Podcasts about flt3 itd

In this week's episode, we'll learn more about how measurable residual disease might help guide decisions about post-transplant gilteritinib maintenance in FLT3-ITD acute myeloid leukemia, or AML; how stemness contributes to chemotherapy resistance in AML; and effects of babesiosis on red blood cells from individuals with sickle cell disease, sickle cell trait, and wild-type hemoglobin. Featured Articles:Measurable residual disease and post-transplantation gilteritinib maintenance for patients with FLT3-ITD-mutated AML GATA2 links stemness to chemotherapy resistance in acute myeloid leukemia Babesiosis and Sickle Red Blood Cells: Loss of Deformability, Heightened Osmotic fragility and Hyper-vesiculation 

Dr. John Sweetenham and Dr. James Foran discuss the evolving treatment landscape in acute myeloid leukemia, including new targeted therapies, advances in immunotherapy, and the current role for allogeneic transplantation. TRANSCRIPT Dr. John Sweetenham: Hello, I'm Dr. John Sweetenham, the host of the ASCO Daily News Podcast. There has been steady progress in the therapies for acute myeloid leukemia (AML) in recent years, largely based on an increasing understanding of the molecular mechanisms which underlie the disease. On today's episode, we'll be discussing the evolving treatment landscape in AML. We'll explore risk group stratification, new targeted therapies, advances in immunotherapy for AML, and also a little about the current role for allogenic transplantation in this disease.  I'm delighted to welcome Dr. James Foran to this discussion. Dr. Foran is a professor of medicine and chair of the Myeloid Malignancies and Blood and Marrow Transplant Disease Group at the Mayo Clinic Comprehensive Cancer Center. He's based in Jacksonville, Florida.  Our full disclosures are available in the transcript of this episode.  James, it's great to have you join us on the podcast today, and thanks so much for being here. Dr. James Foran: I'm delighted and thank you for the invitation. Thank you very much. Dr. John Sweetenham: Sure, James, let's get right into it. So, our understanding of the molecular mechanisms underlying AML has resulted not only in new methods for risk stratification in this disease, which have added refinement to cytogenetics, but also has resulted in the development of many new targeted agents. Understanding that this is a complex area of investigation, and our time is somewhat limited, can you give us a high-level update on the current state of the art in terms of how risk factors are being used for treatment selection now? Dr. James Foran: Absolutely. I think in the past, you know, we had things broken down pretty simply into make a diagnosis based on morphology, do cytogenetics, break patients into the groups of those who were more likely to benefit from therapy – so-called favorable risk – those where the intensive therapies were less likely to work – so-called poor adverse risk, and then this large intermediate group that really had variable outcomes, some better, some worse. And for a long time, the progress was in just identifying new subtle cytogenetic risk groups. And then, late 1990s, we began to understand that FLT3 mutations or NRAS mutations may be more adverse than others that came along. In the first part of this millennium, in the, you know, 2000-2010 range, a lot of work was being done to understand better or worse risk factors with single genes. The ability to do multiplex PCR, and then more recently NGS platforms, have allowed us to really look at many genes and identify many mutations in patients. At the beginning that was used just to sort of refine – who did a little better, who did a little worse with intensive therapy – helped us decide who may benefit more from an allogeneic transplanter for whom that would not be necessary.  But the good news is that really, we're now starting to target those mutations. One of the first molecularly targeted treatments in leukemia was FLT3 mutations, where we knew they were adverse. Then along came targeted treatments. I was involved in some of those early studies looking at sunitinib, sorafenib, more recently midostaurin, now quizartinib, FDA approved, and gilteritinib in the relapse refractory setting.  So we're moving into a state where we're not just refining prognosis, we're identifying targets. You know, it's been slow progress, but definite incremental progress in terms of outcomes by looking for FLT3 mutations, then looking for IDH mutations, and more recently, mutations involving NPM1 or rearrangement of what we used to call the MLL gene, now the lysine methyltransferase 2A or KMT2A rearrangement, where we now have targets. And it's not just for refinement of prognosis, but now we're identifying therapeutic targets for patients and ways to even look for measurable residual disease which is impacting our care. Dr. John Sweetenham: That's great, James. And I'm going to expand on that theme just a little bit and perhaps ask you to elaborate a little bit more on how the introduction of these new therapies have specifically impacted frontline therapy. And a couple of ancillary questions maybe to go along with that: First of all, is ‘7+3' a standard therapy for anybody in 2025? And maybe secondly, you know, could you comment also maybe briefly on older patients with AML and how you think maybe the treatment landscape is changing for them compared with, say, 5 or 10 years ago? Dr. James Foran: I'll start with the therapy and then work my way back. So we've had ‘7+3' cytarabine daunorubicin or cytarabine anthracycline since 1976, and we're still using it as the backbone of our intensive therapy. There is still an important role for it, particularly in younger or fitter patients, and particularly for those with intermediate or favorable risk genetic groups or cytogenetic risk groups just because we achieve high rates of remission. Our 30-day induction mortality rates are lower now than they were 10 and 20 years ago. Our supportive care is better. And we still have a busy inpatient hospital service here at Mayo Florida and my colleagues in Rochester and Arizona as well giving intensive therapy. So that remains the backbone of curative therapy for younger adults. We are trying to be a little more discriminating about who we administer that to. We are trying to add targeted agents. We know from, now, two different randomized trials that the addition of a FLT3 inhibitor, either midostaurin or more recently quizartinib, has a survival advantage in patients with a FLT3 mutation, or for quizartinib, a FLT3/ITD mutation. And so yes, ‘7+3' remains important.  Off protocol for somebody who just comes in with acute leukemia in a 40-year-old or 30-year-old or even early 60s and fit, we would still be considering ‘7+3' therapy and then waiting for an expedited gene mutation panel and an expedited cytogenetics panel to come back to help us discriminate is that a patient for whom we should be giving a FLT3 inhibitor? I think there's a little more nuance about when we do a day 14 bone marrow, do they really matter as much anymore? I still do them. Some of my colleagues find them less important. But we're still giving intensive therapy. We're still giving high-dose ARA-C consolidation for younger patients who achieve complete remission.  In older adults, it's a different story. You know, it was only in the early part of the 2000s – 2004, 2007 range – where we really got buy-in from randomized studies that low-dose therapy was better than no therapy. There was a lot of nihilism before then about therapy for older adults, especially over age 75. We know that low-dose ARA-C is better than nothing. It looked like azacitidine was better than ARA-C or at least equivalent or slightly better. But with the advent of venetoclax it was a game changer. I ran a national randomized study of intensive therapy in AML. It was the last national randomized study of intensive therapy in older patients right before venetoclax got approved. And we were very excited about our results, and we thought we had some really interesting clinical results. And suddenly that's a little bit obsolete in patients over 70 and particularly over age 75 because of the high remission rates with azacytidine venetoclax or hypomethylating agents, so-called HMAs and venetoclax and the survival advantage. Now, it's not a home run for everybody. We quote 60% to 70% remission rates, but it's a little different based on your cytogenetics and your mutation profile. You have to continue on therapy so it's continuous treatment. It's not with curative intent, although there are some people with long-term remission in it. And the median survival went from 10 months to 15 months. So home run? No, but definitely improved remissions, meaningful for patients off transfusions and better survival. So right now it's hard to find an older adult who you wouldn't give azacitidine and venetoclax or something similar, decitabine, for instance, and venetoclax, unless somebody really was moribund or had very poor performance status or some reason not to. And so ‘7+3' is still relevant in younger adults. We're trying to get better results with ‘7+3' by adding targeted agents and azacitine and venetoclax in older adults.  I think the area of controversy, I guess there are two of them, is what to do in that overlap age between 60 and 75. Should people in that age still get intensive therapy, which we've used for years – the VIALE-A trial of aza-venetoclax was age 75 plus – or with cardiac comorbidities? And I think if you're 68 or 72, many of us are starting to bias towards aza-venetoclax as generally being better tolerated, generally being more outpatient, generally being slow and steady way to get a remission. And it doesn't stop you from going to transplant for somebody who might still be a candidate.  The other area of controversy is somebody under 60 who has adverse cytogenetics where we don't do very well with ‘7+3,' we still give it and we might do just as well with decitabine venetoclax. A lot of us feel that there's equipoise in the 60 to 75 group where we really can ask a question of a randomized study. Retrospective studies might suggest that intensive therapy is a little better, but there are now a couple of randomized studies happening saying, “Can we replace ‘7+3' in that intermediate age with aza-venetoclax?” And for younger adults similarly, we're looking to see how we apply that technology. Those are the areas where we're really trying to investigate what's optimal for patients and that's going to require randomized trials. Dr. John Sweetenham: Oh, that's great, thank you. And I'll just extend that question a little bit more, particularly with respect to the new targeted therapies. How much are they impacting the treatment of these patients in the relapse and refractory setting now? Dr. James Foran: Oh, they're definitely impacting it. When I trained and probably when you trained, AML was still a medical emergency. But that was the thing that you admitted to the hospital immediately, you started therapy immediately. The rule was always that's the one thing that brings the fellow and the consultant in at night to see that new patient on a Friday or Saturday. Now, we'll still admit a patient for monitoring, but we try not to start therapy for the first three or five or seven days if they're stable, until we get those genetics and those genomics back, because it helps us discriminate what therapy to pursue. And certainly, with FLT3 mutations, especially FLT3/ITD mutations, we're adding FLT3 inhibitors and we're seeing a survival advantage. Now, on the surface, that survival advantage is in the range of 7% or 10%. But if you then pursue an allogeneic transplant in first remission, you're taking disease where we used to see 30%, 40% long-term survival, maybe less, and you're pushing that to 60%, 70% in some studies. And so we're now taking a disease that– I don't want to get off topic and talk about Ph+ ALL. But that's a disease where we're actually a little excited. We have a target now, and it used to be something really adverse and now we can do a lot for it and a lot about it.  The other mutations, it's a little more subtle. Now, who knew until 2010 that a mutation in a sugar metabolism gene, in isocitrate dehydrogenase, or IDH was going to be so important, or even that it existed. We know that IDH1 and IDH2 mutations are still a minority of AML, certainly less than 10% to 15%, maybe overall. But we're able to target those with specific IDH1 and IDH2 inhibitors. We get single-agent responses. There are now two approved IDH1 inhibitors on the market. We don't yet have the randomized data that adding those to intensive therapy is better, but we're getting a very strong hint that it might be better in older adults who have an IDH mutation, maybe adding those is helpful and maybe adding those to low-intensity therapy is helpful. Those studies are ongoing, and we're also trying with low-intensity treatments to add these agents and get higher remission rates, deeper remissions, longer remissions. I think a lot of work has to be done to delineate the safety of that and the long-term efficacy. But we're getting hints it's better, so I think it is impacting.  The other area it's impacting is when you pick up adverse mutations and those have crept into our classification systems like an ASXL1 mutation or RUNX1 mutation for instance, or some of the secondary AML mutations like BCOR and others, where that's helping us discriminate intermediate-risk patients who we think aren't going to do as well and really helping us select a group who's more likely to get benefit from allogeneic transplant or for whom at least our cure rates without allo transplant are low. And so I think it's impacting a lot. Dr. John Sweetenham: Great. And I'm going to pick up now, if I may, on a couple of things that you've just mentioned and continue the theme of the relapsed and refractory setting. We've started to see some reports which have looked at the role of immune strategies for patients with AML, in particular CAR T or NK cells. Can you comment a little on this and let us know whether you think either these two strategies or other immune strategies are likely to have a significant role in AML in the future? Dr. James Foran: They are, but I think we're still a step behind finding the right target or the right way to do it. If you think of allogeneic transplantation as the definitive immune therapy, and we know for adverse AML we can improve survival rates and cure rates with an allotransplant, then we know inherently that immune therapy matters. And so how do we do what they've done in large cell lymphoma or in CD19 targeting for B cell malignancies? How do we bring that to acute myeloid leukemia? There have been a number of efforts. There have been at least 50 trials looking at different targets. CD33, CD123, CD7, others, CLL-1. So, there have been a number of different trials looking at how to bind a CAR T or a CAR T construct that can be active. And we have hints of efficacy. There was kind of a provocative paper in the New England Journal of Medicine a year ago in April of last year from a Chinese group that looked at a CD7-based CAR T and it was 10 patients, but they used CD7 positive acute leukemia, AML or ALL and had a CD7-targeted CAR T and they actually incorporated that with a haploidentical transplant and they had really high remission rates. People tolerated it quite well. It was provocative. It hasn't yet been reproduced on a larger scale, but the strong hints that the strategy is going to work.  Now, CD33 is a little tricky to have a CAR T when CD33 is expressed on normal hematopoietic cells. CD123 likewise. That's been something where there's, I think, still promise, but we've struggled to find the trials that make that work. Right now, there's a lot of interest in leveraging NK cells and looking, for a couple of reasons, but NK cells are attractive and NK cell markers might be attractive targets. NK cells might have similar degrees of immune efficacy. It's speculative, but they are likely to have less cytokine release syndrome and less neurotoxicity than you see with CAR T. And so it's kind of attractive to leverage that. We have had some ongoing trials looking at it with bispecifics and there certainly are trials looking at it with CAR NK-based strategies. One of the antigens that people looked at is the NK group 2D. NK group 2D or NKG2D is overexpressed in AML and its ligands overexpressed. And so that's a particular potential target. So, John, it's happening and we're looking for the hints of efficacy that could then drive a pivotal trial to get something approved.  