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Monogiou Belik D, Bernasconi R, Xu L, Della Verde G, Lorenz V, Grüterich V, Balzarolo M, Mochizuki M, Pfister O, Kuster GM. The Flt3-inhibitor quizartinib augments apoptosis and promotes maladaptive remodeling after myocardial infarction in mice. Apoptosis 2024; 29:357-371. [PMID: 37945814 PMCID: PMC10873224 DOI: 10.1007/s10495-023-01911-8] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Tyrosine kinase inhibitors (TKIs) targeting fms-like tyrosine kinase 3 (Flt3) such as quizartinib were specifically designed for acute myeloid leukemia treatment, but also multi-targeting TKIs applied to solid tumor patients inhibit Flt3. Flt3 is expressed in the heart and its activation is cytoprotective in myocardial infarction (MI) in mice. OBJECTIVES We sought to test whether Flt3-targeting TKI treatment aggravates cardiac injury after MI. METHODS AND RESULTS Compared to vehicle, quizartinib (10 mg/kg/day, gavage) did not alter cardiac dimensions or function in healthy mice after four weeks of therapy. Pretreated mice were randomly assigned to MI or sham surgery while receiving quizartinib or vehicle for one more week. Quizartinib did not aggravate the decline in ejection fraction, but significantly enhanced ventricular dilatation one week after infarction. In addition, apoptotic cell death was significantly increased in the myocardium of quizartinib-treated compared to vehicle-treated mice. In vitro, quizartinib dose-dependently decreased cell viability in neonatal rat ventricular myocytes and in H9c2 cells, and increased apoptosis as assessed in the latter. Together with H2O2, quizartinib potentiated the phosphorylation of the pro-apoptotic mitogen activated protein kinase p38 and augmented H2O2-induced cell death and apoptosis beyond additive degree. Pretreatment with a p38 inhibitor abolished apoptosis under quizartinib and H2O2. CONCLUSION Quizartinib potentiates apoptosis and promotes maladaptive remodeling after MI in mice at least in part via a p38-dependent mechanism. These findings are consistent with the multi-hit hypothesis of cardiotoxicity and make cardiac monitoring in patients with ischemic heart disease under Flt3- or multi-targeting TKIs advisable.
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Affiliation(s)
- Daria Monogiou Belik
- Department of Biomedicine, University Hospital Basel and University of Basel, Hebelstrasse 20, Basel, 4031, Switzerland
| | - Riccardo Bernasconi
- Department of Biomedicine, University Hospital Basel and University of Basel, Hebelstrasse 20, Basel, 4031, Switzerland
| | - Lifen Xu
- Department of Biomedicine, University Hospital Basel and University of Basel, Hebelstrasse 20, Basel, 4031, Switzerland
| | - Giacomo Della Verde
- Department of Biomedicine, University Hospital Basel and University of Basel, Hebelstrasse 20, Basel, 4031, Switzerland
| | - Vera Lorenz
- Department of Biomedicine, University Hospital Basel and University of Basel, Hebelstrasse 20, Basel, 4031, Switzerland
| | - Vivienne Grüterich
- Department of Biomedicine, University Hospital Basel and University of Basel, Hebelstrasse 20, Basel, 4031, Switzerland
| | - Melania Balzarolo
- Department of Biomedicine, University Hospital Basel and University of Basel, Hebelstrasse 20, Basel, 4031, Switzerland
| | - Michika Mochizuki
- Department of Biomedicine, University Hospital Basel and University of Basel, Hebelstrasse 20, Basel, 4031, Switzerland
| | - Otmar Pfister
- Department of Biomedicine, University Hospital Basel and University of Basel, Hebelstrasse 20, Basel, 4031, Switzerland
- Department of Cardiology, University Heart Center, University Hospital Basel, Basel, Switzerland
| | - Gabriela M Kuster
- Department of Biomedicine, University Hospital Basel and University of Basel, Hebelstrasse 20, Basel, 4031, Switzerland.
- Department of Cardiology, University Heart Center, University Hospital Basel, Basel, Switzerland.
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Lap CJ, Abrahim MS, Nassereddine S. Perspectives and challenges of small molecule inhibitor therapy for FLT3-mutated acute myeloid leukemia. Ann Hematol 2023:10.1007/s00277-023-05545-3. [PMID: 37975931 DOI: 10.1007/s00277-023-05545-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
Acute myeloid leukemia (AML) is a heterogeneous clonal disease characterized overall by an aggressive clinical course. The underlying genetic abnormalities present in leukemic cells contribute significantly to the AML phenotype. Mutations in FMS-like tyrosine kinase 3 (FLT3) are one of the most common genetic abnormalities identified in AML, and the presence of these mutations strongly influences disease presentation and negatively impacts prognosis. Since mutations in FLT3 were identified in AML, they have been recognized as a valid therapeutic target resulting in decades of research to develop effective small molecule inhibitor treatment that could improve outcome for these patients. Despite the approval of several FLT3 inhibitors over the last couple of years, the treatment of patients with FLT3-mutated AML remains challenging and many questions still need to be addressed. This review will provide an up-to-date overview of our current understanding of FLT3-mutated AML and discuss what the current status is of the available FLT3 inhibitors for the day-to-day management of this aggressive disease.
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Affiliation(s)
- Coen J Lap
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Marwa Sh Abrahim
- The George Washington Cancer Center, George Washington University, Washington, DC, USA
| | - Samah Nassereddine
- The George Washington Cancer Center, George Washington University, Washington, DC, USA.
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3
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Jaramillo S, Le Cornet L, Kratzmann M, Krisam J, Görner M, Hänel M, Röllig C, Wass M, Scholl S, Ringhoffer M, Reichart A, Steffen B, Kayser S, Mikesch JH, Schaefer-Eckart K, Schubert J, Geer T, Martin S, Kieser M, Sauer T, Kriegsmann K, Hundemer M, Serve H, Bornhäuser M, Müller-Tidow C, Schlenk RF. Q-HAM: a multicenter upfront randomized phase II trial of quizartinib and high-dose Ara-C plus mitoxantrone in relapsed/refractory AML with FLT3-ITD. Trials 2023; 24:591. [PMID: 37715270 PMCID: PMC10504729 DOI: 10.1186/s13063-023-07421-x] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 05/27/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND About 50% of older patients with acute myeloid leukemia (AML) fail to attain complete remission (CR) following cytarabine plus anthracycline-based induction therapy. Salvage chemotherapy regimens are based on high-dose cytarabine (HiDAC), which is frequently combined with mitoxantrone (HAM regimen). However, CR rates remain low, with less than one-third of the patients achieving a CR. FLT3-ITD has consistently been identified as an unfavorable molecular marker in both relapsed and refractory (r/r)-AML. One-quarter of patients who received midostaurin are refractory to induction therapy and relapse rate at 2 years exceeds 40%. The oral second-generation bis-aryl urea tyrosine kinase inhibitor quizartinib is a very selective FLT3 inhibitor, has a high capacity for sustained FLT3 inhibition, and has an acceptable toxicity profile. METHODS In this multicenter, upfront randomized phase II trial, all patients receive quizartinib combined with HAM (cytarabine 3g/m2 bidaily day one to day three, mitoxantrone 10mg/m2 days two and three) during salvage therapy. Efficacy is assessed by comparison to historical controls based on the matched threshold crossing approach with achievement of CR, complete remission with incomplete hematologic recovery (CRi), or complete remission with partial recovery of peripheral blood counts (CRh) as primary endpoint. During consolidation therapy (chemotherapy and allogeneic hematopoietic cell transplantation), patients receive either prophylactic quizartinib therapy or measurable residual disease (MRD)-triggered preemptive continuation therapy with quizartinib according to up-front randomization. The matched threshold crossing approach is a novel study-design to enhance the classic single-arm trial design by including matched historical controls from previous clinical studies. It overcomes common disadvantages of single-armed and small randomized studies, since the expected outcome of the observed study population can be adjusted based on the matched controls with a comparable distribution of known prognostic and predictive factors. Furthermore, balanced treatment groups lead to stable statistical models. However, one of the limitations of our study is the inability to adjust for unobserved or unknown confounders. Addressing the primary endpoint, CR/CRi/CRh after salvage therapy, the maximal sample size of 80 patients is assessed generating a desirable power of the used adaptive design, assuming a logistic regression is performed at a one-sided significance level α=0.05, the aspired power is 0.8, and the number of matching partners per intervention patient is at least 1. After enrolling 20 patients, the trial sample size will be recalculated in an interim analysis based on a conditional power argument. CONCLUSION Currently, there is no commonly accepted standard for salvage chemotherapy treatment. The objective of the salvage therapy is to reduce leukemic burden, achieve the best possible remission, and perform a hemopoietic stem-cell transplantation. Thus, in patients with FLT3-ITD mutation, the comparison of quizartinib with intensive salvage therapy versus chemotherapy alone appears as a logical consequence in terms of efficacy and safety. ETHICS AND DISSEMINATION Ethical approval and approvals from the local and federal competent authorities were granted. Trial results will be reported via peer-reviewed journals and presented at conferences and scientific meetings. TRIAL REGISTRATION ClinicalTrials.gov NCT03989713; EudraCT Number: 2018-002675-17.
