the gilteritinib arm and 14 of 124 patients in the SC arm were alive for ≥2 years. Twenty-six gilteritinib-treated patients remained alive for ≥2 years without relapse; 18 of these patients underwent transplantation (hematopoietic stem cell transplantation [HSCT]) and 16 restarted gilteritinib as post-HSCT maintenance therapy. The most common adverse events of interest during years 1 and 2 of gilteritinib therapy were increased liver transaminase levels; adverse event incidence decreased in year 2. Thus, continued and post-HSCT gilteritinib maintenance treatment sustained remission with a stable safety profile. These findings confirm that prolonged gilteritinib therapy is safe and is associated with superior survival vs SC. This trial was registered at www.clinicaltrials.gov as #NCT02421939.
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Affiliation(s)
- Alexander E Perl
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | | | | | | | - Eunice S Wang
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Ehab Atallah
- Division of Hematology and Oncology, Medical College of Wisconsin, Cancer Center-Froedtert Hospital, Milwaukee, WI
| | | | - Giovanni Martinelli
- IRCCS Istituto Romagnolo per lo Studio dei Tumori "Dino Amadori," IRST S.r.l., Meldola, Italy
| | | | - Jorge Sierra
- Hospital de la Santa Creu I Sant Pau and Josep Carreras Leukemia Research Institute, Barcelona, Spain
| | | | - Christian Récher
- Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer deToulouse Oncopole, Université de Toulouse 3 Paul Sabatier, Toulouse, France
| | - Sung-Soo Yoon
- Seoul National University Hospital, Seoul, Republic of Korea
| | | | | | - Shigeru Chiba
- Department of Hematology, University of Tsukuba, Tsukuba, Japan
| | - Hee-Je Kim
- Catholic Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | | | - Qiaoyang Lu
- Astellas Pharma US, Inc., Northbrook, IL; and
| | - Ramon Tiu
- Astellas Pharma US, Inc., Northbrook, IL; and
| | - Mark J Levis
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
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Abstract
OPINION STATEMENT Treatment options in acute myeloid leukemia (AML) have improved significantly over the last decade with better understanding of disease biology and availability of a multitude of targeted therapies. The use of FLT3 inhibitors (FLT3i) in FLT3-mutated (FLT3mut) AML is one such development; however, the clinical decisions that govern their use and dictate the choice of the FLT3i are evolving. Midostaurin and gilteritinib are FDA-approved in specific situations; however, available data from clinical trials also shed light on the utility of sorafenib maintenance post-allogeneic stem cell transplantation (allo-SCT) and quizartinib as part of combination therapy in FLT3mut AML. The knowledge of the patient's concurrent myeloid mutations, type of FLT3 mutation, prior FLT3i use, and eligibility for allo-SCT helps to refine the choice of FLT3i. Data from ongoing studies will further precisely define their use and help in making more informed choices. Despite improvements in FLT3i therapy, the definitive aim is to enable the eligible patient with FLT3mut AML (esp. ITD) to proceed to allo-SCT with regimens containing FLT3i incorporated prior to SCT and as maintenance after SCT.
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Affiliation(s)
- Jayastu Senapati
- Department of Leukemia, MD Anderson Cancer Center, 1515 Holcombe Blvd. - Unit 428, Houston, 77030, USA
| | - Tapan Mahendra Kadia
- Department of Leukemia, MD Anderson Cancer Center, 1515 Holcombe Blvd. - Unit 428, Houston, 77030, USA.
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Abstract
Patients treated with Fms-like tyrosine kinase 3 (FLT3) inhibitor-based acute myeloid leukemia therapies nearly always develop resistance. In this issue, Alotaibi and colleagues describe the patterns of mutations that emerge upon relapse after FLT3 inhibitor therapy after initial response, as well as in treatment-refractory disease in a single-institution study; the findings offer insights for sequential therapies targeting the dominant clone at the time of relapse. See related article by Alotaibi et al., p. 125.
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Affiliation(s)
- Aditi Shastri
- Division of Hematologic Malignancies, Department of Oncology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.,Department of Developmental & Molecular Biology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Jesus Gonzalez-Lugo
- Division of Hematologic Malignancies, Department of Oncology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Amit Verma
- Division of Hematologic Malignancies, Department of Oncology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.,Department of Developmental & Molecular Biology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
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Hunter BD. Quizartinib for Relapsed/Refractory FLT3-Mutated Acute Myeloid Leukemia: More Patients Make It to Transplant, but Are There Any Other Benefits? Transplant Cell Ther 2021; 27:99-100. [PMID: 33781547 DOI: 10.1016/j.jtct.2021.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 01/03/2021] [Indexed: 11/21/2022]
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