One of the other areas is not restricting yourself just to a single antigen. For instance, there is a compound that's looking at a multi-tumor-associated antigen-specific T-cell therapy, looking at multiple antigens in AML that could be overexpressed. And there were some hints of activity and efficacy and actually a new trial looking at a so-called multi-tumor associated antigen-specific T cell therapy. So without getting into specific conflicts of interest or trials, I do think that's an exciting area and an evolving area, but still an investigational area. I'll stop there and say that we're excited about it. A lot of work's going there, but I'm not quite sure which direction the field's going to pivot to there. I think that's going to take us some time to sort out. Dr. John Sweetenham: Yeah, absolutely. But as you say, exciting area and I guess continue to watch this space for now.  So you've mentioned allogeneic stem cell transplants two or three times during this discussion. Recognizing that we don't have an imatinib for AML, which has kind of pushed transplant a long way further back in the treatment algorithm, can you comment a little on, you know, whether you think the role of stem cell transplantation is changing in AML or whether it remains pretty much as it was maybe 10 years ago? Dr. James Foran: By the way, I love that you use imatinib as an introduction because that was 6 TKIs ago, and it tells you the evolution in CML and you know, now we're looking at myristoyl pocket as a target, and so on. That's a great way to sort of show you the evolution of the field.  Allogeneic transplant, it remains a core treatment for AML, and I think we're getting much smarter and much better about learning how to use it. And I'm just going to introduce the topic of measurable residual disease to tell you about that. So I am a little bit of a believer. Part of my job is I support our allogeneic transplant program, although my focus is acute myeloid leukemia, and I've trained in transplant and done it for years and did a transplant fellowship and all that. I'm much more interested in finding people who don't need a transplant than people who do. So I'm sort of looking for where can we move away from it. But it still has a core role. I'll sidestep and tell you there was an MDS trial that looked at intermediate or high-risk MDS and the role of allogeneic transplant that shows that you about double your survival. It was a BMT CTN trial published several years ago that showed you about double your three-year survival if you can find a donor within three months and get to a transplant within six months. And so it just tells you the value of allotransplant and myeloid malignancy in general. In AML we continue to use it for adverse risk disease – TP53 is its own category, I can talk about that separately – but adverse risk AML otherwise, or for patients who don't achieve a really good remission. And I still teach our fellows that an allotransplant decreases your risk of relapse by about 50%. That's still true, but you have to have a group of patients who are at high enough risk of relapse to merit the non-relapse mortality and the chronic graft versus host disease that comes with it. Now, our outcomes with transplant are better because we're better at preventing graft versus host disease with the newer strategies such as post-transplant cyclophosphamide. There are now new FDA-approved drugs for acute and chronic graft versus host disease, ruxolitinib, belumosudil, axatilimab now. So we have better ways of treating it, but we still want to be discriminating about who should get it.  And it's not just a single-minded one-size-fits-all. We learned from the MORPHO study that was published in the JCO last year that if you have FLIT3-positive AML, FLIT3/IDT-positive AML, where we would have said from retrospective studies that your post-transplant survival is 60% give or take, as opposed to 15% or 20% without it, that we can discriminate who should or shouldn't get a transplant. Now that trial was a little bit nuanced because it did not meet its primary endpoint, but it had an embedded randomization based upon MRD status and they used a very sensitive test of measurable residual disease. They used a commercial assay by Invivoscribe that could look at the presence of a FLT3/ITD in the level of 10 to the minus 5th or 10 to the minus 6th. And if you were MRD-negative and you went through a transplant, you didn't seem to get an advantage versus not. That was of maintenance with gilteritinib, I'll just sort of put that on there. But it's telling us more about who should get a transplant and who shouldn't and who should get maintenance after transplant and who shouldn't.  A really compelling study a year ago from I don't know what to call the British group now, we used to call them the MRC and then the NCRI. I'm not quite sure what to call their studies at the moment. But Dr. Jad Othman did a retrospective study a year ago that looked at patients who had NPM1 mutation, the most common mutation AML, and looked to see if you were MRD positive or MRD negative, what the impact of a transplant was. And if you're MRD negative there was not an advantage of a transplant, whereas if you're MRD positive there was. And when they stratified that by having a FLT3 mutation that cracked. If you had a FLT3 mutation at diagnosis but your NPM1 was negative in remission, it was hard to show an advantage of a transplant. So I think we're getting much more discriminating about who should or should not get a transplant by MRD testing for NPM1 and that includes the patients who have a concomitant FLT3 mutation. And we're really trying to learn more and more. Do we really need to be doing transplants in those who are MRD-negative? If you have adverse risk genetics and you're MRD-negative, I'll really need good data to tell me not to do a transplant, but I suspect bit by bit, we'll get that data. And we're looking to see if that's really the case there, too. So measurable residual disease testing is helping us discriminate, but there is still a core role of allogeneic transplant. And to reassure you, compared to, I think your allotransplant days were some time ago if I'm right. Dr. John Sweetenham: Yes. Dr. James Foran: Yeah. Well, compared to when you were doing transplants, they're better now and better for patients now. And we get people through graft versus host disease better, and we prevent it better. Dr. John Sweetenham: That's a great answer, James. Thanks for that. It really does help to put it in context, and I think it also leads us on very nicely into what's going to be my final question for you today and perhaps the trickiest, in a way. I think that everything you've told us today really emphasizes the fact that the complexity of AML treatment has increased, primarily because of an improved understanding of the molecular landscape of the disease. And it's a complicated area now. So do you have any thoughts on what type of clinical environment patients with AML should be evaluated and treated in in 2025? Dr. James Foran: Yeah, I want to give you a kind of a cautious answer to that because, you know, I'm a leukemia doctor. I work at a leukemia center and it's what we focus on. And we really pride ourselves on our outcomes and our diagnostics and our clinical trials and so on. I am very aware that the very best oncologists in America work in private practice and work in community practice or in networks, not necessarily at an academic site. And I also know they have a much harder job than I have. They have to know lung cancer, which is molecularly as complicated now as leukemia, and they have to know about breast cancer and things that I don't even know how to spell anymore. So it's not a question of competence or knowledge. It's a question of infrastructure. I'll also put a little caveat saying that I have been taught by Rich Stone at Dana-Farber, where I did a fellowship a long time ago, and believe Rich is right, that I see different patients than the community oncologists see with AML, they're seeing different people. But with that caveat, I think the first thing is you really want to make sure you've got access to excellence, specialized hematopathology, that you can get expedited cytogenetics and NGS testing results back. There was a new drug, approved just a few months ago, actually, for relapsed AML with a KMT2A rearrangement, revumenib. We didn't talk about the menin inhibitors. I'll mention them in just a second. That's a huge area of expansion and growth for us. But they're not found on NGS platforms. And normal cytogenetics might miss a KMT2A-rearrangement. And we're actually going back to FISH panels, believe it or not, on AML, to try to identify who has a KMT2A-rearrangement. And so you really want to make sure you can access the diagnostic platforms for that.  I think the National Referral Labs do an excellent job. Not always a really fast job, but an excellent job. At my institution, I get NGS results back within three days or four days. We just have an expedited platform. Not everybody has that. So that's the key, is you have to be able to make the diagnosis, trust the pathologist, get expedited results. And then it's the question of trying to access the targeted medications because a lot of them are not carried in hospital on formulary or take time to go through an insurance approval process. So that's its own little headache, getting venetoclax, getting gilteritinib, getting an IDH1 inhibitor in first line, if that's what you're going for. And so I think that requires some infrastructure. We have case managers and nurses who really expedite that and help us with it, but that's a lot of work. The other piece of the puzzle is that we're still with AML in the first month and maybe even the second month. We make everybody worse before we make them better. And you have to have really good blood bank support. I can give an outpatient platelet transfusion or red cell transfusion seven days a week. We're just built for that. That's harder to do if you're in a community hospital and you have to be collaborating with a local blood bank. And that's not always dead easy for somebody in practice. So with those caveats, I do find that my colleagues in community practice do a really good job making the diagnosis, starting people on therapy, asking for help. I think the real thing is to be able to have a regional leukemia center that you can collaborate with, connect with, text, call to make sure that you're finding the right patients who need the next level of diagnostics, clinical trial, transplant consults, to really get the best results.  There was some data at ASH a couple of years ago that looked at – the American Society of Hematology and ASCOs had similar reports – that looked at how do we do in academic centers versus community practice for keeping people on therapy. And on average, people were more likely to get six cycles of therapy instead of three cycles of therapy with azacitidine venetoclax at an academic center. Now, maybe it's different patients and maybe they had different cytogenetics and so on, but I think you have to be patient, I think you have to collaborate. But you can treat those patients in the community as long as you've got the infrastructure in place. And we've learned with virtual medicine, with Zoom and other platforms that we can deliver virtual care more effectively with the pandemic and beyond. So I think we're trying to offer virtual consults or virtual support for patients so they can stay in their home, stay in their community, stay with their oncologists, but still get access to excellent diagnostics and supportive care and transplant consults, and so on. I hope that's a reasonable answer to that question. It's a bit of a nuanced answer, which is, I think there's an important role of a leukemia center, and I think there's a really fundamental role of keeping somebody in the community they live in, and how we collaborate is the key to that. And we've spent a lot of time and effort working with the oncologists in our community to try to accomplish that.  John, I want to say two other things. I didn't mention in the molecular platforms that NPM1 mutations, we can now target those on clinical trials with menin inhibitors. We know that NPM1 signals through the Hoxa9/Meis1 pathway. We know that similar pathways are important in KMT2A rearrangements. We know that there are some other rare leukemias like those with NUP98 rearrangement. We can target those with menin inhibitors. The first menin inhibitor, revuminib, was approved by the FDA for KMT2A. We have others going to the FDA later this year for NPM1. There are now pivotal trials and advanced expanded phase 1/2 studies that are showing 30% response rates. And we're looking to see can we add those into the first-line therapy. So, we're finding more targets.  I'll say one last thing about molecular medicine. I know I'm a little off topic here, but I always told patients that getting AML was kind of like being struck by lightning. It's not something you did. Now, obviously, there are risk factors for AML, smoking or obesity or certain farm environments, or radioactive exposures and so on. But bit by bit, we're starting to learn about who's predisposed to AML genetically. We've identified really just in the last five or eight years that DDX41 mutations can be germline half the time. And you always think germline mutations are going to cause AML in a younger patient, but the median age is 60 to 70 just like other AMLs. They actually might do pretty well once they get AML. We've reported that in several papers. And so we're trying to understand who that has a RUNX1 mutation needs germline testing, who with a DDX41 needs germline testing. And we're trying to actually come up with a cleaner pathway for germline testing in patients to really understand predisposition, to help with donor selection, to help with family counseling. So I think those are other areas where a leukemia center can contribute for somebody in who's community practice to understand genomic or genetic complexity in these patients. And we're starting to develop the databases that support that. Dr. John Sweetenham: Yeah, great. Thanks, James. I loved your answer about the clinical environment too. And I know from a patient-centric perspective that I know that patients would certainly appreciate the fact that we're in a situation now where the folks taking care of them will make every effort to keep them close to home if they possibly can.  I want to thank you, James, for an incredible review of a very complex subject and I think you did a great job. I think we all will have learned a lot. And thanks again for being willing to share your insights with us today on the ASCO Daily News Podcast. Dr. James Foran: John, it's my pleasure. And as you know, I'll do anything for a latte, so no problem at all. Dr. John Sweetenham: Okay. I owe you one, so thank you for that.  And thank you to our listeners for your time today. You'll find links to the studies we've discussed today in the transcript of this episode. And finally, if you value the insights that you hear on the ASCO Daily News Podcast, please take a moment to rate, review and subscribe wherever you get your podcasts. Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement. Find out more about today's speakers:  Dr. John Sweetenham  Dr. James Foran Follow ASCO on social media: @ASCO on Twitter ASCO on Bluesky ASCO on Facebook  ASCO on LinkedIn  Disclosures:    Dr. John Sweetenham:    No relationships to disclose Dr. James Foran: Stock and Other Ownership Interests: Aurinia Pharmaceuticals Consulting or Advisory Role: Peerview, CTI BioPharma Corp, Remix Therapeutics, Cardinal Health, Medscape, Syndax, Autolus Therapeutics Research Funding (Inst.): Chordia Therapeutics, Abbvie, Actinium Pharmaceuticals, Kura Oncology, Sellas Life Sciences, Novartis, Roivant, Celgene/Bristol-Myers Squibb, Astellas Pharma, SERVIER Travel, Accommodations, Expenses: Peerview

In this podcast, we bring you exclusive updates in acute myeloid leukemia (AML) from the 66th American Society of Hematology... The post Post-ASH AML highlights: novel approaches to frontline therapy, advances with menin inhibitors, & managing FLT3-ITD+ AML appeared first on VJHemOnc.