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Affiliation(s)
- Sonia Jaramillo
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany.
| | - Lucian Le Cornet
- NCT-Trial Center, National Center of Tumor Diseases, Heidelberg University Hospital and German Cancer Research Center, Heidelberg, Germany
| | - Markus Kratzmann
- NCT-Trial Center, National Center of Tumor Diseases, Heidelberg University Hospital and German Cancer Research Center, Heidelberg, Germany
| | - Johannes Krisam
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Martin Görner
- Department of Hematology, Oncology and Palliative Medicine, Community Hospital Bielefeld, Bielefeld, Germany
| | - Mathias Hänel
- Department of Medicine III, Hospital Chemnitz gGmbH, Chemnitz, Germany
| | - Christoph Röllig
- Department of Medicine and Polyclinic I, TU Dresden University Hospital, Dresden, Germany
| | - Maxi Wass
- Department of Medicine IV, Halle (Saale) University Hospital, Halle, Germany
| | - Sebastian Scholl
- Department of Medicine II, Jena University Hospital, Jena, Germany
| | - Mark Ringhoffer
- Department of Medicine, III, Hospital Karlsruhe, Karlsruhe, Germany
| | - Alexander Reichart
- Department of Hematology, Oncology and Palliative Medicine, Hospital Winnenden, Winnenden, Germany
| | - Björn Steffen
- Department of Medicine II, Frankfurt University Hospital, Frankfurt, Germany
| | - Sabine Kayser
- Department of Medicine I - Hematology and Cell Therapy, Leipzig University Hospital, Leipzig, Germany
| | | | | | - Jörg Schubert
- Department of Inner Medicine II, Elbland Hospital Riesa, Riesa, Germany
| | - Thomas Geer
- Department of Medicine II, Diaconal Hospital Schwäbisch-Hall, Schwäbisch Hall, Germany
| | - Sonja Martin
- Department of Hematology, Oncology and Palliative Medicine, Robert-Bosch Hospital, Stuttgart, Germany
| | - Meinhard Kieser
- Department of Hematology, Oncology and Palliative Medicine, Robert-Bosch Hospital, Stuttgart, Germany
| | - Tim Sauer
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Katharina Kriegsmann
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Hundemer
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Hubert Serve
- Department of Medicine II, Frankfurt University Hospital, Frankfurt, Germany
| | - Martin Bornhäuser
- Department of Medicine and Polyclinic I, TU Dresden University Hospital, Dresden, Germany
| | - Carsten Müller-Tidow
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Richard F Schlenk
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
- NCT-Trial Center, National Center of Tumor Diseases, Heidelberg University Hospital and German Cancer Research Center, Heidelberg, Germany
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Darici S, Jørgensen HG, Huang X, Serafin V, Antolini L, Barozzi P, Luppi M, Forghieri F, Marmiroli S, Zavatti M. Improved efficacy of quizartinib in combination therapy with PI3K inhibition in primary FLT3-ITD AML cells. Adv Biol Regul 2023; 89:100974. [PMID: 37245251 DOI: 10.1016/j.jbior.2023.100974] [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] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/09/2023] [Accepted: 05/22/2023] [Indexed: 05/30/2023]
Abstract
Acute myeloid leukemia is a heterogeneous hematopoietic malignancy, characterized by uncontrolled clonal proliferation of abnormal myeloid progenitor cells, with poor outcomes. The internal tandem duplication (ITD) mutation of the Fms-like receptor tyrosine kinase 3 (FLT3) (FLT3-ITD) represents the most common genetic alteration in AML, detected in approximately 30% of AML patients, and is associated with high leukemic burden and poor prognosis. Therefore, this kinase has been regarded as an attractive druggable target for the treatment of FLT3-ITD AML, and selective small molecule inhibitors, such as quizartinib, have been identified and trialled. However, clinical outcomes have been disappointing so far due to poor remission rates, also because of acquired resistance. A strategy to overcome resistance is to combine FLT3 inhibitors with other targeted therapies. In this study, we investigated the preclinical efficacy of the combination of quizartinib with the pan PI3K inhibitor BAY-806946 in FLT3-ITD cell lines and primary cells from AML patients. We show here that BAY-806946 enhanced quizartinib cytotoxicity and, most importantly, that this combination increases the ability of quizartinib to kill CD34+ CD38-leukemia stem cells, whilst sparing normal hematopoietic stem cells. Because constitutively active FLT3 receptor tyrosine kinase is known to boost aberrant PI3K signaling, the increased sensitivity of primary cells to the above combination can be the mechanistic results of the disruption of signaling by vertical inhibition.
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Affiliation(s)
- Salihanur Darici
- Cellular Signaling Unit, Section of Human Morphology, Department of Biomedical, Metabolic and Neural Sciences, Largo del Pozzo 71, University of Modena and Reggio Emilia, Modena, 41125, Italy; Haemato-Oncology/Systems Medicine Group, Paul O'Gorman Leukaemia Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, G12 0ZD, UK
| | - Heather G Jørgensen
- Haemato-Oncology/Systems Medicine Group, Paul O'Gorman Leukaemia Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, G12 0ZD, UK
| | - Xu Huang
- Haemato-Oncology/Systems Medicine Group, Paul O'Gorman Leukaemia Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, G12 0ZD, UK
| | - Valentina Serafin
- Department of Surgery Oncology and Gastroenterology Oncology and Immunology Section University of Padova, Italy
| | - Ludovica Antolini
- Cellular Signaling Unit, Section of Human Morphology, Department of Biomedical, Metabolic and Neural Sciences, Largo del Pozzo 71, University of Modena and Reggio Emilia, Modena, 41125, Italy
| | - Patrizia Barozzi
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Mario Luppi
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy.
| | - Fabio Forghieri
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via del Pozzo 71, 41124, Modena, Italy.
| | - Sandra Marmiroli
- Cellular Signaling Unit, Section of Human Morphology, Department of Biomedical, Metabolic and Neural Sciences, Largo del Pozzo 71, University of Modena and Reggio Emilia, Modena, 41125, Italy.
| | - Manuela Zavatti
- Cellular Signaling Unit, Section of Human Morphology, Department of Biomedical, Metabolic and Neural Sciences, Largo del Pozzo 71, University of Modena and Reggio Emilia, Modena, 41125, Italy
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5
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Fukuda S, Matsuda N, Shoji T, Onishi C, Hirade T, Taketani T, Pelus LM. The magnitude of CXCR4 signaling regulates resistance to quizartinib in FLT3/ITD(+) cells via RUNX1. Leuk Res 2023; 124:106983. [PMID: 36473282 DOI: 10.1016/j.leukres.2022.106983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 12/12/2022]
Abstract
CXCR4 antagonists sensitize FLT3/ITD+ AML cells to FLT3 inhibitors; however, CXCR4 signaling can induce apoptosis in AML cells, raising the question of whether CXCR4 signaling exerts divergent effects on FLT3/ITD+ cells. The present study investigated the paradoxical function of CXCR4 in resistance to FLT3 inhibitors. The FLT3 inhibitor quizartinib significantly decreased the number of FLT3/ITD+ Ba/F3 cells, whereas 1 ng/ml CXCL12 showed a significant protective effect against quizartinib. In contrast, CXCL12 over 100 ng/ml significantly decreased FLT3/ITD+ cell viability with concomitant downregulation of Runx1. Moreover, the survival of FLT3/ITD+ Ba/F3 or MOLM13 cells with low surface CXCR4 expression incubated with quizartinib was significantly enhanced by 100 ng/ml CXCL12; however, this protective effect of CXCL12 against quizartinib was barely detected in cells with high surface CXCR4 expression. Although silencing Runx1 downregulated CXCR4 expression, RUNX1 expression levels were significantly higher in CXCR4LOW FLT3/ITD+ Ba/F3 cells incubated with 100 ng/ml CXCL12 than in CXCR4HIGH cells, coincident with an increase in FLT3 phosphorylation. Silencing RUNX1 partially abrogated resistance to quizartinib in CXCR4LOW cells incubated with CXCL12, whereas ectopic RUNX1 significantly restored resistance in CXCR4HIGH cells. These results indicate that CXCR4 signaling of different magnitudes paradoxically regulates resistance to quizartinib in FLT3/ITD+ cells via RUNX1.
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6
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Najima Y. [Breakthroughs in FLT3-mutated acute myeloid leukemia treatments]. Rinsho Ketsueki 2023; 64:932-941. [PMID: 37793868 DOI: 10.11406/rinketsu.64.932] [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] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
FMS-like tyrosine kinase 3 (FLT3) mutation is present in 25% of acute myeloid leukemia (AML) cases. It is associated with poor prognosis due to a high relapse rate and short remission duration. Consequently, various FLT3 inhibitors were developed. Two second-generation FLT3 inhibitors, including gilteritinib and quizartinib, are used for treating relapsed/refractory FLT3-mutated AML. Additionally, in May 2023, quizartinib was approved for newly-diagnosed FLT3-mutated AML, in combination with standard remission induction, consolidation, and maintenance therapies based on a phase 3 trial. Furthermore, high relapse rates were observed even in patients who underwent allogeneic hematopoietic cell transplantation while in their first complete remission, and post-transplant maintenance therapy using oral FLT3 inhibitors has been tried. This review summarizes breakthroughs in treatments of FLT3-mutated AML aiming for a better prognosis.