BUFFALO, NY- October 23, 2024 – A new #editorial was #published in Oncotarget's Volume 15 on October 11, 2024, entitled, “Gene regulatory network and signalling pathway rewiring: How blood cancer cells shift their shapes to evade drug treatment.” As highlighted in the paper, Acute Myeloid Leukemia (AML) is a complex and diverse disease caused by multiple mutations in genes that regulate transcription and growth. These mutations lead to extensive rewiring of the gene regulatory network (GRN), which alters the identity of hematopoietic stem and progenitor cells, ultimately blocking normal myeloid differentiation. A key feature of AML is the presence of mutations in growth factor receptor and signaling genes, such as FLT3, KIT, and RAS. Notably, FLT3 is one of the most commonly mutated genes in AML, with around 25% of cases showing an internal tandem duplication (ITD) that causes the receptor to remain constantly active. In their paper, researchers Constanze Bonifer and Peter N. Cockerill from the Institute of Cancer and Genomic Sciences at the University of Birmingham, UK, and the Murdoch Children's Research Institute, Royal Children's Hospital in Melbourne, Australia, discuss recent publications from their group addressing this issue through a multi-omics study. The authors investigated how gene regulatory networks (GRNs) in FLT3-ITD patients were rewired compared to normal cells and in response to FLT3 inhibitor treatment. Several key findings stood out, including: 1) Mapping of open chromatin regions revealed that patients initially responsive to FLT3 inhibition showed significant rewiring of their GRNs, forming new connections between transcription factors (TFs) and target genes, while non-responsive patients did not; 2) Chromatin immunoprecipitation (ChIP) experiments showed that drug treatment led to the loss of binding of RUNX1, the master regulator of hematopoiesis, and the MAP-Kinase (MAPK)-inducible TF AP-1; 3) Disruption of AP-1 binding via a dominant-negative version of the TF (dnFOS) also abolished RUNX1 binding at hundreds of sites, indicating that RUNX1 binding is AP-1 dependent; and 4) Inhibition of both AP-1 and RUNX1 led to a pronounced cell cycle block. “In summary, drugs that target individual signalling pathways in AML often fail to stop proliferation malignant growth, due to the wide variety, redundancy and cross talk between multiple pathways regulating and differentiation.” DOI - https://doi.org/10.18632/oncotarget.28662 Correspondence to - Constanze Bonifer - constanze.bonifer@mcri.edu.au Video short - https://www.youtube.com/watch?v=5c_uT6aE36A Sign up for free Altmetric alerts about this article: https://oncotarget.altmetric.com/details/email_updates?id=10.18632%2Foncotarget.28662 Subscribe for free publication alerts from Oncotarget: https://www.oncotarget.com/subscribe/ Keywords - cancer, acute myeloid leukemia, gene regulatory networks, aberrant growth factor signaling, transcription, RUNX1/AP-1 axis About Oncotarget Oncotarget (a primarily oncology-focused, peer-reviewed, open access journal) aims to maximize research impact through insightful peer-review; eliminate borders between specialties by linking different fields of oncology, cancer research and biomedical sciences; and foster application of basic and clinical science. Oncotarget is indexed and archived by PubMed/Medline, PubMed Central, Scopus, EMBASE, META (Chan Zuckerberg Initiative) (2018-2022), and Dimensions (Digital Science). To learn more about Oncotarget, please visit https://www.oncotarget.com and connect with us: Facebook - https://www.facebook.com/Oncotarget/ X - https://twitter.com/oncotarget Instagram - https://www.instagram.com/oncotargetjrnl/ YouTube - https://www.youtube.com/@OncotargetJournal LinkedIn - https://www.linkedin.com/company/oncotarget Pinterest - https://www.pinterest.com/oncotarget/ Reddit - https://www.reddit.com/user/Oncotarget/ Spotify - https://open.spotify.com/show/0gRwT6BqYWJzxzmjPJwtVh

In this week's episode we'll learn about iron, HFE hemochromatosis, and infections. In this large, population-based study, both high and low levels of plasma iron and transferrin saturation were associated with increased risks of infection. Then, we'll discuss how bispecific antibodies improve CAR T-cell response in B-cell malignancies. In-vitro and in-vivo data demonstrate enhanced therapeutic efficacy when a CD20-directed bispecific antibody is given in combination with CD19-directed CAR-T cells. Finally, we'll hear about determinants of outcome in NPM1-mutated AML. In a large series of patients with NPM1-mutated AML, investigators identified several variables beyond FLT3-ITD that adversely impacted outcomes. Featured Articles:Iron, hemochromatosis genotypes, and risk of infections: a cohort study of 142 188 general population individualsMolecular, clinical, and therapeutic determinants of outcome in NPM1-mutated AMLCD20-bispecific antibodies improve response to CD19-CAR T cells in lymphoma in vitro and CLL in vivo models

BUFFALO, NY- July 2, 2024 – A new editorial paper was published in Oncotarget's Volume 15 on June 20, 2024, entitled, “Genomics has more to reveal.” In this new editorial, researchers Laurène Fenwarth and Nicolas Duployez from the University of Lille and CHU Lille discuss molecular and cytogenetic analyses that are now used to identify mutations and structural variants defining distinct subtypes of acute myeloid leukemias (AML) and myelodysplastic syndromes (MDS). These genetic considerations have become essential for risk stratification and the selection of appropriate treatments, including the use of allogeneic hematopoietic stem cell transplantation. “Despite over 15 years of genomic research since the first publication of the AML genome and large studies like The Cancer Genome Atlas (TCGA) [2], around 15% of AML cases remained genetically unclassifiable with current knowledge.” Notably, several studies in both adults and children identified a subset of AML without known initiating events but particularly enriched in FLT3- ITD and WT1 mutations, and normal karyotypes with an overall unfavorable prognosis. In 2021–2022, notably thanks to advancements in bioinformatic approaches and tools, recurrent somatic tandem duplications (TD) of a portion of the UBTF gene were identified in high-risk pediatric AML cases. “With increased screenings of retrospective cohorts, the characteristics associated with this molecular alteration have since been confirmed. UBTF-TD are considered initiating events in leukemogenesis and define a distinct entity of myeloid malignancies.” DOI - https://doi.org/10.18632/oncotarget.28596 Correspondence to - Nicolas Duployez - nicolas.duployez@chu-lille.fr Video short - https://www.youtube.com/watch?v=WVY_ejhr7Fc Sign up for free Altmetric alerts about this article - https://oncotarget.altmetric.com/details/email_updates?id=10.18632%2Foncotarget.28596 Subscribe for free publication alerts from Oncotarget - https://www.oncotarget.com/subscribe/ Keywords - cancer, acute myeloid leukemia, genomics, UBTF About Oncotarget Oncotarget (a primarily oncology-focused, peer-reviewed, open access journal) aims to maximize research impact through insightful peer-review; eliminate borders between specialties by linking different fields of oncology, cancer research and biomedical sciences; and foster application of basic and clinical science. Oncotarget is indexed and archived by PubMed/Medline, PubMed Central, Scopus, EMBASE, META (Chan Zuckerberg Initiative) (2018-2022), and Dimensions (Digital Science). To learn more about Oncotarget, please visit https://www.oncotarget.com and connect with us: Facebook - https://www.facebook.com/Oncotarget/ X - https://twitter.com/oncotarget Instagram - https://www.instagram.com/oncotargetjrnl/ YouTube - https://www.youtube.com/@OncotargetJournal LinkedIn - https://www.linkedin.com/company/oncotarget Pinterest - https://www.pinterest.com/oncotarget/ Reddit - https://www.reddit.com/user/Oncotarget/ Spotify - https://open.spotify.com/show/0gRwT6BqYWJzxzmjPJwtVh Media Contact MEDIA@IMPACTJOURNALS.COM 18009220957

At the 2024 European Hematology Association (EHA) Congress, CancerNetwork® spoke with a variety of experts in the hematologic oncology space about optimizing outcomes across different patient populations and subgroups based on updated research they presented at the meeting.  Manali Kamdar, MD, an associate professor of medicine-hematology and clinical director of Lymphoma Services at the University of Colorado Anschutz Medical Campus, in Colorado, spoke about data from the phase 1 TRANSCEND NHL 001 trial (NCT02631044) supporting the use of lisocabtagene maraleucel (liso-cel; Breyanzi) in earlier lines of therapy for patients with relapsed/refractory mantle cell lymphoma (MCL).1  Specifically, Kamdar highlighted how research should continue to focus on the potential utility of liso-cel in MCL subgroups such as those with TP53 mutations or blastoid morphology. Additionally, she stated that liso-cel may need to be further tested in earlier lines of therapy for patients with diffuse large B-cell lymphoma, including those with double-hit lymphoma. Michael R. Grunwald, MD, chief of the Leukemia Division and director of the Transplantation and Cellular Therapy Program at Atrium Health's Levine Cancer Institute, in North Carolina, discussed findings from the Prospective Observational Study of Patients With Polycythemia Vera (PV) in US Clinical Practices Trial (REVEAL) exploring risk factors for disease progression in patients with polycythemia vera (PV).2 According to Grunwald, a history of thromboembolic events, elevated white blood cell counts, and higher variant allele frequencies may contribute to a patient's likelihood of experiencing progression to myelofibrosis or acute myeloid leukemia (AML). Additionally, he highlighted ongoing research into the potential molecular factors that may prognosticate disease transformation in PV among a small cohort of patients enrolled on the REVEAL trial.3 Harry P. Erba, MD, PhD, a professor of medicine in the Division of Hematologic Malignancies and Cellular Therapy and the director of the Leukemia Program and Phase I Development in Hematologic Malignancies at Duke Cancer Institute, in North Carolina, discussed the clinical implications of data from the phase 3 QuANTUM-First study (NCT02668653).4  Specifically, findings demonstrated that continuation therapy with quizartinib (Vanflyta) elicited a more pronounced survival benefit vs placebo in patients with newly diagnosed FLT3-ITD–positive AML who did not undergo allogeneic hematopoietic stem cell transplant (allo-HSCT). However, Erba noted that survival outcomes were not significantly different in the quizartinib and placebo arms among patients who received allo-HSCT. References 1.        Palomba ML, Siddiqi T, Gordon LI, et al. Subgroup analyses in patients with R/R MCL treated with lisocabtagene maraleucel by prior lines of therapy and response to Bruton tyrosine kinase inhibitor from the TRANSCEND NHL 001 MCL cohort. Presented at the European Hematology Association (EHA) 2024 Congress; Madrid, Spain; June 13-16, 2024. P1126. 2.        Grunwald M, Zwicker J, Gerds A, et al. A real-world evaluation of risk factors for disease progression in patients with polycythemia vera (PV) enrolled in REVEAL. Presented at the 2024 European Hematology Association (EHA) Congress; June 13-16, 2024; Madrid, Spain. Abstract P1047. 3.        Crowgey E, Timmers C, Xue Z, et al. Analysis of molecular mechanisms and predictive biomarkers of disease transformation in polycythemia vera. Presented at the 2024 European Hematology Association (EHA) Congress; June 13-16, 2024; Madrid, Spain. Abstract S217. 4.        Sekeres MA, Erba H, Montesinos P, et al. QuANTUM-First: efficacy in newly diagnosed patients with FMS-like tyrosine kinase 3-internal tandem duplication–positive (FLT3-ITD+) acute myeloid leukemia (AML) who received continuation therapy. Presented at the 2024 European Hematology Association (EHA) Congress; June 13-16, 2024; Madrid, Spain. Abstract S142.

Michael Heuser, MD - Case Study Challenge: Managing FLT3-ITD–Positive AML

Michael Heuser, MD - Case Study Challenge: Managing FLT3-ITD–Positive AML

BUFFALO, NY- March 25, 2024 – A new #research paper was #published in Oncotarget's Volume 15 on March 14, 2024, entitled, “ABT199/venetoclax synergism with thiotepa enhances the cytotoxicity of fludarabine, cladribine and busulfan in AML cells.” ABT199/venetoclax, an inhibitor of the pro-survival BCL-2 protein, has improved AML treatment. Its efficacy in hematopoietic stem cell transplantation (HSCT), when combined with other chemotherapeutic drugs, has not been thoroughly investigated. In this new study, researchers Benigno C. Valdez, Bin Yuan, David Murray, Jeremy L. Ramdial, Uday Popat, Yago Nieto, and Borje S. Andersson from The University of Texas MD Anderson Cancer Center and the University of Alberta demonstrate the synergistic cytotoxicity of ABT199/venetoclax with the DNA alkylator thiotepa (Thio) in AML cells. “The results may provide relevant information for the design of clinical trials using these drugs to circumvent recognized drug-resistance mechanisms when used as part of pre-transplant conditioning regimens for AML patients undergoing allogenic HSCT.” Cleavage of Caspase 3, PARP1 and HSP90, as well as increased Annexin V positivity, suggest potent activation of apoptosis by this two-drug combination; increased levels of γ-H2AX, P-CHK1 (S317), P-CHK2 (S19) and P-SMC1 (S957) indicate an enhanced DNA damage response. Likewise, the increased level of P-SAPK/JNK (T183/Y185) and decreased P-PI3Kp85 (Y458) suggest enhanced activation of stress signaling pathways. These molecular readouts were synergistically enhanced when ABT199/venetoclax and Thio were combined with fludarabine, cladribine and busulfan. The five-drug combination decreased the levels of BCL-2, BCL-xL and MCL-1, suggesting its potential clinical relevance in overcoming ABT199/venetoclax resistance. Moreover, this combination is active against P53-negative and FLT3-ITD-positive cell lines. Enhanced activation of apoptosis was observed in leukemia patient-derived cell samples exposed to the five-drug combination, suggesting a clinical relevance. “The results provide a rationale for clinical trials using these two- and five-drug combinations as part of a conditioning regimen for AML patients undergoing HSCT.” DOI - https://doi.org/10.18632/oncotarget.28563 Correspondence to - Benigno C. Valdez - mbalasik@yahoo.com Sign up for free Altmetric alerts about this article - https://oncotarget.altmetric.com/details/email_updates?id=10.18632%2Foncotarget.28563 Subscribe for free publication alerts from Oncotarget - https://www.oncotarget.com/subscribe/ Keywords - cancer, acute myeloid leukemia, aml, pre-transplant regimens, venetoclax, thiotepa, busulfan About Oncotarget Oncotarget (a primarily oncology-focused, peer-reviewed, open access journal) aims to maximize research impact through insightful peer-review; eliminate borders between specialties by linking different fields of oncology, cancer research and biomedical sciences; and foster application of basic and clinical science. Oncotarget is indexed and archived by PubMed/Medline, PubMed Central, Scopus, EMBASE, META (Chan Zuckerberg Initiative) (2018-2022), and Dimensions (Digital Science). To learn more about Oncotarget, please visit https://www.oncotarget.com and connect with us: Facebook - https://www.facebook.com/Oncotarget/ X - https://twitter.com/oncotarget Instagram - https://www.instagram.com/oncotargetjrnl/ YouTube - https://www.youtube.com/@OncotargetJournal LinkedIn - https://www.linkedin.com/company/oncotarget Pinterest - https://www.pinterest.com/oncotarget/ Reddit - https://www.reddit.com/user/Oncotarget/ Spotify - https://open.spotify.com/show/0gRwT6BqYWJzxzmjPJwtVh Media Contact MEDIA@IMPACTJOURNALS.COM 18009220957

Featuring perspectives from Dr Richard M Stone, including the following topics:  • Introduction: ASH 2023 Update — Key Oral Presentations (0:00) • Case: A woman in her early 90s with dementia who presented with anemia and was diagnosed with low-risk myelodysplastic syndromes (MDS) with ring sideroblasts, now receiving luspatercept — Eric H Lee, MD, PhD (9:09) • Case: An African American woman in her early 60s with high-risk del(5q) MDS who receives oral decitabine/cedazuridine — Henna Malik, MD (26:05) • Case: A man in his late 60s with therapy-related acute myeloid leukemia (AML) with a FLT3-ITD mutation — Rebecca L Olin, MD, MSCE (34:49) • Case: A woman in her early 70s with PMH of inflammatory breast cancer diagnosed with FLT3-ITD AML who achieved a complete response (CR) with azacitidine/venetoclax, followed by gilteritinib maintenance for 2 years — Zanetta S Lamar, MD (40:43) • Case: A man in his mid 30s who presents with pathologic spinal fracture, is diagnosed with myeloid sarcoma and receives induction CLAG-M with CR followed by consolidation high-dose cytarabine — Anna Halpern, MD (43:56) • Case: A man in his mid 80s with MDS, complex cytogenetics and a TP53 mutation treated with azacitidine/venetoclax — Neil Morganstein, MD (46:40) • Case: A woman in her early 70s with newly diagnosed, poor-risk AML, ineligible for intensive chemotherapy (ECOG PS 2) who receives a hypomethylating agent/venetoclax — Amany R Keruakous, MD, MS (49:56) • Case: A man in his early 70s with relapsed AML (SRSF2, IDH1, ASXL1 mutations) after azacitidine/venetoclax, now receiving ivosidenib — Dr Halpern (55:23)   CME information and select publications  

On today's episode we'll discuss the findings from a phase 2 study of sorafenib plus intensive chemotherapy in newly diagnosed FLT3-ITD AML, learn more about the inhibition of PLK4 in TP53-mutated AML, and discuss the role of CD44 in Plasmodium falciparum infection.

In this episode, we dive into the management of newly diagnosed and relapsed FLT3-positive AML with Dr. Alexander Perl.Here are the shownotes:1. Assessment of minimal residual disease in standard-risk AML https://www.nejm.org/doi/full/10.1056/nejmoa1507471 2. RATIFY study: Midostaurin plus chemotherapy for AML with a FLT3 mutationhttps://www.nejm.org/doi/full/10.1056/nejmoa1614359 3. QuANTUM-First trial: Quizartinib plus chemotherapy in newly diagnosed patients with FLT3-internal-tandem-duplication-positive acute myeloid leukaemia (QuANTUM-First): a randomised, double-blind, placebo-controlled, phase 3 trialhttps://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00464-6/fulltext 4. Benefit of high-dose daunorubicin in AML induction extends across cytogenetic and molecular groupshttps://ashpublications.org/blood/article/127/12/1551/35035/Benefit-of-high-dose-daunorubicin-in-AML-induction 5. Prospective Randomized Comparison of Idarubicin and High-Dose Daunorubicin in Induction Chemotherapy for Newly Diagnosed Acute Myeloid Leukemiahttps://ascopubs.org/doi/10.1200/JCO.2017.72.8618?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed 6. Phase 3 trial of gilteritinib plus azacitidine vs. azacitidine for newly diagnosed FLT3mut+ AML ineligible for intensive chemotherapyhttps://ashpublications.org/blood/article/140/17/1845/486088/Phase-3-trial-of-gilteritinib-plus-azacitidine-vs 7. ADMIRAL: Gilteritinib or Chemotherapy for Relapsed or Refractory FLT3-Mutated AMLhttps://www.nejm.org/doi/full/10.1056/nejmoa1902688 8. Venetoclax Plus Gilteritinib for FLT3-Mutated Relapsed/Refractory Acute Myeloid Leukemiahttps://ascopubs.org/doi/10.1200/JCO.22.00602?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed 9. Levis MJ, Hamadani M, Logan B, et al: BMT-CTN 1506 (MORPHO): A randomized trial of the FLT3 inhibitor gilteritinib as post-transplant maintenance for FLT3-ITD AML. EHA 2023 Hybrid Congress. Abstract LB2711. Presented June 11, 2023. 10. Sorafenib maintenance in patients with FLT3-ITD acute myeloid leukaemia undergoing allogeneic haematopoietic stem-cell transplantation: an open-label, multicentre, randomised phase 3 trial https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(20)30455-1/fulltext?dgcid=raven_jbs_etoc_email

Our faculty discuss the importance of biomarker testing for FLT3 and FLT3-ITD and the prognostic impact for these patients, especially now that there are therapies targeting these mutations. Visit www.morningcommutepodcast.com/aml1 to view the activity and CME/CE information, download the transcript, and complete the post-test and evaluation to earn CME/CE credit.

Featuring perspectives from Dr Gail J Roboz, including the following topics: Introduction (0:00) Case: A man in his early 50s presents with fatigue and pancytopenia; bone marrow shows myelodysplastic syndromes (MDS) with 11% blasts; normal FISH MDS panel; next-generation sequencing shows BCOR, RUNX1 and UTAF1 mutations; normal metaphase cytogenetics — Warren S Brenner, MD (10:12) Case: An African American woman in her early 60s with high-risk MDS receives oral decitabine/cedazuridine — Henna Malik, MD (16:39) Case: A woman in her early 70s with anemia and low-grade MDS with ring sideroblasts experiences a poor response to erythropoietin and is now on luspatercept — Neil Morganstein, MD (22:15) Case: A woman in her early 60s with newly diagnosed acute myeloid leukemia (AML) and a FLT3-ITD mutation receives 7 + 3 induction with midostaurin induction, consolidation, allogeneic transplant and maintenance — Amany R Keruakous, MD, MS (35:23) Case: A man in his mid 60s with AML and an IDH1 mutation receives venetoclax/azacitidine/ivosidenib — Rebecca L Olin, MD, MSCE (53:23) Case: A woman in her late 30s with refractory leiomyosarcoma develops anthracycline-related secondary AML with an IDH2 mutation and is unable to obtain foundation funding assistance for enasidenib copays — Eric H Lee, MD, PhD (56:48) CME information and select publications

Featuring perspectives from Dr Naval Daver, including the following topics: Introduction: Biology, Classification, p53, Magrolimab (0:00) Case: A man in his early 70s with acute myeloid leukemia (AML) with a TP53 mutation, myelodysplastic syndromes (MDS)-related changes and complex cytogenetics who received CPX-351receives azacitidine/venetoclax and is now in palliative care — Anna Halpern, MD (9:06) Case: A woman in her late 50s with multiple comorbidities and FLT3-ITD-positive AML who experienced disease progression on azacitidine/venetoclax now receives gilteritinib — Bhavana (Tina) Bhatnagar, DO (17:01) Case: A woman in her early 70s with AML with FLT3-ITD and IDH1 mutations receives a hypomethylating agent with ivosidenib — Amany R Keruakous, MD, MS (29:10) Case: A man in his early 60s with newly diagnosed MDS with ring sideroblasts receives oral decitabine/cedazuridine — Khuda Dad Khan, MD, PhD (33:54) Case: A man in his mid 60s presents with copper deficiency and ring sideroblasts; genetic analysis reveals SF3B1 and DNMT3A mutations — Rachel J Cook, MD (42:25) Case: A woman in her early 70s with a history of extensively treated follicular lymphoma develops AML and receives CPX-351 — Ranju Gupta, MD (46:05) Case: A woman in her late 70s with newly diagnosed AML receives decitabine/venetoclax with concurrent voriconazole — Rebecca L Olin, MD, MSCE (51:05) Case: A woman in her late 90s is diagnosed with multiple myeloma and del(5q) MDS — Erik Rupard, MD (54:26) Journal Club with Dr Daver (57:28) CME information and select publications

Dr Sekeres discusses the FDA approval of quizartinib plus chemotherapy in patients with newly diagnosed, FLT3-ITD–positive AML, key efficacy and safety data from the QuANTUM-First trial, and how this quizartinib regimen addresses an unmet need for older patients in this population.