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Affiliation(s)
- Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Disease Center, Komagome Hospital
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7
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Capelli D, Menotti D, Fiorentini A, Saraceni F, Olivieri A. Overcoming Resistance: FLT3 Inhibitors Past, Present, Future and the Challenge of Cure. Cancers (Basel) 2022; 14:4315. [PMID: 36077850 DOI: 10.3390/cancers14174315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/27/2022] [Accepted: 08/29/2022] [Indexed: 11/17/2022] Open
Abstract
FLT3 ITD and TKD mutations occur in 20% and 10% of Acute Myeloid Leukemia (AML), respectively, and they represent the target of the first approved anti-leukemic therapies in the 2000s. Type I and type II FLT3 inhibitors (FLT3i) are active against FLT3 TKD/ITD and FLT3 ITD mutations alone respectively, but they still fail remissions in 30-40% of patients due to primary and secondary mechanisms of resistance, with variable relapse rate of 30-50%, influenced by NPM status and FLT3 allelic ratio. Mechanisms of resistance to FLT3i have recently been analyzed through NGS and single cell assays that have identified and elucidated the polyclonal nature of relapse in clinical and preclinical studies, summarized here. Knowledge of tumor escape pathways has helped in the identification of new targeted drugs to overcome resistance. Immunotherapy and combination or sequential use of BCL2 inhibitors and experimental drugs including aurora kinases, menin and JAK2 inhibitors will be the goal of present and future clinical trials, especially in patients with FLT3-mutated (FLT3mut) AML who are not eligible for allogeneic transplantation.
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8
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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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9
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Zhao JC, Agarwal S, Ahmad H, Amin K, Bewersdorf JP, Zeidan AM. A review of FLT3 inhibitors in acute myeloid leukemia. Blood Rev 2022; 52:100905. [PMID: 34774343 PMCID: PMC9846716 DOI: 10.1016/j.blre.2021.100905] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 01/26/2023]
Abstract
FLT3 mutations are the most common genetic aberrations found in acute myeloid leukemia (AML) and associated with poor prognosis. Since the discovery of FLT3 mutations and their prognostic implications, multiple FLT3-targeted molecules have been evaluated. Midostaurin is approved in the U.S. and Europe for newly diagnosed FLT3 mutated AML in combination with standard induction and consolidation chemotherapy based on data from the RATIFY study. Gilteritinib is approved for relapsed or refractory FLT3 mutated AML as monotherapy based on the ADMIRAL study. Although significant progress has been made in the treatment of AML with FLT3-targeting, many challenges remain. Several drug resistance mechanisms have been identified, including clonal selection, stromal protection, FLT3-associated mutations, and off-target mutations. The benefit of FLT3 inhibitor maintenance therapy, either post-chemotherapy or post-transplant, remains controversial, although several studies are ongoing.
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Affiliation(s)
- Jennifer C Zhao
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Sonal Agarwal
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Hiba Ahmad
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Kejal Amin
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Jan Philipp Bewersdorf
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA.
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10
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Friedman R. The molecular mechanisms behind activation of FLT3 in acute myeloid leukemia and resistance to therapy by selective inhibitors. Biochim Biophys Acta Rev Cancer 2021; 1877:188666. [PMID: 34896257 DOI: 10.1016/j.bbcan.2021.188666] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 11/01/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 12/17/2022]
Abstract
Acute myeloid leukemia is an aggressive cancer, which, in spite of increasingly better understanding of its genetic background remains difficult to treat. Mutations in the FLT3 gene are observed in ≈30% of the patients. Most of these mutations are internal tandem duplications (ITDs) of a sequence within the protein coding region, an activation mechanism that is almost non-existent with other genes and cancers. As patients each carry their own unique set of mutations, it is challenging to understand how ITDs activate the protein, and ascertain the risk for each individual patient. Available treatment options are limited due to development of drug resistance. Here, recent studies are reviewed that help to better understand the molecular mechanism behind activation of the FLT3 protein due to mutations. It is argued that difference in mutation sequences and especially location might be coupled to prognosis. When it comes to FLT3 inhibitors, key differences between them can be attributed to the mode of inhibition (type-1 and type-2 inhibitors), effective inhibitory coefficient in the blood plasma and off-target binding. Accounting for the position and length of insertions may in the future be used to predict prognosis and rationalise treatment. Development of new inhibitors must take into account the potential for resistance mutations. Inhibitors aimed at multiple specific targets are currently being developed. These, and as well as combination therapies will hopefully lead to longer periods during which targeted FLT3 therapy will remain effective.
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Affiliation(s)
- Ran Friedman
- Department of Chemistry and Biomedical Sciences, Faculty of Health and Life Sciences, Linnæus University, 391 82 Kalmar, Sweden.
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11
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Darici S, Zavatti M, Braglia L, Accordi B, Serafin V, Horne GA, Manzoli L, Palumbo C, Huang X, Jørgensen HG, Marmiroli S. Synergistic cytotoxicity of dual PI3K/mTOR and FLT3 inhibition in FLT3-ITD AML cells. Adv Biol Regul 2021; 82:100830. [PMID: 34555701 DOI: 10.1016/j.jbior.2021.100830] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 08/30/2021] [Revised: 09/09/2021] [Accepted: 09/13/2021] [Indexed: 01/17/2023]
Abstract
Acute myeloid leukemia (AML) is an aggressive hematopoietic malignancy, characterized by a heterogeneous genetic landscape and complex clonal evolution, with poor outcomes. Mutation at the internal tandem duplication of FLT3 (FLT3-ITD) is one of the most common somatic alterations in AML, associated with high relapse rates and poor survival due to the constitutive activation of the FLT3 receptor tyrosine kinase and its downstream effectors, such as PI3K signaling. Thus, aberrantly activated FLT3-kinase is regarded as an attractive target for therapy for this AML subtype, and a number of small molecule inhibitors of this kinase have been identified, some of which are approved for clinical practice. Nevertheless, acquired resistance to these molecules is often observed, leading to severe clinical outcomes. Therapeutic strategies to tackle resistance include combining FLT3 inhibitors with other antileukemic agents. Here, we report on the preclinical activity of the combination of the FLT3 inhibitor quizartinib with the dual PI3K/mTOR inhibitor PF-04691502 in FLT3-ITD cells. Briefly, we show that the association of these two molecules displays synergistic cytotoxicity in vitro in FLT3-ITD AML cells, triggering 90% cell death at nanomolar concentrations after 48 h.
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Affiliation(s)
- Salihanur Darici
- Cellular Signaling Unit, Section of Human Morphology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, 41125, Italy; Haemato-Oncology/Systems Medicine Group, Paul O'Gorman Leukaemia Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, G12 0ZD, UK
| | - Manuela Zavatti
- Cellular Signaling Unit, Section of Human Morphology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, 41125, Italy
| | - Luca Braglia
- Cellular Signaling Unit, Section of Human Morphology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, 41125, Italy; Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Benedetta Accordi
- Department of Woman and Child Health, Haemato-Oncology Laboratory, University of Padua, Via Giustiniani 3 and IRP Città Della Speranza, Corso Stati Uniti 4, 35128, Padua, Italy
| | - Valentina Serafin
- Department of Woman and Child Health, Haemato-Oncology Laboratory, University of Padua, Via Giustiniani 3 and IRP Città Della Speranza, Corso Stati Uniti 4, 35128, Padua, Italy
| | - Gillian A Horne
- Haemato-Oncology/Systems Medicine Group, Paul O'Gorman Leukaemia Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, G12 0ZD, UK
| | - Lucia Manzoli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Carla Palumbo
- Cellular Signaling Unit, Section of Human Morphology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, 41125, Italy
| | - Xu Huang
- Haemato-Oncology/Systems Medicine Group, Paul O'Gorman Leukaemia Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, G12 0ZD, UK.
| | - Heather G Jørgensen
- Haemato-Oncology/Systems Medicine Group, Paul O'Gorman Leukaemia Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, G12 0ZD, UK
| | - Sandra Marmiroli
- Cellular Signaling Unit, Section of Human Morphology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, 41125, Italy.
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12
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Novatcheva ED, Anouty Y, Saunders I, Mangan JK, Goodman AM. FMS-Like Tyrosine Kinase 3 Inhibitors for the Treatment of Acute Myeloid Leukemia. Clin Lymphoma Myeloma Leuk 2021; 22:e161-e184. [PMID: 34649791 DOI: 10.1016/j.clml.2021.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 09/07/2021] [Indexed: 12/18/2022]
Abstract
Acute myeloid leukemia (AML) is the most common acute leukemia of adults, with a five-year survival that remains poor (approximately 25%). Knowledge and understanding of AML genomics have expanded tremendously over the past decade and are now included in AML prognostication and treatment decisions. FMS-like tyrosine kinase 3 (FLT3) is a Class III receptor tyrosine kinase (RTK) expressed primarily in the cell membranes of early hematopoietic progenitor cells, found in 28% of all patients with AML. FLT3 is the second most frequent mutation in adult AML following Nuclear-cytoplasmic shuttling phosphoprotein (NPM1), which is found in 50% of cases.1 FLT3 inhibitors are promising new molecular therapeutics increasingly becoming standard of care for both newly diagnosed and relapsed/refractory FLT3 positive AML. This review will focus on the clinical trials/evidence, similarities, differences, clinical toxicities, and drug interactions relevant to treating clinicians as pertains to 5 FLT3-inhibitors: midostaurin, sorafenib, gilteritinib, crenolanib, and quizartinib.
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Affiliation(s)
| | - Yasmine Anouty
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA
| | - Ila Saunders
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA; UC San Diego Skaggs School of Pharmacy & Pharmaceutical Sciences, La Jolla, CA
| | - James K Mangan
- Department of Medicine, Division of Blood and Marrow Transplantation, University of California San Diego, La Jolla, CA
| | - Aaron M Goodman
- Department of Medicine, Division of Blood and Marrow Transplantation, University of California San Diego, La Jolla, CA.