 In this week's New FDA Approval's podcast episode, Dr. Emma Hitt Nichols discusses the latest FDA approvals from July 17, 2023 – July 21, 2023.  Please check back every Monday morning so that you can stay up to date.  Here are the highlights:   Vanflyta® for FLT3-ITD+ AML The FDA has approved Vanflyta (quizartinib), developed by Daiichi Sankyo, for treating adult patients with acute myeloid leukemia (AML) having the FLT3-ITD mutation. The approval came after data from the QuANTUM-First trial showed improved overall survival rates when Vanflyta was added to treatment. This makes Vanflyta the third drug approved for FLT3-positive AML, joining Novartis' Rydapt® and Astellas Pharma's Xospata®.   BeyfortusTM for RSV AstraZeneca's BeyfortusTM (nirsevimab) has been approved by the FDA for preventing respiratory syncytial virus (RSV) lower respiratory tract disease in neonates, infants, and children up to 24 months of age. The approval was supported by data from three clinical trials, and the drug has also been given a fast-track designation. Beyfortus becomes the second antibody available for RSV protection in young children, following palivizumab or Synagis®. Cyfendus Anthrax Vaccine The FDA has approved CyfendusTM (Anthrax Vaccine Adsorbed, Adjuvanted) for post-exposure prophylaxis following exposure to Bacillus anthracis, the bacterium causing Anthrax, in adults aged 18 to 65. The vaccine is administered in two doses, two weeks apart, and clinical trials have found it to be non-inferior to the already available BioThrax® vaccine. Cyfendus has been in use since 2019 under a pre-emergency use authorization. YcanthTM for Molluscum Contagiosum The FDA has approved Verrica Pharmaceuticals' YcanthTM (cantharidin) topical solution for treating molluscum contagiosum in patients aged 2 and older. The approval is based on results from two identical phase 3 trials involving over 500 patients. Despite being available via compounding sources for years, Ycanth is the first FDA-approved standardized product for molluscum contagiosum. This podcast is brought to you by Nascent Medical. If you're a project manager at a CME or medical communications agency and need on-call medical writing assistance please visit Nascent Medical. We are a team of MD- and PhD-level medical writers and can create slide decks, white papers, ad board summaries, manuscripts, needs assessments, and much more. We also do medical editing using AMA style and factchecking. Visit Nascent Medical. Intro and outro music Garden Of Love by Pk jazz Collective

In this week's episode we will review a study in sub-Saharan Africa where treatment of sickle cell anemia with hydroxyurea is associated with a lower incidence of malaria. New research suggests mild myelosuppression associated with hydroxyurea treatment may actually have a salutary effect. Next, a potential new treatment approach in lower GI acute GVHD. Adding an interleukin-22 therapy to corticosteroid treatment was well tolerated with a high rate of response in this very challenging patient population. Finally, common AML driver mutations such as FLT3ITD (or internal tandem duplications) orchestrate distinct transcriptional and epigenetic programs based on different genetic contexts. In the context of a common pediatric AML mutation, FLT3ITD selectively activated type I interferon signaling, suggesting a distinct therapeutic vulnerability.

Featuring perspectives from Dr Rebecca Olin, including the following topics: Introduction: Journal Club with Rebecca L Olin, MD, MSCE — Evaluation of the older patient with acute myeloid leukemia (AML) (0:00) Case: A woman in her late 80s with transfusion-dependent AML secondary to myelodysplastic syndrome — Raman Sood, MD (7:52) Case: A frail man in his mid 70s with newly diagnosed poor-risk AML with FLT3-ITD and IDH1 mutations — Amany R Keruakous, MD, MS (12:46) Case: A woman in her late 60s with relapsed AML and a FLT3-ITD mutation — Prashant Sharma, MD (18:23) Case: A man in his late 50s with AML receives 7 + 3 induction prior to discovery of complex cytogenetics — Rachel J Cook, MD (22:04) ASH 2021 review — Part 1 (25:07) Case: A man in his early 70s with relapsed AML and an IDH2 mutation — Erik J Rupard, MD (29:13) Case: A man in his late 50s with therapy-related AML and an IDH2 mutation — Bhavana (Tina) Bhatnagar, DO (32:28) Case: A woman in her mid 40s with newly diagnosed poor-risk AML and an ejection fraction of 35% — Dr Keruakous (32:28) ASH 2021 review — Part 2 (39:28) Faculty survey (58:32) CME information and select publications

Featuring perspectives from Dr Amir Fathi, including the following topics: Introduction: Differentiation Syndrome (0:00) Case: A woman in her late 70s who received decitabine/venetoclax for acute myeloid leukemia (AML) — Bhavana (Tina) Bhatnagar, DO (14:24) Case: A man in his early 30s with AML harboring a FLT3-ITD mutation with an allelic ratio of 0.6 and NPM1 and IDH2 mutations — Jeanne Palmer, MD (24:04) Case: A woman in her late 70s with ovarian cancer who develops AML with a TP53 mutation and a complex karyotype — Dr Bhatnagar (33:37) Case: A woman in her mid-30s with inversion 16 AML — Dr Palmer (46:33) Faculty Survey (50:05) Journal Club with Amir Fathi, MD (57:25) CME information and select publications

Molecular Testing PearlsIn Part 4 of our Heme Path series, we thoroughly examine the details of molecular testing and how it relates to hematologic and oncologic malignancies I. Molecular Testing BasicsA. Provides a means of assessing patient's genotypes, specifically at smaller changes in the genetic information B. How is it performed?1. Polymerase chain reaction (PCR)-based testing, which involves using a specific primer that is complementary to the area of interest on the patient's DNA2. PCR can allow for both amplification and quantification of gene of interest C. Can look for either single gene mutations (faster) or a panel of mutations (slower but more information) also known as NGSII. Clinical Utility of Molecular TestingA. Very useful in risk stratification based on the mutations noted (some mutations are unfavorable and some are favorable)B. Certain genetic mutations have drugs that are effective against them, therefore provides information about targeted therapeutic options C. In hematologic malignancies, can be used to also assess response to treatment1. You can determine minimal residual disease or MRD2. Can look for a gene mutation that was present in the original cancer clone and see if there is any amount of residual cancer left over on the order of 1 in a million cellsD. In solid cancers, used to determine presence of genetic changes that have prognostic and targeted treatment implications1. BRAF V600E mutation in melanoma → BRAF inhibitor pill treatment2. EGFR mutation in lung cancer → EGFR inhibitor pill treatmentIII. How is molecular testing different than FISH?A. Both require choosing probes and understanding what you are looking for before running the testB. FISH (discussed in part 3!) reports out of 200 cells and provides information about only larger kilobase sized genetic changes (translocations, inversions, deletions)C. Molecular testing analyzes a much larger number of cells and can detect changes at the single base pair level. Much more detailed and microscopic evaluation of genetic changesIV. Single Gene Molecular TestingA. Look for a specific gene mutation (i.e. EGFR for lung cancer, BRAF for melanoma, FLT3-ITD for AML)B. Pros: 1. Faster turnaround time 2. Has a higher resolution and effective for detecting MRDB. Cons:1. Only looks for one genetic mutation as opposed to a panel like in NGS2. Some diseases ideally require understanding of multiple mutations not just one for prognostication and treatment planningV. Next Generation Sequencing (NGS)A. Allows to sift through a larger part of the genome to identify a panel of mutations B. Panel of mutations chosen is based on the clinical context1. For example: NGS for acute myeloid leukemia is much different than NGS testing for lung cancer as each cancer has a much different genetic mutation profileC. Overview of technical aspects of running NGS1. Massively parallel sequencing meaning that many tiny primers are used and the areas that primers encode may be overlapping2. A computer takes all of the smaller pieces and puts them together to determine the correct sequenceD. Pros:1. Gives us an understanding of many different mutations present based on the panel chosen2. Again, this has both prognostic and predictive treatment implicationsE. Cons:1. May find mutations of undetermined significance meaning we currently do not understand how these mutations will affect prognosis and treatment decisions2. Very time consuming (~2-4 week turnaround time)3. CostlyReferences:1. https://jamanetwork.com/journals/jamaoncology/fullarticle/2734828 - Quick overview of NGS2. https://ashpublications.org/blood/article/125/26/3996/34323/Minimal-residual-disease-diagnostics-in-acute - Look at table 1 to see the difference in sensitivity for MRD testing3. https://www.oncotarget.com/article/27602/text/ - Emphasizes prognostic relevance of EGFR mutations in NSCLC4. https://www.nejm.org/doi/full/10.1056/NEJMoa1612674 - Phase 3 trial showed that targeted treatment for EGFR mutation in NSCLC was superior to chemotherapy5. https://www.nejm.org/doi/full/10.1056/nejmoa1614359 - Phase 3 trial showed that targeted treatment of FLT3 mutation in AML improved outcomesPlease visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

Featuring perspectives from Professor Andrew Wei, including the following topics: Introduction: The Biology of Acute Myeloid Leukemia (AML) (0:00) Case: A man in his mid-70s with AML — Khuda Dad Khan, MD, PhD (11:59) Case: A woman in her late 60s with AML and a FLT3-ITD mutation — Prashant Sharma, MD (30:46) Case: A 72-year-old man with AML and underlying myeloproliferative disorder — IDH1 mutation — Priya Rudolph, MD, PhD (44:35) Case: A 90-year-old man with AML and extramedullary disease — Rachel J Cook, MD (55:08) CME information and select publications

Featuring case presentations from Drs Courtney DiNardo, Daniel Pollyea, David Sallman and Eunice Wang, including the following topics: Case: A woman in her mid-80s with newly diagnosed acute myeloid leukemia (AML) — Daniel A Pollyea, MD, MS (0:00) Case: A man in his early 70s with AML and a complex monosomal karyotype — Dr Pollyea (4:02) Case: A woman in her mid-70s with newly diagnosed AML with trisomy 21 and AXLS1 and RUNX1 mutations — Dr Pollyea (5:22) Case: A woman in her late 70s with AML and a FLT3-ITD mutation — Courtney D DiNardo, MD, MSCE (7:41) Case: A man in his late 70s with AML and diploid cytogenetics — Dr DiNardo (11:46) Case: A man in his mid-60s with secondary AML and DNMT3A and FLT3-ITD mutations — Eunice S Wang, MD (17:33) Case: A woman in her late 60s with lower-risk myelodysplastic syndrome (MDS) — David Sallman, MD (25:55) Case: A man in his late 70s with high-risk MDS — Dr Sallman (29:26) CME information and select publications

Featuring perspectives from Dr Keith Pratz, including the following topics: Introduction: AML Molecular Workup (0:00) Case: A woman in her early 70s with AML with MDS-related changes — Shachar Peles, MD (10:39) Case: A man in his late 70s with AML and an IDH1 mutation — Raji Shameem, MD (23:47) Case: A man in his early 60s with therapy-related AML — Rebecca L Olin, MD, MSCE (35:20) Case: A woman in her early 70s with AML and FLT3-ITD and WT1 mutations — John Yang, MD (44:22) Case: A man in his early 60s with relapsed AML — Dr Olin (51:02) CME information and select publications

Featuring perspectives from Drs Courtney DiNardo, Daniel Pollyea, David Sallman and Eunice Wang, including the following topics: Introduction (0:00) Prologue: A Personal Reflection on Acute Myeloid Leukemia (AML) (1:01) Case: A woman in her mid-80s with newly diagnosed AML — Daniel A Pollyea, MD, MS (8:28) Up-Front Treatment of AML in Patients Who Are Not Eligible for Intensive Therapy (11:54) Case: A man in his early 70s with AML and a complex monosomal karyotype — Dr Pollyea (24:32) Management of AML with Targetable Mutations (33:14) Case: A woman in her late 70s with AML and a FLT3-ITD mutation — Courtney D DiNardo, MD, MSCE (40:04) Case: A man in his late 70s with AML and diploid cytogenetics — Dr DiNardo (48:41) Other Currently Available and Investigational Treatment Strategies for AML (51:57) Case: A man in his mid-60s with secondary AML and DNMT3A and FLT3-ITD mutations — Eunice S Wang, MD (54:50) Case: A woman in her late 50s with leukemia cutis — Dr Wang (1:06:25) Case: A woman in her late 60s with lower-risk myelodysplastic syndrome (MDS) — David Sallman, MD (1:09:20) Case: A man in his late 70s with high-risk MDS — Dr Sallman (1:15:37) Case: A man in his mid-80s with high-risk MDS — Dr Sallman (1:22:27) CME information and select publications