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Kidoguch K, Shibusawa M, Tanimoto T. A critical appraisal of Japan's new drug approval process: a case study of FLT3-ITD inhibitor quizartinib. Invest New Drugs 2021; 39:1457-1459. [PMID: 34268710 DOI: 10.1007/s10637-021-01151-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Abstract
In the last two decades, simultaneous global development of novel drugs become more common by conducting multiregional clinical trials. However, regulatory authorities of different regions often make different decisions on the approvals of the same new drugs. We would like to discuss the appropriateness of Japanese regulatory approach through a case study of quizartinib, a novel anti-leukemia drug developed in Japan. The pivotal clinical trial "QuANTUM-R" conducted in 19 countries showed a modest increase in median overall survival with quizartinib than the conventional chemotherapy. However, because several critical defects in this trial were pointed out by the United States Food and Drug Administration (US FDA) and the European Medicines Agency (EMA), quizartinib has not been approved in the US and Europe to date. On the contrary, the regulatory authority of Japan gave a notice of approval to quizartinib as a "standard of care", and the country becomes the sole country that granted market authorization. In our paper, we provide more detailed discussion about the methodology for scientific evaluation of the new drug.
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Affiliation(s)
- Keisuke Kidoguch
- Saga-Ken medical centre KOSEIKAN, Department of Hematology, Saga, Japan.
| | - Motoharu Shibusawa
- Department of Hematology, Shinmatsudo Central General Hospital, Chiba, Japan
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Wang F, Huang J, Guo T, Zheng Y, Zhang L, Zhang D, Wang F, Naren D, Cui Y, Liu X, Qu Y, Luo H, Yang Y, Wei H, Guo Y. Homoharringtonine synergizes with quizartinib in FLT3-ITD acute myeloid leukemia by targeting FLT3-AKT-c-Myc pathway. Biochem Pharmacol 2021; 188:114538. [PMID: 33831397 DOI: 10.1016/j.bcp.2021.114538] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 11/02/2020] [Revised: 03/14/2021] [Accepted: 03/26/2021] [Indexed: 02/05/2023]
Abstract
Acute myeloid leukemia (AML) with FLT3 internal tandem duplication (FLT3-ITD) has a dismal prognosis. FLT3 inhibitors have been developed to treat patients with FLT3-ITD AML; however, when used alone, their efficacy is insufficient. FLT3 inhibitors combined with chemotherapy may be a promising treatment for FLT3-ITD AML. Homoharringtonine (HHT) is a classical anti-leukaemia drug with high sensitivity to FLT3-ITD AML cells. Here, we showed that HHT synergizes with a selective next-generation FLT3 inhibitor, quizartinib, to inhibit cell growth/viability and induce cell-cycle arrest and apoptosis in FLT3-ITD AML cells in vitro, significantly inhibit acute myeloid leukemia progression in vivo, and substantially prolong survival of mice-bearing human FLT3-ITD AML. Mechanistically, HHT and quizartinib cooperatively inhibit FLT3-AKT and its downstream targets GSK3β, c-Myc, and cyclin D1, cooperatively up-regulate the pro-apoptosis proteins Bim and Bax, and down-regulate the anti-apoptosis protein Mcl1. Most strikingly, HHT and quizartinib cooperatively reduce the numbers of side-population (SP) and aldehyde dehydrogenase (ALDH)-positive cells, which reportedly are rich in LSCs. In conclusion, HHT combined with quizartinib may be a promising treatment strategy for patients with FLT3-ITD AML.
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Affiliation(s)
- Fangfang Wang
- Hematology Research Laboratory, Department of Hematology, West China Hospital of Sichuan University, Chengdu, China
| | - Jingcao Huang
- Hematology Research Laboratory, Department of Hematology, West China Hospital of Sichuan University, Chengdu, China
| | - Tingting Guo
- Precision Medicine Research Laboratory, West China Hospital of Sichuan University, Chengdu, China
| | - Yuhuan Zheng
- Hematology Research Laboratory, Department of Hematology, West China Hospital of Sichuan University, Chengdu, China
| | - Li Zhang
- Hematology Research Laboratory, Department of Hematology, West China Hospital of Sichuan University, Chengdu, China
| | - Dan Zhang
- Hematology Research Laboratory, Department of Hematology, West China Hospital of Sichuan University, Chengdu, China
| | - Fujue Wang
- Hematology Research Laboratory, Department of Hematology, West China Hospital of Sichuan University, Chengdu, China
| | - Duolan Naren
- Department of Hematology, The Second Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yushan Cui
- Hematology Research Laboratory, Department of Hematology, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaoyan Liu
- Hematology Research Laboratory, Department of Hematology, West China Hospital of Sichuan University, Chengdu, China
| | - Ying Qu
- Hematology Research Laboratory, Department of Hematology, West China Hospital of Sichuan University, Chengdu, China
| | - Hongmei Luo
- Hematology Research Laboratory, Department of Hematology, West China Hospital of Sichuan University, Chengdu, China
| | - Yan Yang
- Hematology Research Laboratory, Department of Hematology, West China Hospital of Sichuan University, Chengdu, China
| | - Haichen Wei
- Hematology Research Laboratory, Department of Hematology, West China Hospital of Sichuan University, Chengdu, China
| | - Yong Guo
- Hematology Research Laboratory, Department of Hematology, West China Hospital of Sichuan University, Chengdu, China.
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15
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Kang D, Ludwig E, Jaworowicz D, Huang H, Fiedler-Kelly J, Cortes J, Ganguly S, Khaled S, Krämer A, Levis M, Martinelli G, Perl A, Russell N, Abutarif M, Choi Y, Yin O. Concentration-QTc analysis of quizartinib in patients with relapsed/refractory acute myeloid leukemia. Cancer Chemother Pharmacol 2021; 87:513-23. [PMID: 33415416 DOI: 10.1007/s00280-020-04204-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/16/2020] [Indexed: 11/29/2022]
Abstract
Purpose This analysis evaluated the relationship between concentrations of quizartinib and its active metabolite AC886 and QT interval corrected using Fridericia’s formula (QTcF) in patients with relapsed/refractory acute myeloid leukemia (AML) treated in the phase 3 QuANTUM-R study (NCT02039726). Methods The analysis dataset included 226 patients with AML. Quizartinib dihydrochloride was administered as daily doses of 20, 30, and 60 mg. Nonlinear mixed-effects modeling was performed using observed quizartinib and AC886 concentrations and time-matched mean electrocardiogram measurements. Results Observed QTcF increased with quizartinib and AC886 concentrations; the relationship was best described by a nonlinear maximum effect (Emax) model. The predicted mean increase in QTcF at the maximum concentration of quizartinib and AC886 associated with 60 mg/day was 21.1 ms (90% CI, 18.3–23.6 ms). Age, body weight, sex, race, baseline QTcF, QT-prolonging drug use, hypomagnesemia, and hypocalcemia were not significant predictors of QTcF. Hypokalemia (serum potassium < 3.5 mmol/L) was a statistically significant covariate affecting baseline QTcF, but no differences in ∆QTcF (change in QTcF from baseline) were predicted between patients with versus without hypokalemia at the same quizartinib concentration. The use of concomitant QT-prolonging drugs did not increase QTcF further. Conclusion QTcF increase was dependent on quizartinib and AC886 concentrations, but patient factors, including sex and age, did not affect the concentration–QTcF relationship. Because concomitant strong cytochrome P450 3A (CYP3A) inhibitor use significantly increases quizartinib concentration, these results support the clinical recommendation of quizartinib dose reduction in patients concurrently receiving a strong CYP3A inhibitor. Clinical Trial Registration NCT02039726 (registered January 20, 2014). Supplementary Information The online version contains supplementary material available at 10.1007/s00280-020-04204-y.
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Majothi S, Adams D, Loke J, Stevens SP, Wheatley K, Wilson JS. FLT3 inhibitors in acute myeloid leukaemia: assessment of clinical effectiveness, adverse events and future research-a systematic review and meta-analysis. Syst Rev 2020; 9:285. [PMID: 33287892 PMCID: PMC7722339 DOI: 10.1186/s13643-020-01540-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 11/22/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND FMS-like tyrosine kinase 3 (FLT3) is the most frequent mutation in AML. With two FLT3 inhibitors recently approved by the FDA (midostaurin and gilteritinib), there is a need to evaluate these targeted agents. PURPOSE To assess the clinical effectiveness of FLT3 inhibitors in AML patients. METHODS Standard systematic review methods were utilised. Searches were conducted to July 2020 for completed and in-progress randomised controlled trials of FLT3 inhibitors in AML. A fixed-effect meta-analysis was undertaken. RESULTS Eight completed trials involving 2656 patients and assessing five different FLT3 inhibitors (sorafenib, lestaurtinib, midostaurin, gilteritinib and quizartinib) were included. The pooled results were as follows (FLT3 inhibitor/control): overall survival hazard ratio (HR) = 0.83 (95% confidence interval [CI] 0.75 to 0.92, p = 0.0005), event-free survival HR = 0.85 (95% CI 0.77 to 0.94, p = 0.002), relapse-free survival HR = 0.76 (95% CI 0.64 to 0.90, p = 0.001), complete remission relative risk (RR) = 1.11 (95% CI 1.00 to 1.22. p = 0.05) and 60-day mortality RR = 1.04 (95% CI 0.77 to 1.40, p = 0.79). Relative risk of grade 3 and above vascular, dermatological, respiratory and hepatobiliary adverse events were found to be statistically significantly higher in the FLT3 inhibitor group compared to control, but the actual numbers of events were relatively small. Nineteen ongoing trials are still in progress, only one of which specifically targets older patients with AML. CONCLUSIONS There is evidence to support the use of FLT3 inhibitors in patients with AML, but more data is needed to verify the optimum use of the drugs regarding type of inhibitor, disease stage and patient characteristics, not only in relation to disease control, but adverse events and quality of life. There are a large number of ongoing trials; therefore, the results of this review are not a fait accompli; thus, is it recommended that the review be updated in a couple of years' time. Given the challenges in extracting the complete data set required to assess clinical effectiveness, it is highly recommended that ongoing and future trials improve transparency and consistency of reporting of all trial outcomes, particularly disease control and adverse events, to enable a global clinical effectiveness assessment. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017055581.
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Affiliation(s)
- S Majothi
- Cancer Research Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - D Adams
- Kingsmead Scientific Services Ltd, High Wycombe, Buckinghamshire, UK
| | - J Loke
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - S P Stevens
- Cancer Research Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - K Wheatley
- Cancer Research Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - J S Wilson
- Cancer Research Clinical Trials Unit, University of Birmingham, Birmingham, UK. .,Institute of Cancer & Genomic Sciences, Robert Aitken Institute of Clinical Research, University of Birmingham, Birmingham, UK.
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17
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Yilmaz M, Alfayez M, DiNardo CD, Borthakur G, Kadia TM, Konopleva MY, Loghavi S, Kanagal-Shamanna R, Patel KP, Jabbour EJ, Garcia-Manero G, Pemmaraju N, Pierce SA, Ghayas I, Short NJ, Montalban-Bravo G, Takahashi K, Assi R, Alotaibi AS, Ohanian M, Andreeff M, Cortes JE, Kantarjian HM, Ravandi F, Daver NG. Outcomes with sequential FLT3-inhibitor-based therapies in patients with AML. J Hematol Oncol 2020; 13:132. [PMID: 33032648 PMCID: PMC7542942 DOI: 10.1186/s13045-020-00964-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/21/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Second-generation FLT3-inhibitors (FLT3i) demonstrated single-agent composite CR rates (CRc) of 45-55% in patients with relapsed/refractory (R/R) FLT3-mutated AML in phase II/III trials. However, > 85% of patients treated were prior FLT3i naïve. The response rates to sequential FLT3i exposure remain poorly defined. METHODS We retrospectively reviewed patients with FLT3-mutated AML between November 2006 and December 2019. RESULTS In frontline patients treated with a FLT3i (cohort 1), the CRc rates and median overall survival (OS) with the first (n = 56), second (n = 32), and third FLT3i-based (n = 8) therapy were 77%, 31%, and 25%, and 16.7 months, 6.0 months, and 1.4 months, respectively. In patients receiving a FLT3i-based therapy for the first time in a R/R AML setting (cohort 2), the CRc rates and median OS were 45%, 21%, and 10%, and 7.9 months, 4.0 months, and 4.1 months with the first (n = 183), second (n = 89), and third/fourth (n = 29) FLT3i-based therapy, respectively. In cohort 1, CRc rates with single-agent FLT3i (n = 21) versus FLT3i-based combinations (n = 19) in second/third sequential FLT3i exposures were 19% versus 42%, respectively. In cohort 2, the CRc rates with single-agent FLT3i (n = 82) versus FLT3i-based combinations (n = 101) in first FLT3i exposure were 34% versus 53%, respectively, and those with single-agent FLT3i (n = 63) versus FLT3i-based combinations (n = 55) in second/third/fourth sequential FLT3i exposures were 13% versus 25%, respectively. CONCLUSION CRc rates drop progressively with sequential exposure to FLT3i's in FLT3-mutated AML. In all settings, CRc rates were higher with FLT3i-based combinations compared with single-agent FLT3i therapy in similar FLT3i exposure settings.
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Affiliation(s)
- Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Mansour Alfayez
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Marina Y Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rashmi Kanagal-Shamanna
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keyur P Patel
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias J Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Sherry A Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Issa Ghayas
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Guillermo Montalban-Bravo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Koichi Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Rita Assi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Ahmad S Alotaibi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Maro Ohanian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Michael Andreeff
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Jorge E Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit FC4.2012, Houston, TX, 77030, USA.
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Ganguly S, Cortes JE, Krämer A, Levis MJ, Martinelli G, Perl AE, Russell NH, Arunachalam M, Santos CD, Gammon G, Lesegretain A, Mires DE, Pham H, Wang Y, Khaled SK. Clinical Outcomes in Patients with FLT3-ITD-Mutated Relapsed/Refractory Acute Myelogenous Leukemia Undergoing Hematopoietic Stem Cell Transplantation after Quizartinib or Salvage Chemotherapy in the QuANTUM-R Trial. Transplant Cell Ther 2020; 27:153-162. [PMID: 33017662 DOI: 10.1016/j.bbmt.2020.09.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 07/31/2020] [Revised: 09/23/2020] [Accepted: 09/27/2020] [Indexed: 12/14/2022]
Abstract
Despite the substantial clinical activity of fms-related tyrosine kinase 3 (FLT3) inhibitors in relapsed or refractory (R/R) FLT3-ITD‒positive acute myelogenous leukemia (AML), durable remissions and prolonged survival in this population require allogeneic hematopoietic stem cell transplantation (allo-HSCT). Quizartinib, a once-daily oral, highly potent, and selective FLT3 inhibitor, significantly prolonged overall survival (OS) and improved clinical benefit compared with salvage chemotherapy (median OS, 6.2 months versus 4.7 months; hazard ratio [HR], .76; 95% confidence interval [CI], .58 to .98; P = .018; composite complete remission [CRc] rate, 48% versus 27%; median duration of CRc, 2.8 months versus 1.2 months; mortality rate, .8% versus 14% by day 30, 7% versus 24% by day 60) in patients with R/R FLT3-ITD AML in the phase 3 QuANTUM-R trial. In this post hoc analysis, we described the characteristics of and clinical outcomes in patients who underwent on-study HSCT in QuANTUM-R at the investigator's discretion and institutional practices. Of 367 randomized patients, 78 (32%) in the quizartinib arm and 14 (11%) in the salvage chemotherapy arm underwent on-study allo-HSCT without any intervening therapy for AML after quizartinib or study-specified salvage chemotherapy. Pooled data of patients from both treatment arms showed a longer median overall survival (OS) in transplant recipients versus those treated without allo-HSCT (12.2 months versus 4.4 months; HR, .315; 95% CI, .233 to .427). Pooled data also showed a longer median OS in patients with a last recorded response of CRc before allo-HSCT versus patients without a CRc (20.1 months versus 8.8 months; HR, .506; 95% CI, .296 to .864). By treatment arm, the median OS was 25.1 months with quizartinib and 20.1 months with salvage chemotherapy in patients with a last recorded response of CRc before allo-HSCT. Forty-eight patients in the quizartinib arm continued quizartinib treatment after allo-HSCT. In the 31 patients with a last recorded response of CRc before allo-HSCT who continued quizartinib after allo-HSCT, the median OS was 27.1 months. Continuation of quizartinib after allo-HSCT was tolerable, and no new safety signals were identified. These results suggest that post-transplantation survival following salvage chemotherapy and quizartinib treatment are similar. However, quizartinib response occurs more frequently than with salvage chemotherapy, potentially allowing more patients to undergo transplantation and achieve durable clinical benefit. In addition, post-transplant quizartinib was found to be tolerable and may be associated with prolonged survival in some patients, highlighting its potential value in the management of patients with FLT3-ITD R/R AML.
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Affiliation(s)
- Siddhartha Ganguly
- Division of Hematological Malignancies and Cellular Therapeutics, The University of Kansas Health System, Kansas City, Kansas.