Featuring Dr Courtney D DiNardo's perspectives on her time spent speaking with patients with acute myeloid leukemia from the practices of community oncologists Drs KS Kumar and Andrew C Rettew, including the following topics: Case: A woman in her early 70s with acute myeloid leukemia (AML) and an IDH mutation receives venetoclax and azacytidine (0:00) Selection of patients for treatment with venetoclax/azacitidine versus intensive 7 + 3 chemotherapy; optimal application of venetoclax/azacytidine (5:41) Tolerability and side effects of venetoclax/azacitidine; testing for IDH mutations and choice of therapy for patients with AML and an IDH mutation (14:24) Duration of therapy and long-term outcomes with venetoclax/azacitidine; clinical research on combination therapy with venetoclax and oral hypomethylating agents (HMAs) (23:08) Treatment options for patients with AML who experience disease progression on venetoclax/azacitidine; use of IDH inhibitors for AML (29:23) Case: A woman in her mid-50s with a complex medical history is diagnosed with AML and receives 7 + 3 chemotherapy and gemtuzumab ozogamicin (34:24) Case: A man in his early 70s with AML and a FLT3-ITD mutation receives 7 + 3 chemotherapy and midostaurin (47:36) Optimal approach to the management of AML with FLT3 mutations (51:20) Impact of COVID-19 on the clinical care of patients with AML (57:37) Case: A man in his early 70s with AML with myelodysplasia-related changes and mutations in RUNX1, SRSF2, ASXL1 and IDH2 receives liposomal daunorubicin and cytarabine (CPX-351) followed by enasidenib (1:07:10) Activity and tolerability of CPX-351 for AML; patient selection (1:11:19) Choice between a venetoclax/HMA combination and an IDH inhibitor for patients with progressive AML and an IDH mutation (1:17:53) Feasibility and efficacy of stem cell transplantation in patients with relapsed AML; use and tolerability of glasdegib and low-dose cytarabine for AML (1:25:52) CME information and select publications

In this week's episode, we will review a study in sickle cell disease patients reporting abnormal retention of mitochondria in circulating red cells and elevated mitochondrial DNA in plasma, learn more about the fate of FLT3-ITD clones in AML patients treated with midostaurin, and look at a study showing, for the first time, that selected elderly patients with newly diagnosed multiple myeloma benefit from modification of standard myeloma treatment based on the level of frailty.

Proceedings from the first in a 2-part nursing webinar series. Featuring perspectives from Ms Rhonda Hewitt and Dr Mark Levis, including the following topics: Introduction (0:00) Case: A man in his early 80s with newly diagnosed poor-risk acute myeloid leukemia (AML) — Rhonda Hewitt, MSN, ANP, AOCNP (1:08) Molecular evaluation of patients with newly diagnosed AML (15:21) Venetoclax combinations for AML and management of tumor lysis syndrome (22:14) Case: A man in his early 80s with AML and a FLT3 ITD mutation — Mark Levis, MD, PhD (37:15) Management of AML with a FLT3 mutation (40:59) Management of AML with an IDH mutation (51:07) Other novel agents and strategies for AML (56:26) CME information and select publications

Oncotarget published this trending paper on July 21, 2020, entitled, “Genomic markers of midostaurin drug sensitivity in FLT3 mutated and FLT3 wild-type acute myeloid leukemia patients,” by researchers from Knight Cancer Institute, Oregon Health and Science University; Division of Hematology and Medical Oncology, Oregon Health and Science University; Howard Hughes Medical Institute; Department of Cell, Developmental, and Cancer Biology, Oregon Health and Science University. The researchers conducted a study to identify features that may predict response to midostaurin in FLT3 mutant and wild-type samples. They performed an ex vivo drug sensitivity screen on primary and relapsed AML samples, with corresponding targeted sequencing and RNA sequencing. In order to understand the impact that different genomic alterations have on midostaurin response, the researchers identified 214 patients with AML and annotated for their FLT3 status. Of these patients, 193 were primary and 21 were relapse AML samples from the Beat AML publicly available dataset. Risk groups within the cohort were as follows: 73 samples were favorable risk, 59 samples were intermediate, and 68 were adverse. The median age of patients in the cohort was 61, with 52% male and 48% female. “We hypothesized that there are additional genomic alterations and gene expression changes outside of FLT3-ITD mutations that can influence AML sample resistance or sensitivity to midostaurin and aimed to further characterize these factors.” To date, this research paper has generated an Altmetric Attention score of 54. Altmetric Attention scores, located at the top-left of trending Oncotarget papers, provide an at-a-glance indication of the volume and type of online attention the research has received. Top Oncotarget publications rated by Altmetric score: https://www.oncotarget.com/news/altmetric/ Sign up for free Altmetric alerts about this article DOI - https://doi.org/10.18632/oncotarget.27656 Full text - https://www.oncotarget.com/article/27656/text/ Correspondence to - Mara W. Rosenberg - rosenberg.mara@gmail.com Keywords - acute myeloid leukemia, drug sensitivity, midostaurin, drug resistance, FLT3 About Oncotarget Oncotarget is a bi-weekly, peer-reviewed, open access biomedical journal covering research on all aspects of oncology. To learn more about Oncotarget, please visit https://www.oncotarget.com or connect with: SoundCloud - https://soundcloud.com/oncotarget Facebook - https://www.facebook.com/Oncotarget/ Twitter - https://twitter.com/oncotarget YouTube - https://www.youtube.com/c/OncotargetYouTube/ LinkedIn - https://www.linkedin.com/company/oncotarget Pinterest - https://www.pinterest.com/oncotarget/ Reddit - https://www.reddit.com/user/Oncotarget/ Oncotarget is published by Impact Journals, LLC please visit https://www.ImpactJournals.com or connect with @ImpactJrnls Media Contact MEDIA@IMPACTJOURNALS.COM 18009220957

Featuring an interview with Dr Andrew H Wei on the following topics: Treatment of acute myeloid leukemia (AML) in patients not eligible for intensive induction therapy (0:00) Case: A man in his late 70s with AML receives re-treatment with venetoclax and azacitidine after attaining a durable remission of 2.5 years with that regimen (21:23) Case: A woman in her late 70s initially diagnosed with AML with an IDH2 mutation receives gilteritinib as third-line therapy after detection of a FLT3-ITD mutation (23:16) CME information and select publications

Featuring a discussion on recent clinical trial data on the use of FLT3 inhibitors in the management of acute myeloid leukemia with Dr Keith Pratz, including the following topics: Targeting FLT3 in Acute Myeloid Leukemia (AML) — Keith W Pratz, MD (0:00) Case: A man in his late 50s with AML and a FLT3-ITD mutation receives midostaurin and 7 + 3 chemotherapy followed by an allogeneic transplant and maintenance sorafenib (23:52) Case: A woman in her late 60s with hypertension and diabetes is diagnosed with AML and FLT3-ITD, IDH2, NPM1 and NRAS mutations (25:41) Case: A woman in her early 80s with AML with FLT3-TKD and NPM1 mutations receives single-agent gilteritinib (27:52) CME information and select publications

Proceedings from a CME symposium held during the 61st ASH Annual Meeting. Featuring perspectives from Drs Mark Levis, Daniel A Pollyea, Richard M Stone and Andrew H Wei. Introduction Program Overview: Dr Neil Love (00:00) Evolving Paradigms in Up-Front Treatment for Older Patients or Those Ineligible for Intensive Chemotherapy          Case (Dr Pollyea): A woman in her mid-30s with acute myeloid leukemia (AML) who is unable to undergo intensive induction chemotherapy because of refusal to accept blood products on religious grounds achieves a complete response to venetoclax/azacytidine (11:28) Case (Dr Pollyea): A women in her late 60s with AML who is ineligible for intensive induction chemotherapy receives venetoclax/azacitidine as first-line therapy (15:18) Faculty Presentation: Dr Pollyea (19:39) Assessment, Incidence and Clinical Significance of FLT3 Mutations in AML Case (Dr Stone): A man in his mid-40s with AML with a FLT3-ITD mutation receives 7 + 3 induction in combination with midostaurin and undergoes allogeneic transplant (47:53) Case (Dr Stone): A man in his early 60s who underwent allogenic transplant 1.5 years ago for high-risk myelodysplastic syndrome (MDS) presents with AML with a FLT3-ITD mutation and receives gilteritinib (50:46) Faculty Presentation: Dr Stone (52:31) Long-Term Treatment for Patients with AML with IDH Mutations Case (Dr Levis): A woman in her mid-80s who previously received azacitidine and lenalidomide for MDS presents with AML with an IDH1 mutation and receives ivosidenib (1:13:52) Case (Dr Levis): A man in his early 60s who is receiving enasidenib for AML with an IDH2 mutation develops differentiation syndrome causing acute kidney injury (1:19:11) Faculty Presentation: Dr Levis (1:21:56) Other Novel Agents and Promising Strategies Under Evaluation for Patients with AML Faculty Presentation: Prof Wei (1:43:54) CME information and select publications

Acute Leukemias Update, Issue 1, 2020 — Part 2: Our interview with Dr Wang highlights the following topics as well as cases from her practice: Case: A woman in her early 60s with previously treated metastatic triple-negative breast cancer is diagnosed with AML with a FLT3-ITD mutation (00:00) Molecular profiling in the diagnosis and treatment of AML (01:54) Activity and tolerability of midostaurin in combination with standard 7 + 3 chemotherapy for newly diagnosed AML with a FLT3 mutation (05:14) CPX-351 for secondary AML (07:16) Incidence and characterization of FLT3 mutations in AML; efficacy of midostaurin and gilteritinib (10:45) Clinical experience with and tolerability of gilteritinib (16:12) Activity of midostaurin in newly diagnosed AML with a FLT3 mutation (20:54) Ongoing Phase III trials of crenolanib, gilteritinib and quizartinib as first-line therapy for AML with a FLT3 mutation (24:17) Significance of allelic ratio in AML with a FLT3-ITD mutation (26:50) Therapeutic options for patients with relapsed/refractory AML and metastatic triple-negative breast cancer (31:01) Activity and safety of immune checkpoint inhibitors in patients with AML (32:58) Biologic rationale for and activity of venetoclax in combination with a hypomethylating agent for patients with AML (35:06) Case: A man in his early 40s with relapsed/refractory AML with an IDH2 mutation receives enasidenib (36:32) Similarities and differences between enasidenib and ivosidenib; recognition and management of treatment-associated differentiation syndrome (39:22) Integration of the FDA-approved IDH inhibitors enasidenib and ivosidenib into clinical practice (44:15) Approach to therapy for older patients with AML with FLT3 or IDH1/2 mutations (46:56) Integration of venetoclax in combination with a hypomethylating agent into community practice (51:23) Use of gemtuzumab ozogamicin for patients with low- to intermediate-risk AML with no adverse cytogenetics (55:33) Activity and unique side-effect profile of the hedgehog inhibitor glasdegib for AML (58:17) Results of the Phase III QUAZAR AML-001 trial: Overall survival benefit with CC-486 as maintenance therapy for newly diagnosed AML in first remission (1:00:34) Mechanism of action and activity of the first-in-class small molecule APR-246 in combination with azacitidine for patients with AML or myelodysplastic syndromes with TP53 mutations (1:04:19) Mechanisms of action and activity of blinatumomab and the antibody-drug conjugate inotuzumab ozogamicin in patients with relapsed/refractory ALL (1:06:44) Tolerability and safety of blinatumomab and inotuzumab ozogamicin (1:09:51) CME information and select publications