| | - Jorge E Cortes
- Division of Hematology and SCT, Georgia Cancer Center, Augusta, GA
| | - Alwin Krämer
- Clinical Cooperation Unit Molecular Hematology/Oncology, Heidelberg University and German Cancer Research Center, Heidelberg, Germany
| | - Mark J Levis
- Hematologic Malignancies and Bone Marrow Transplant Program, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
| | - Giovanni Martinelli
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, IRCCS, Meldola, Italy
| | - Alexander E Perl
- Division of Hematology/Oncology, Perelman Center for Advanced Medicine, Abramson Cancer Center of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nigel H Russell
- Department of Haematology, Centre for Clinical Haematology, Nottingham University Hospital, Nottingham, UK
| | - Meena Arunachalam
- Global Medical Affairs, Oncology, Daiichi Sankyo, Inc, Basking Ridge, New Jersey
| | - Cedric Dos Santos
- Translational Sciences, Global Oncology R&D, Daiichi Sankyo, Inc, Basking Ridge, New Jersey
| | - Guy Gammon
- Global Medical Affairs, Oncology, Daiichi Sankyo, Inc, Basking Ridge, New Jersey
| | | | - Derek E Mires
- Global Oncology R&D, Daiichi Sankyo, Inc, Basking Ridge, New Jersey
| | - Hoang Pham
- Clinical Safety, Global Oncology, Daiichi Sankyo, Inc, Basking Ridge, New Jersey
| | - Yibin Wang
- Biostatistics, Daiichi Sankyo, Inc, Basking Ridge, New Jersey
| | - Samer K Khaled
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
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Perelló-Reus CM, Català A, Caviedes-Cárdenas L, Vega-García N, Camós M, Pérez-Torras S, Pastor-Anglada M. FMS-like tyrosine kinase 3 (FLT3) modulates key enzymes of nucleotide metabolism implicated in cytarabine responsiveness in pediatric acute leukemia. Pharmacol Res 2019; 151:104556. [PMID: 31778791 DOI: 10.1016/j.phrs.2019.104556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 11/13/2019] [Accepted: 11/18/2019] [Indexed: 02/06/2023]
Abstract
Treatment of pediatric acute leukemia might involve combined therapies targeting the FMS-like tyrosine kinase 3 (FLT3) receptor (i.e. quizartinib - AC220) and nucleotide metabolism (cytarabine - AraC). This study addressed the possibility of FLT3 modulating nucleoside salvage processes and, eventually, cytarabine action. Bone marrow samples from 108 pediatric leukemia patients (B-cell precursor acute lymphoblastic leukemia, BCP-ALL: 83; T-ALL: 9; acute myeloid leukemia, AML: 16) were used to determine the mRNA expression levels of FLT3, the cytarabine activating kinase dCK, and the nucleotidases cN-II and SAMHD1. FLT3 mRNA levels positively correlated with dCK, cN-II and SAMHD1 in the studied cohort. FLT3 inhibition using AC220 promoted the expression of cN-II in MV4-11 cells. Indeed, inhibition of cN-II with anthraquinone-2,6-disulfonic acid (AdiS) further potentiated the synergistic action of AC220 and cytarabine, at low concentrations of this nucleoside analog. FLT3 inhibition also down-regulated phosphorylated forms of SAMHD1 in MV4-11 and SEM cells. Thus, inhibition of FLT3 may also target the biochemical machinery associated with nucleoside salvage, which may modulate the ability of nucleoside-derived drugs. In summary, this contribution highlights the need to expand current knowledge on the mechanistic events linking tyrosine-kinase receptors, likely to be druggable in cancer treatment, and nucleotide metabolism, particularly considering tumor cells undergo profound metabolic reprogramming.
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Affiliation(s)
- Catalina M Perelló-Reus
- Molecular Pharmacology and Experimental Therapeutics, Department of Biochemistry and Molecular Biomedicine, Institute of Biomedicine, University of Barcelona (IBUB), Barcelona, Spain; Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBER EHD), Instituto de Salud Carlos III, Madrid, Spain; Institut de Recerca Hospital Sant Joan de Déu de Barcelona (IRP-HSJD), Esplugues de Llobregat, Barcelona, Spain
| | - Albert Català
- Institut de Recerca Hospital Sant Joan de Déu de Barcelona (IRP-HSJD), Esplugues de Llobregat, Barcelona, Spain; Pediatric Hematology Department, Hospital Sant Joan de Déu de Barcelona, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, Spain
| | - Liska Caviedes-Cárdenas
- Molecular Pharmacology and Experimental Therapeutics, Department of Biochemistry and Molecular Biomedicine, Institute of Biomedicine, University of Barcelona (IBUB), Barcelona, Spain; Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBER EHD), Instituto de Salud Carlos III, Madrid, Spain; Institut de Recerca Hospital Sant Joan de Déu de Barcelona (IRP-HSJD), Esplugues de Llobregat, Barcelona, Spain
| | - Nerea Vega-García
- Institut de Recerca Hospital Sant Joan de Déu de Barcelona (IRP-HSJD), Esplugues de Llobregat, Barcelona, Spain; Hematology Laboratory, Hospital Sant Joan de Deu (IR SJD), Esplugues de Llobregat, Universitat de Barcelona, Barcelona, Spain
| | - Mireia Camós
- Institut de Recerca Hospital Sant Joan de Déu de Barcelona (IRP-HSJD), Esplugues de Llobregat, Barcelona, Spain; Hematology Laboratory, Hospital Sant Joan de Deu (IR SJD), Esplugues de Llobregat, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, Spain
| | - Sandra Pérez-Torras
- Molecular Pharmacology and Experimental Therapeutics, Department of Biochemistry and Molecular Biomedicine, Institute of Biomedicine, University of Barcelona (IBUB), Barcelona, Spain; Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBER EHD), Instituto de Salud Carlos III, Madrid, Spain; Institut de Recerca Hospital Sant Joan de Déu de Barcelona (IRP-HSJD), Esplugues de Llobregat, Barcelona, Spain.
| | - Marçal Pastor-Anglada
- Molecular Pharmacology and Experimental Therapeutics, Department of Biochemistry and Molecular Biomedicine, Institute of Biomedicine, University of Barcelona (IBUB), Barcelona, Spain; Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBER EHD), Instituto de Salud Carlos III, Madrid, Spain; Institut de Recerca Hospital Sant Joan de Déu de Barcelona (IRP-HSJD), Esplugues de Llobregat, Barcelona, Spain.
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Bazarbachi AH, Al Hamed R, Malard F, Mohty M, Bazarbachi A. Allogeneic transplant for FLT3- ITD mutated AML: a focus on FLT3 inhibitors before, during, and after transplant. Ther Adv Hematol 2019; 10:2040620719882666. [PMID: 31700594 PMCID: PMC6826920 DOI: 10.1177/2040620719882666] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/25/2019] [Indexed: 01/17/2023] Open
Abstract
FMS-like tyrosine kinase 3 (FLT3) mutations are one of the most frequently encountered genetic alterations in acute myeloid leukemia (AML), and are generally associated with unfavorable outcomes. Several tools are currently available to provide an accurate prognosis for patients with these mutations, including FLT3 mutation type (internal tandem duplication versus tyrosine kinase domain), mutation allelic ratio (high versus low), and concurrent nucleophosmin-1 (NPM1) mutation, to help decide on optimal treatment. Recent advances in targeted therapies have paved the way for modern treatment strategies, such as the development of FLT3 kinase inhibitors. These novel drugs can be incorporated into any treatment component, including induction and consolidation, the relapse/refractory setting, bridging for transplant, salvage post-transplant, and as prophylactic long-term post-transplant maintenance. Many challenges remain though, such as their intolerability with high-dose chemotherapy in frail patients; whether their optimal use involves watchful waiting for molecular or hematologic relapse compared with prophylactic use as maintenance; and the exact role and indication for allogeneic stem cell transplantation, which arguably remains the only curative option for these high-risk patients.
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Affiliation(s)
- Abdul Hamid Bazarbachi
- Department of Haematology, Saint Antoine Hospital, Paris, France, INSERM UMR 938, Paris, France
- Sorbonne University, Paris, Île-de-France, France
| | - Rama Al Hamed
- Department of Haematology, Saint Antoine Hospital, Paris, France, INSERM UMR 938, Paris, France
- Sorbonne University, Paris, Île-de-France, France
| | - Florent Malard
- Department of Haematology, Saint Antoine Hospital, Paris, France, INSERM UMR 938, Paris, France
- Sorbonne University, Paris, Île-de-France, France
| | - Mohamad Mohty
- Department of Haematology, Saint Antoine Hospital, Paris, France, INSERM UMR 938, Paris, France
- Sorbonne University, Paris, Île-de-France, France
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, PO Box 113-6044, Beirut, Lebanon
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Li J, Trone D, Mendell J, O'Donnell P, Cook N. A drug-drug interaction study to assess the potential effect of acid-reducing agent, lansoprazole, on quizartinib pharmacokinetics. Cancer Chemother Pharmacol 2019; 84:799-807. [PMID: 31385001 PMCID: PMC6768889 DOI: 10.1007/s00280-019-03915-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 07/26/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Quizartinib, a potent, selective FMS-like tyrosine kinase 3 (FLT3) inhibitor, is currently in phase 3 development for patients with FLT3-internal tandem duplication-mutated acute myeloid leukemia (AML). Acid-reducing agents (ARAs; e.g., proton pump inhibitors) are frequently used during AML treatment. Since quizartinib demonstrates pH-dependent solubility, the effect of lansoprazole coadministration on pharmacokinetics (PK) of quizartinib tablet formulation was assessed. METHODS An open-label, parallel-group study randomized 64 healthy adults to single-dose quizartinib 30 mg alone (reference) or lansoprazole (60 mg once daily, days 1-5) + single-dose quizartinib 30 mg (day 5) (test). Plasma concentrations of quizartinib and its active metabolite, AC886, were measured to 504 h postdose; the effect of lansoprazole on quizartinib PK was assessed by analysis of variance. RESULTS Quizartinib geometric mean ratios (test/reference) and 90% confidence intervals for maximum observed plasma concentration (Cmax), area under the concentration-time curve to last measurable drug concentration (AUClast), and AUC to infinity were 86.11% (78.4%, 94.6%), 93.96% (79.6%, 110.9%), and 95.30% (80.2%, 113.3%), respectively. Comparisons showed a modest decrease in quizartinib absorption when co-administered with lansoprazole, with lower limits for Cmax and AUClast just below 80-125% limits. Treatment-emergent adverse events were mild or moderate; the most frequent in either treatment group were headache [quizartinib alone: (n = 3) 10%], upper respiratory tract infection [quizartinib alone: (n = 2) 6.7%; lansoprazole + quizartinib: (n = 3) 9.1%], and muscle tightness [quizartinib alone: (n = 2) 6.7%]. CONCLUSIONS Concomitant lansoprazole had minimal effect on quizartinib PK as a formulated tablet, indicating that quizartinib can be administered with ARAs.
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Affiliation(s)
- Jianke Li
- Daiichi Sankyo, Inc., 10201 Wateridge Circle, Suite 240, San Diego, CA, 92121, USA.
| | - Denise Trone
- Daiichi Sankyo, Inc., 10201 Wateridge Circle, Suite 240, San Diego, CA, 92121, USA
| | | | - Patrick O'Donnell
- Daiichi Sankyo, Inc., 10201 Wateridge Circle, Suite 240, San Diego, CA, 92121, USA
| | - Natalie Cook
- Daiichi Sankyo, Inc., 10201 Wateridge Circle, Suite 240, San Diego, CA, 92121, USA
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Takahashi T, Usuki K, Matsue K, Ohno H, Sakura T, Imanaka R, Murakami M, Ohwada S, Takagi T, Sakajiri S. Efficacy and safety of quizartinib in Japanese patients with FLT3-ITD positive relapsed or refractory acute myeloid leukemia in an open-label, phase 2 study. Int J Hematol 2019; 110:665-74. [PMID: 31473943 DOI: 10.1007/s12185-019-02727-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 08/13/2019] [Accepted: 08/19/2019] [Indexed: 10/26/2022]
Abstract
FMS-like tyrosine kinase 3 (FLT3) internal tandem duplication (ITD) mutations in patients with acute myeloid leukemia (AML) are associated with early relapse and poor survival. This multicenter, single-arm, two-stage phase 2 study (NCT02984995) was conducted to evaluate the efficacy and safety of quizartinib hydrochloride (initial dose 20/30 mg/day), an oral, highly potent, selective FLT3 inhibitor in Japanese patients (median age 65 years) with FLT3-ITD positive relapsed/refractory (R/R) AML. The composite complete remission (CRc) rate (primary endpoint) was 53.8% (90% confidence interval 36.2-70.8%) for evaluable patients in the efficacy analysis set. The median duration of CRc and overall survival was 16.1 weeks and 34.1 weeks, respectively. The most frequent treatment-emergent adverse events (TEAEs) were febrile neutropenia (43.2%), platelet count decreased (37.8%), and QT prolonged (35.1%). Two (5.4%) patients experienced TEAEs associated with treatment discontinuation. All serious TEAEs (45.9%), except febrile neutropenia (16.2%), were reported in ≤ 2 patients. The incidence of QTcF 451-480 ms and 481-500 ms was 37.8% and 2.7%, respectively. No QTcF > 500 ms, events of torsade de pointes or arrhythmia with clinical symptoms were reported. Quizartinib monotherapy was well tolerated and resulted in clinically meaningful reductions in blast count in Japanese patients with FLT3-ITD R/R AML.
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23
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Usuki K, Handa H, Choi I, Yamauchi T, Iida H, Hata T, Ohwada S, Okudaira N, Nakamura K, Sakajiri S. Safety and pharmacokinetics of quizartinib in Japanese patients with relapsed or refractory acute myeloid leukemia in a phase 1 study. Int J Hematol 2019; 110:654-64. [PMID: 31359361 DOI: 10.1007/s12185-019-02709-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/17/2019] [Accepted: 07/17/2019] [Indexed: 10/26/2022]
Abstract
Expanded therapeutic options are warranted for patients with relapsed or refractory (R/R) acute myeloid leukemia (AML) who have FMS-like tyrosine kinase 3-internal tandem duplication (FLT3-ITD) mutations. The present phase 1, multicenter, open-label, dose-escalation and dose-expansion study was conducted to assess the safety, pharmacokinetics, and efficacy of multiple-dose monotherapy of the FLT3 inhibitor, quizartinib, in Japanese patients with R/R AML. Patients received oral quizartinib, once daily, under fasting conditions in 28-day cycles. Sixteen patients (median age, 68.0 years; male, 56.3%; FLT3-ITD positive, 43.8%) received quizartinib (9, 3, and 4 patients at 20, 30, and 60 mg/day, respectively; median treatment duration, 95.0 days; median relative dose intensity, 100.0%). No dose-limiting toxicities were observed. The most common treatment-emergent adverse events were electrocardiogram QT prolonged (43.8%, grade 1 or 2) followed by nausea and pyrexia (37.5% each). No quizartinib-related deaths were reported. A dose-dependent increase of quizartinib and its active metabolite AC886 levels was observed at the steady state. The composite complete remission rate was 37.5%. Quizartinib was well tolerated in Japanese R/R AML patients at doses up to 60 mg/day; quizartinib 60 mg/day was considered as the recommended dose for the Japanese patient population in a subsequent study.Trial registration ClinicalTrials.gov identifier NCT02675478.
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Weis TM, Marini BL, Bixby DL, Perissinotti AJ. Clinical considerations for the use of FLT3 inhibitors in acute myeloid leukemia. Crit Rev Oncol Hematol 2019; 141:125-38. [PMID: 31279288 DOI: 10.1016/j.critrevonc.2019.06.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 05/22/2019] [Accepted: 06/21/2019] [Indexed: 12/18/2022] Open
Abstract
Internal tandem duplications and tyrosine kinase mutations in the fms-like tyrosine kinase 3 (FLT3) receptor can occur in acute myeloid leukemia (AML) and portend a poor prognosis. Midostaurin, a multikinase inhibitor that targets FLT3, demonstrated a survival benefit in FLT3-mutated AML in combination with front-line chemotherapy. Despite this advancement, the use of FLT3 inhibitors in clinical practice is complicated by significant drug-drug interactions and uncertainty about optimal timing, duration, and sequencing of therapy. As monotherapy, the utility of FLT3 inhibitors was initially limited by incomplete and transient clinical responses and the development of acquired resistance. This led to the development of more potent and selective FLT3 inhibitors designed to overcome common resistance mechanisms. One of these second generation FLT3 inhibitors, gilteritinib, is now FDA-approved for the treatment of relapsed or refractory AML. Now that multiple FLT3 inhibitors are commercially available, it is important to further delineate the role of these agents in the AML population. This review aims to provide a comprehensive overview of the role of FLT3 inhibitors in AML and apply the current literature to clinical practice.
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Wang ES. Incorporating FLT3 inhibitors in the frontline treatment of FLT3 mutant acute myeloid leukemia. Best Pract Res Clin Haematol 2019; 32:154-162. [PMID: 31203997 DOI: 10.1016/j.beha.2019.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 04/21/2019] [Revised: 05/08/2019] [Accepted: 05/10/2019] [Indexed: 12/21/2022]
Abstract
FLT3 mutations occur in up to a third of newly diagnosed patients with acute myeloid leukemia (AML) and confer poor prognosis. Clinical development of FLT3 tyrosine kinase inhibitors for AML initially involved broad-spectrum inhibitors (midostaurin, sorafenib) targeting multiple kinases. Addition of midostaurin to upfront intensive chemotherapy for younger patients with FLT3 mutant AML significantly improved overall survival and validated FLT3 as a therapeutic target. Other regimens such as sorafenib and hypomethylating agents (azacitidine, decitabine) have expanded the use of FLT3 inhibitors to other populations with FLT3 mutant AML. However, emerging data on new highly potent and specific FLT3 inhibitors such as quizartinib, gilteritinib, and crenolanib suggest that these agents may soon supplant midostaurin and sorafenib in the upfront setting. Using case presentations, this review provides guidelines and practical management strategies for frontline therapy of patients with newly diagnosed FLT3 mutant AML in the current era.
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Affiliation(s)
- Eunice S Wang
- Leukemia Service, Department of Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, 14263, USA.
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26
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Wang J, Gan C, Retmana IA, Sparidans RW, Li W, Lebre MC, Beijnen JH, Schinkel AH. P-glycoprotein (MDR1/ABCB1) and Breast Cancer Resistance Protein (BCRP/ABCG2) limit brain accumulation of the FLT3 inhibitor quizartinib in mice. Int J Pharm 2018; 556:172-180. [PMID: 30553002 DOI: 10.1016/j.ijpharm.2018.12.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 09/21/2018] [Revised: 11/27/2018] [Accepted: 12/03/2018] [Indexed: 12/31/2022]
Abstract
Quizartinib, a second-generation FLT3 inhibitor, is in clinical development for the treatment of acute myeloid leukemia. We studied its pharmacokinetic interactions with the multidrug efflux transporters ABCB1 and ABCG2 and the multidrug metabolizing enzyme CYP3A, using in vitro transport assays and knockout and transgenic mouse models. Quizartinib was transported by human ABCB1 in vitro, and by mouse (m)Abcb1 and mAbcg2 in vivo. Upon oral administration, the brain accumulation of quizartinib was 6-fold decreased by mAbcb1 and 2-fold by mAbcg2 (together: 12-fold). Unexpectedly, the absence of mAbcb1 resulted in a ∼2-fold lower plasma exposure in Abcb1a/1b-/- and Abcb1a/1b;Abcg2-/- mice, suggesting that loss of mAbcb1 causes compensatory alterations in alternative quizartinib elimination or uptake systems. mAbcb1 and mAbcg2 themselves did not appear to restrict quizartinib oral availability. Oral and intravenous pharmacokinetics of quizartinib were not substantially altered between wild-type, Cyp3a knockout and CYP3A4-humanized mice. All three strains showed relatively high (33-51%) oral bioavailability. If this also applies in humans, this would suggest a limited risk of CYP3A-related inter-individual variation in exposure for this drug. Our results provide a possible rationale for using pharmacological ABCB1/ABCG2 inhibitors together with quizartinib when treating malignant lesions situated in part or in whole behind the blood-brain barrier.