Acute Leukemias Update — Part 1: Our interview with Dr Levis highlights the following topics as well as cases from his practice: Molecular profiling in the diagnosis and treatment of acute myeloid leukemia (AML) (00:00) Management of AML with p53 mutations (03:13) Efficacy of hypomethylating agents with venetoclax in older patients with AML (06:41) Therapeutic options for patients with AML and FLT3 mutations (10:31) Monitoring and management of venetoclax-associated tumor lysis syndrome (13:06) Case: A 62-year-old woman who presents with fatigue and bleeding gums is diagnosed with AML with FLT3 and NPM1 mutations (16:08) Role of the FLT3 pathway in myeloid cell development and types of FLT3 mutations (17:10) Impact of FLT3 mutations on therapeutic decision-making (21:01) Activity of midostaurin in newly diagnosed AML with a FLT3 mutation (23:48) BMT CTN 1506: A Phase III trial of gilteritinib as maintenance therapy after allogeneic transplant for patients with AML and FLT3-ITD mutations (25:20) Case: A 60-year-old man with AML and a FLT3-ITD mutation receives gilteritinib with standard 7 + 3 chemotherapy induction followed by allotransplant and maintenance gilteritinib on a clinical trial (27:20) Similarities and differences among midostaurin, quizartinib and gilteritinib (28:58) Case: A 63-year-old man with refractory AML and an IDH2 mutation receives enasidenib and develops differentiation syndrome (31:46) Biologic rationale for targeting IDH1/2 mutations and activity of ivosidenib or enasidenib in patients with relapsed/refractory AML (35:57) Efficacy and side effects of CPX-351 (liposomal cytarabine/daunorubicin) in patients with AML (40:46) Case: A 28-year-old obese man with acute lymphoblastic leukemia (ALL) and an MLL rearrangement develops hepatic toxicity after treatment with the Berlin-Frankfurt-Munster pediatric-inspired regimen containing L-asparaginase (43:01) Mechanism of action, activity and tolerability of blinatumomab for ALL (46:38) Neurologic side effects associated with blinatumomab (49:03) Use of blinatumomab for minimal residual disease-positive ALL (51:53) Optimal use of tyrosine kinase inhibitors in the management of Philadelphia chromosome-positive ALL (53:30) Case: A 41-year-old woman receives chimeric antigen receptor (CAR) T-cell therapy for relapsed ALL (58:37) Role of CAR T-cell therapy in the management of ALL (1:01:31) Use of the antibody-drug conjugates gemtuzumab ozogamicin and inotuzumab ozogamicin for acute leukemias (1:07:42) Activity of gemtuzumab ozogamicin in patients with high-risk acute promyelocytic leukemia (APL) (1:10:30) Select publications

If you enjoyed this podcast, make sure to subscribe for more weekly education content from ASCO University. We truly value your feedback and suggestions, so please take a moment to leave a review. If you are an oncology professional and interested in contributing to the ASCO University Weekly Podcast, email ascou@asco.org for more information. TRANSCRIPT The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. [MUSIC PLAYING] Hello and welcome to the ASCO Guidelines podcast series. My name is Shannon McKernin and today I'm interviewing Dr. Valerie de Haas from Princess Máxima Center for Pediatric Oncology in the Netherlands, lead author on "Initial Diagnostic Workup of Acute Leukemia: ASCO Clinical Practice Guideline Endorsement of the CAP and ASH Guideline.” Thank you for being here today, Dr. de Haas. Thank you. So first, can you give us a general overview of what this guideline covers? Well, yes. The laboratory evaluation of patients who are suspected of having acute leukemia is very complex, and it has evolved significantly with the incorporation of advanced laboratory techniques. The traditional backbone of initial workup of AL, of acute leukemia, is composed of ctyomorphology, cytochemistry, immunophenotyping, and molecular cytogenetics. These techniques are the backbone of the initial diagnostic workup of acute leukemia. This is leading to risk stratification and fine tuning of the therapy by molecular signatures. The advanced molecular diagnostics, such as next-generation sequencing, has become more important in the diagnosis and in the risk stratification of acute leukemia. This guideline is meant for both pediatric and adult patients, and it was initially published in 2017. This year, we reviewed this guideline, and we have taken into account two important developments. First, since 2017, we've seen that there are major advances in molecular techniques and also that we can identify and validate new molecular markers. And those two events have contribute to a better risk stratification. And the second development is the effect that the WHO classification was revised in 2017 which also has led to new risk recoveries and refined subclassifications. So what are the key recommendations of this guideline? Well, in total, we have reviewed 27 guideline statements by the ASCO endorsement expert panelists. And discussion points are used to summarize issues that were identified from the updated literature. The ASCO expert panel determined that the recommendations from the guideline as published in 2016 are clear, thorough, and they are based upon the most relevant scientific evidences. We fully endorse the CAP-ASH guideline on initial diagnostic workup of acute leukemia. And we decided to include some discussion points according to clinical practice and according to the updated literature. In fact, we identified four categories of key recommendations. The first one is the initial diagnostics focusing on basic diagnostics and determination of risk parameters. This concerns, in total, about 11 guideline recommendations, and they give an overview of the initial workup varying from the collection of the clinical history of the patient to initial basic diagnostics by cytomorphology, flow cytometry and molecular cytogenetic analysis of peripheral blood, bone marrow, and cerebrospinal fluids. Secondly, the second category were molecular markers and MRD detection, and they were addressed by 10 of the recommendations. And these recommendations give a structural overview of the molecular and cytogenetic workup for acute lymphoblastic leukemia versus acute myeloid leukemia identifying different prognostic markers. Also, the detection of MRD is taken into account in this recommendation. There is a major difference between children and adults, and this part is given most attention in the discussion part as the developments have been major during the past few years. The third one is the context of referral to another institution with expertise in the management of acute leukemia. This is addressed by four recommendations, emphasizing the point that referral to an institution with specific expertise is of major importance for the central workup of acute leukemia. And finally, the final reporting and report keeping is reflected in three recommendations, mainly supporting conclusions from 2017 which were describing the fact that the complete report with basic diagnostics in one central report should be available within 48 to 72 hours. And this should be followed by complete, final, comprehensive report in one or two weeks. So can you tell us about those discussion points that were made and why the panel decided to include these? The discussion points include mostly issues regarding diagnostics that involve flow cytometry and molecular techniques as addressed in part one and two of the guidelines. We think that the cytomorphologic assessment is essential for initial diagnosis of acute leukemia. Multicolor flow cytometry using 8 to 10 colors has led to a better distinction between myeloids, lymphoid, and mixed lineage blast origin. Even when the number of cells are limited, for instance in CNS involvement, fine needle aspirate of extramedullary leukemic infiltration, or skin biopsy for leukemic cutis. Also, it was suggested to better assess the central nervous system involved in leukemia. The expert panel recommends the immunophenotyping studies as an additional detection technique next to the cytomorphological examination of cytospins and particularly for those with a low level involvement of acute leukemia that cannot be well addressed by a morphologic examination only. The TDT immunohistochemistry staining of cytospins has alternatively been used for detection of CNS disease in AML and evaluation of CSF by multicolor flow cytometry has been recently adopted in some centers. Flow cytometry, using at least six, but we now use in some laboratories, even 8 to 10 colors has led to a much more specific in tentative diagnosis. And this has improved the detection of CNS involvement. The use of molecular tools, for instance, polymerase change reaction, PCR, NGS for low-level CSF involvement is still under study, and therefore, we did not recommend this in our discussion. Regarding the molecular markers and MRD detection, the discussion here was mainly based upon the results of translational research supported by better molecular detection techniques. And those molecular diagnoses have been developing in the past few years with the inclusion of many more molecular markers. And they included one of the key diagnostic criteria in the revised WHO classification, which was revised in 2017. And we made substantial changes that have been made in the ASH-CAP guidelines concerning molecular diagnostics. Those newly identified targets by advanced molecular techniques give possibilities for better risk stratification. Some examples of better molecular characterization of acute lymphoblastic leukemia are, for instance, additional testing for MLL translocations. Furthermore, we can look in patients with T-ALL for NOTCH1, and FBXW7 mutations. The Ikaros family zinc finger gene, the IKZF1 gene is frequently deleted in adults as well in children with B-ALL. And it was shown to have an independent prognostic significance and was also associated with poor clinical outcome. In the current text of the current risk that the protocols IKZF1 should be regularly included in the screening panels for all ALL patients. If we look for examples for better characterization of AML, acute myeloid leukemia, we have found an increasing number of additional cytogenetic aberrations, like for instance FLT3 ITD which is associated with poor outcome. Another example is appropriate mutational analysis for kids, which can be detected both in adult patient as pediatric patients with a confirmed core binding factor acute myeloid leukemia. So this is myeloid leukemia with a translocation A21, RUNX1, or inversion 16. This recommendation is very strong in adults, whereas in children, this prognostic fact impact remains unclear. So there have been proven several publications which refer to a similar prognosis for children and others who refer to a poor prognosis in comparison to known mutated genes. So we suggest to test for this mutation in adults, especially, but also in children to learn from it. Finally, emerging evidence supports molecular studies as principle test for monitoring minimal residual disease of acute leukemia. And there are several key molecular markers that are included in the initial workup, which will be carried on for monitoring MRD, for instance, PML- RAR-alpha, RUNX1-RUNXT1, CBFB-MYH11, and NPM1, CEBP-alpha and others. Beside those aforementioned markers, it's very important to screen for other molecular markers that have predictive or prognostic value in the individual. And it is possible to use them for MRD. We have found a recent consensus from the European Leukemia Net MRD Working Group, who was proposing that for detection of molecular MRD, and they refer the RT PCR platform to NGS and digital PCR platforms. Although all those molecular techniques have been developed very quickly and it is very tempting to use them for initial diagnostics, currently, not all laboratories will have all those techniques available. So the expert panel strongly advises understanding to make distinction between diagnostic that are needed in the first phase to start treatment and subsequently, treatment stratification, in contrast to the usual dose findings in a broader research. For instance, available karyotyping, FISH, PCR techniques, if possible, NGS can be used in the initial start of treatment, whereas techniques like whole exome sequencing, whole genome sequencing, RNA sequencing, and epigenomic studies are meant for a broader research. And finally, how will these guideline recommendations affect patients? Well, in the end, the patients will receive better and especially, more personalized treatment. If we have results available within two weeks from diagnosis, it will be possible to better identify which basis will better benefit from more intensified and more personalized treatment, whereas others may need less intensive treatment with less toxicity. If you use traditional techniques to do this supported by molecular techniques like karyotyping, FISH, and PCR techniques, and in the end, following MRD to see which patients are responding to treatment, MRD detection will help to identify these patients and stratify them finally to the best treatment. Great. Thank you for your work on this important guideline, and thank you for your time today, Dr. de Haas. OK. Thanks a lot. And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. If you've enjoyed what you've heard today, please rate and review the podcast and refer this show to a colleague.