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Affiliation(s)
- Jing Wang
- The Netherlands Cancer Institute, Division of Pharmacology, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Changpei Gan
- The Netherlands Cancer Institute, Division of Pharmacology, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Irene A Retmana
- Utrecht University, Faculty of Science, Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
| | - Rolf W Sparidans
- Utrecht University, Faculty of Science, Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
| | - Wenlong Li
- The Netherlands Cancer Institute, Division of Pharmacology, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Maria C Lebre
- The Netherlands Cancer Institute, Division of Pharmacology, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Jos H Beijnen
- The Netherlands Cancer Institute, Division of Pharmacology, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; Utrecht University, Faculty of Science, Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands; The Netherlands Cancer Institute/Slotervaart Hospital, Department of Pharmacy & Pharmacology, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Alfred H Schinkel
- The Netherlands Cancer Institute, Division of Pharmacology, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
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Abstract
Determining which FLT3 inhibitor holds the greatest promise is a difficult task, as the drugs vary according to potency, specificity, protein-binding, drug interactions, and side effect profile. The best choice depends on when in the course of the disease the inhibitor will be used. Moreover, as the results of ongoing trials become available, newer agents could supplant former 'best' drugs. This paper reviews FLT3 inhibitors in combination with chemotherapy early in the disease in FLT3 mutant patients, as single agents or in combination in advanced disease, or in the post-transplant setting to provide separate answers to the main question.
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Affiliation(s)
- Richard M Stone
- Director, Adult Leukemia Program, Dana-Farber Cancer Institute, 450 Brookline Avenue, D2053, Boston, MA, 02215, USA.
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28
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Papadopoulos KP, Ben-Ami E, Patnaik A, Trone D, Li J, Demetri GD. Safety and tolerability of quizartinib, a FLT3 inhibitor, in advanced solid tumors: a phase 1 dose-escalation trial. BMC Cancer 2018; 18:790. [PMID: 30081867 PMCID: PMC6080548 DOI: 10.1186/s12885-018-4692-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 07/24/2018] [Indexed: 01/10/2023] Open
Abstract
Background Quizartinib, an inhibitor of class III receptor tyrosine kinases (RTKs), is currently in phase 3 development for the treatment of acute myeloid leukemia (AML) bearing internal tandem duplications in the FLT3 gene. Aberrant RTK signaling is implicated in the pathogenesis of a variety of solid tumors, suggesting that inhibiting quizartinib-sensitive RTKs may be beneficial in precision cancer therapy. Methods This was a phase 1, open-label, modified Fibonacci dose-escalation study of orally administered quizartinib in patients with advanced solid tumors whose disease progressed despite standard therapy or for which there was no available standard treatment. Patients received quizartinib dihydrochloride (henceforth referred to as quizartinib) once daily throughout a 28-day treatment cycle. The primary endpoint was evaluation of the maximum tolerated dose (MTD) of quizartinib. Secondary endpoints included preliminary evidence of antitumor activity and determination of the pharmacokinetic and pharmacodynamic parameters of quizartinib. Results Thirteen patients were enrolled. Five patients received a starting dose of quizartinib 135 mg/day; dose-limiting toxicities (DLTs) of grade 3 pancytopenia, asymptomatic grade 3 QTc prolongation, and febrile neutropenia were observed in 1 patient each at this dose. A lower dose of quizartinib (90 mg/day [n = 8]) was administered without DLTs. The most common treatment-related treatment-emergent adverse events (AEs) were fatigue (n = 7, 54%), dysgeusia (n = 5, 38%), neutropenia (n = 3, 23%), and QTc prolongation (n = 3, 23%). Overall, all patients experienced at least 1 AE, and 4 experienced serious AEs (2 patients each in the 135-mg and 90-mg dose groups) including hematologic AEs, infections, and gastrointestinal disorders. Six patients (including 3 patients with gastrointestinal stromal tumors [GIST]) had a best response of stable disease. Conclusion The MTD of quizartinib in patients with advanced solid tumors was 90 mg/day. Overall, the safety and tolerability of quizartinib were manageable, with no unexpected AEs. Quizartinib monotherapy had limited evidence of activity in this small group of patients with advanced solid tumors. Trial registration Clinical Trials Registration Number: NCT01049893; First Posted: January 15, 2010. Electronic supplementary material The online version of this article (10.1186/s12885-018-4692-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kyriakos P Papadopoulos
- South Texas Accelerated Research Therapeutics, 4383 Medical Dr, Suite 4021, San Antonio, TX, 78229, USA
| | - Eytan Ben-Ami
- Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA
| | - Amita Patnaik
- South Texas Accelerated Research Therapeutics, 4383 Medical Dr, Suite 4021, San Antonio, TX, 78229, USA
| | - Denise Trone
- Formerly Daiichi Sankyo Pharma Development, 3172 Mount Acmar Court, San Diego, CA, 92111, USA
| | - Jianke Li
- Daiichi Sankyo Pharma Development, 10201 Wateridge Circle, Suite 240, San Diego, CA, 92121, USA
| | - George D Demetri
- Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA. .,Ludwig Center at Harvard, Harvard Medical School, 450 Brookline Ave, Boston, MA, 02215, USA.
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Retmana IA, Wang J, Schinkel AH, Schellens JHM, Beijnen JH, Sparidans RW. Liquid chromatography-tandem mass spectrometric assay for the quantitative determination of the tyrosine kinase inhibitor quizartinib in mouse plasma using salting-out liquid-liquid extraction. J Chromatogr B Analyt Technol Biomed Life Sci 2017; 1061-1062:300-305. [PMID: 28772226 DOI: 10.1016/j.jchromb.2017.07.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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: 04/18/2017] [Revised: 06/16/2017] [Accepted: 07/19/2017] [Indexed: 10/19/2022]
Abstract
A bioanalytical assay for quizartinib -a potent, and selective FLT3 tyrosine kinase inhibitor- in mouse plasma was developed and validated. Salting-out assisted liquid-liquid extraction (SALLE), using acetonitrile and magnesium sulfate, was selected as sample pretreatment with deuterated quizartinib as internal standard. Separation was performed with reversed-phase liquid chromatography followed by detection with positive electrospray-triple quadrupole mass spectrometry in the selected reaction monitoring mode. The assay was successfully validated for mouse plasma in a 2-2000ng/ml calibration range with r2=0.9958±0.0028 (n=7) for linear regression with the inverse square of the concentration as a weighting factor. The within-run precision (n=18), between-run precision and accuracy were 2.9-6.0%, 4.5-8.9% and 91.7-109.4% respectively. The drug was stable under all relevant conditions. Finally, the assay was successfully applied in a pharmacokinetic pilot study in plasma of FVB/NRj mice treated with quizartinb orally.
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Affiliation(s)
- Irene A Retmana
- Utrecht University, Faculty of Science, Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands.
| | - Jing Wang
- The Netherlands Cancer Institute, Department of Molecular Oncology, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
| | - Alfred H Schinkel
- The Netherlands Cancer Institute, Department of Molecular Oncology, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
| | - Jan H M Schellens
- Utrecht University, Faculty of Science, Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands; The Netherlands Cancer Institute, Department of Clinical Pharmacology, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
| | - Jos H Beijnen
- Utrecht University, Faculty of Science, Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands; The Netherlands Cancer Institute, Department of Clinical Pharmacology, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; MC Slotervaart, Department of Pharmacy & Pharmacology, Louwesweg 6, 1066 EC Amsterdam, The Netherlands.
| | - Rolf W Sparidans
- Utrecht University, Faculty of Science, Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands; Utrecht University, Faculty of Science, Department of Pharmaceutical Sciences, Division of Chemical Biology & Drug Development, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands.
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30
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Abstract
OPINION STATEMENT Granulocytic sarcoma (GS) is a rare manifestation of myeloid proliferation, characterized by formation of a mass comprised of immature cells of myeloid origin. Orbital granulocytic sarcoma is rarer still, with only a small fraction of GS patients having orbital involvement. Given the rarity of orbital GS, no unified therapy plan has been identified, as large prospective trials are not feasible, but it is widely accepted that patients with GS ought to be treated with systemic intensive chemotherapy consistent with standard of care regimens for acute myelogenous leukemia (AML) or chronic myelogenous leukemia (CML). Development of a treatment plan for GS in poor responders involves a systemic leukemia plan as novel therapeutics have not been investigated for treatment GS per se, but used more widely for AML. GS is most commonly associated with AML and thus will be addressed in that context in this review. Patients with GS associated with CML should receive CML-specific therapy. When conventional and traditional cytotoxic GS/AML chemotherapy regimens are insufficient, patients often require a combination of novel therapeutics, stem cell transplantation (SCT), and radiation. Much of the recent advancement in AML therapy, as well as in AML translational research, has been in targeting molecular facets of the disease and enabling more specificity with treatment. The aim of treating patients for whom conventional treatment was unsuccessful with personalized therapy has not yet been realized, but many of the novel therapeutics reviewed below have demonstrated promise and are cause for optimism. In our center, when a GS/AML patient is refractory to frontline therapy, we rely on novel chemotherapy therapeutic options as outlined below.
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Affiliation(s)
- Nathan Gossai
- Division of Pediatric Hematology/Oncology, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, 55455, USA
| | - Rachel Cafferty
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Brenda Weigel
- Division of Pediatric Hematology/Oncology, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, 55455, USA.
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