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. [MUSIC PLAYING] Hello and welcome to the ASCO Guidelines podcast series. My name is Shannon McKernin and today I'm interviewing Dr. Valerie de Haas from Princess Máxima Center for Pediatric Oncology in the Netherlands, lead author on "Initial Diagnostic Workup of Acute Leukemia: ASCO Clinical Practice Guideline Endorsement of the CAP and ASH Guideline.” Thank you for being here today, Dr. de Haas. Thank you. So first, can you give us a general overview of what this guideline covers? Well, yes. The laboratory evaluation of patients who are suspected of having acute leukemia is very complex, and it has evolved significantly with the incorporation of advanced laboratory techniques. The traditional backbone of initial workup of AL, of acute leukemia, is composed of ctyomorphology, cytochemistry, immunophenotyping, and molecular cytogenetics. These techniques are the backbone of the initial diagnostic workup of acute leukemia. This is leading to risk stratification and fine tuning of the therapy by molecular signatures. The advanced molecular diagnostics, such as next-generation sequencing, has become more important in the diagnosis and in the risk stratification of acute leukemia. This guideline is meant for both pediatric and adult patients, and it was initially published in 2017. This year, we reviewed this guideline, and we have taken into account two important developments. First, since 2017, we've seen that there are major advances in molecular techniques and also that we can identify and validate new molecular markers. And those two events have contribute to a better risk stratification. And the second development is the effect that the WHO classification was revised in 2017 which also has led to new risk recoveries and refined subclassifications. So what are the key recommendations of this guideline? Well, in total, we have reviewed 27 guideline statements by the ASCO endorsement expert panelists. And discussion points are used to summarize issues that were identified from the updated literature. The ASCO expert panel determined that the recommendations from the guideline as published in 2016 are clear, thorough, and they are based upon the most relevant scientific evidences. We fully endorse the CAP-ASH guideline on initial diagnostic workup of acute leukemia. And we decided to include some discussion points according to clinical practice and according to the updated literature. In fact, we identified four categories of key recommendations. The first one is the initial diagnostics focusing on basic diagnostics and determination of risk parameters. This concerns, in total, about 11 guideline recommendations, and they give an overview of the initial workup varying from the collection of the clinical history of the patient to initial basic diagnostics by cytomorphology, flow cytometry and molecular cytogenetic analysis of peripheral blood, bone marrow, and cerebrospinal fluids. Secondly, the second category were molecular markers and MRD detection, and they were addressed by 10 of the recommendations. And these recommendations give a structural overview of the molecular and cytogenetic workup for acute lymphoblastic leukemia versus acute myeloid leukemia identifying different prognostic markers. Also, the detection of MRD is taken into account in this recommendation. There is a major difference between children and adults, and this part is given most attention in the discussion part as the developments have been major during the past few years. The third one is the context of referral to another institution with expertise in the management of acute leukemia. This is addressed by four recommendations, emphasizing the point that referral to an institution with specific expertise is of major importance for the central workup of acute leukemia. And finally, the final reporting and report keeping is reflected in three recommendations, mainly supporting conclusions from 2017 which were describing the fact that the complete report with basic diagnostics in one central report should be available within 48 to 72 hours. And this should be followed by complete, final, comprehensive report in one or two weeks. So can you tell us about those discussion points that were made and why the panel decided to include these? The discussion points include mostly issues regarding diagnostics that involve flow cytometry and molecular techniques as addressed in part one and two of the guidelines. We think that the cytomorphologic assessment is essential for initial diagnosis of acute leukemia. Multicolor flow cytometry using 8 to 10 colors has led to a better distinction between myeloids, lymphoid, and mixed lineage blast origin. Even when the number of cells are limited, for instance in CNS involvement, fine needle aspirate of extramedullary leukemic infiltration, or skin biopsy for leukemic cutis. Also, it was suggested to better assess the central nervous system involved in leukemia. The expert panel recommends the immunophenotyping studies as an additional detection technique next to the cytomorphological examination of cytospins and particularly for those with a low level involvement of acute leukemia that cannot be well addressed by a morphologic examination only. The TDT immunohistochemistry staining of cytospins has alternatively been used for detection of CNS disease in AML and evaluation of CSF by multicolor flow cytometry has been recently adopted in some centers. Flow cytometry, using at least six, but we now use in some laboratories, even 8 to 10 colors has led to a much more specific in tentative diagnosis. And this has improved the detection of CNS involvement. The use of molecular tools, for instance, polymerase change reaction, PCR, NGS for low-level CSF involvement is still under study, and therefore, we did not recommend this in our discussion. Regarding the molecular markers and MRD detection, the discussion here was mainly based upon the results of translational research supported by better molecular detection techniques. And those molecular diagnoses have been developing in the past few years with the inclusion of many more molecular markers. And they included one of the key diagnostic criteria in the revised WHO classification, which was revised in 2017. And we made substantial changes that have been made in the ASH-CAP guidelines concerning molecular diagnostics. Those newly identified targets by advanced molecular techniques give possibilities for better risk stratification. Some examples of better molecular characterization of acute lymphoblastic leukemia are, for instance, additional testing for MLL translocations. Furthermore, we can look in patients with T-ALL for NOTCH1, and FBXW7 mutations. The Ikaros family zinc finger gene, the IKZF1 gene is frequently deleted in adults as well in children with B-ALL. And it was shown to have an independent prognostic significance and was also associated with poor clinical outcome. In the current text of the current risk that the protocols IKZF1 should be regularly included in the screening panels for all ALL patients. If we look for examples for better characterization of AML, acute myeloid leukemia, we have found an increasing number of additional cytogenetic aberrations, like for instance FLT3 ITD which is associated with poor outcome. Another example is appropriate mutational analysis for kids, which can be detected both in adult patient as pediatric patients with a confirmed core binding factor acute myeloid leukemia. So this is myeloid leukemia with a translocation A21, RUNX1, or inversion 16. This recommendation is very strong in adults, whereas in children, this prognostic fact impact remains unclear. So there have been proven several publications which refer to a similar prognosis for children and others who refer to a poor prognosis in comparison to known mutated genes. So we suggest to test for this mutation in adults, especially, but also in children to learn from it. Finally, emerging evidence supports molecular studies as principle test for monitoring minimal residual disease of acute leukemia. And there are several key molecular markers that are included in the initial workup, which will be carried on for monitoring MRD, for instance, PML- RAR-alpha, RUNX1-RUNXT1, CBFB-MYH11, and NPM1, CEBP-alpha and others. Beside those aforementioned markers, it's very important to screen for other molecular markers that have predictive or prognostic value in the individual. And it is possible to use them for MRD. We have found a recent consensus from the European Leukemia Net MRD Working Group, who was proposing that for detection of molecular MRD, and they refer the RT PCR platform to NGS and digital PCR platforms. Although all those molecular techniques have been developed very quickly and it is very tempting to use them for initial diagnostics, currently, not all laboratories will have all those techniques available. So the expert panel strongly advises understanding to make distinction between diagnostic that are needed in the first phase to start treatment and subsequently, treatment stratification, in contrast to the usual dose findings in a broader research. For instance, available karyotyping, FISH, PCR techniques, if possible, NGS can be used in the initial start of treatment, whereas techniques like whole exome sequencing, whole genome sequencing, RNA sequencing, and epigenomic studies are meant for a broader research. And finally, how will these guideline recommendations affect patients? Well, in the end, the patients will receive better and especially, more personalized treatment. If we have results available within two weeks from diagnosis, it will be possible to better identify which basis will better benefit from more intensified and more personalized treatment, whereas others may need less intensive treatment with less toxicity. If you use traditional techniques to do this supported by molecular techniques like karyotyping, FISH, and PCR techniques, and in the end, following MRD to see which patients are responding to treatment, MRD detection will help to identify these patients and stratify them finally to the best treatment. Great. Thank you for your work on this important guideline, and thank you for your time today, Dr. de Haas. OK. Thanks a lot. And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. If you've enjoyed what you've heard today, please rate and review the podcast and refer this show to a colleague.

Die akute myeloische Leukämie (AML) ist aus genetischer Sicht eine sehr heterogene Erkrankung. Rezeptortyrosinkinasen (RTKs) wie FLT3 sind in der Leukämogenese von zentraler Bedeutung. Durch Mutationen aktivierte RTKs sind allerdings alleine nicht in der Lage eine AML zu induzieren. Die Kooperation mit anderen Mutationen ist hierfür notwendig. Zu den am häufigsten gemeinsam auftretenden Mutationen in der AML gehören NPM1- und FLT3-ITD- (internal tandem duplication) Mutationen. Klinische Daten zeigen, dass eine FLT3-ITD die gute Prognose von NPM1-mutierten (NPM1c+) Patienten in Abhängigkeit des FLT3-ITD-mRNA-Levels in negativer Weise beeinflusst. Dies lässt auf ein pathogenes Zusammenwirken beider Genmutationen in der AML schließen, welches im Rahmen dieser Arbeit untersucht wurde. Dazu wurde basierend auf der humanen AML-Zelllinie OCI-AML3 mittels stabiler, lentiviraler Transduktion das erste zelluläre Modellsystem etabliert, das die relevanten Genotypen (NPM1c+/FLT3-ITD; NPM1c+/FLT3-WT) sowie unterschiedliche Verhältnisse von FLT3-ITD zu FLT3-WT (ITD/WT) im NPM1-mutierten Hintergrund modelliert. Zunächst wurde die NPM1-Mutation sowie die Funktionalität des FLT3-WT- und FLT3-ITD-Rezeptors in den nativen und transgenen Zellen bestätigt. Mit Hilfe des Zellmodells konnte gezeigt werden, dass Zellen, die beide Mutationen tragen, in vitro wie auch in vivo einen Wachstumsvorteil besitzen. Dieser vergrößerte sich zudem mit zunehmendem ITD/WT-Verhältnis. Ab einem bestimmten ITD/WT-Verhältnis konnte dieser Wachstumsvorteil in vitro mit einem FLT3-Inhibitor über eine gewisse Dauer gehemmt werden. Diese Ergebnisse könnten auf ein Zusammenwirken der beiden Mutationen bei der Leukämogenese hinweisen und eine Ursache für die schlechteren Überlebenskurven von Patienten mit beiden Mutationen und zunehmender FLT3-ITD-Last darstellen. Der insgesamt jedoch nur schwach ausgeprägte Phänotyp des etablierten Zellmodells erfordert zum eindeutigen Nachweis der funktionellen Interaktion von NPM1- und FLT3-ITD Mutationen ein alternatives Modellsystem. In diesem Zellmodell zeigten Zellen, die den FLT3-WT-Rezeptor überexprimierten, ebenfalls einen schwachen Wachstumsvorteil gegenüber nativen Zellen mit endogener FLT3-WT-Expression. Neben aktivierenden FLT3-Mutationen wie einer ITD, führen auch hohe FLT3-WT-Expressionslevel zur konstitutiven Aktivierung der FLT3-Kinase und verschlechtern die Prognose der Patienten. Deshalb wurde in dieser Arbeit mit der Untersuchung der transkriptionellen Regulation von FLT3, als mögliche Ursache hoher FLT3-WT-Expressionslevel, begonnen. In silico wurden im proximalen FLT3-Promotor Bindestellen für die hämatopoetischen Transkriptionsfaktoren (TF) PAX5 und MYB identifiziert. Mit Hilfe des Dual-Luciferase® Reporter Assay Systems wurden PAX5 als schwacher Repressor und MYB als Aktivator des Flt3-Promotors bestätigt. Auch der Transkriptionsfaktor CEBPA verhielt sich auf gleiche Weise als Aktivator der Flt3-Promotoraktivität. Eine Punktmutation im CEBPA-Gen, die aus zwei AML-Fällen bekannt ist, führte zu einer erhöhten Flt3-Promotoraktivität. Die Identifizierung weiterer mutierter, FLT3-regulierender TF und ihre Korrelation mit der FLT3-Expression sollen zukünftig tiefere Einblicke in die transkriptionelle Regulierung von FLT3 als Ursache der FLT3-Überexpression in AML-Patienten gewähren. Für eine Reihe von in AML-Patienten gefundenen Mutationen ist deren Rolle in der Pathogenese der AML noch unbekannt. Dazu gehören Mutationen in den Rezeptortyrosinkinasen DDR1 und DDR2. In der vorliegenden Arbeit wurden DDR1- und DDR2-Mutationen stabil in Ba/F3 Zellen und transient in HEK-293T Zellen exprimiert, um ihr transformierendes Potential zu untersuchen und diese funktionell zu charakterisieren. Transgene, DDR1- und DDR2-exprimierende Ba/F3 Zellen zeigten keinen transformierenden Phänotyp. Weitere Untersuchungen zeigten eine konstitutive Phosphorylierung der extrazellulären DDR2-Mutanten (G222R, M291I) in HEK-293T Zellen und eine Adhäsion von Ba/F3 Zellen mit wildtypischem sowie mutiertem DDR1-Rezeptor in Anwesenheit des DDR-Liganden Kollagen. DDR1- und DDR2-Rezeptoren sind bisher vor allem in soliden Tumoren untersucht. Weitere funktionelle Analysen sind notwendig, um ihren Stellenwert bei der Entstehung von AML zu erfassen. Diese Arbeit zeigt, dass Rezeptortyrosinkinasen in der Leukämogenese auf unterschiedliche Weise eine wesentliche Rolle spielen können. Da Rezeptortyrosinkinasen zudem wichtige Zielmoleküle für therapeutische Ansätze darstellen, sind sie von besonderer Bedeutung.

Um den Wirkmechanismus verschiedener Krebstherapeutika aufzuklären bzw. besser zu verstehen wurden in der vorliegenden Arbeit deren Wirkungen auf Zelllinien untersucht. Hierfür wurde die Wirkung verschiedener kommerziell erhältlicher und einiger Roche-eigener Kinaseinhibitoren auf Leukämiezelllinien untereinander und mit der Wirkung von FLT3-siRNAs verglichen. Die Auswirkungen von Behandlungen mit anti-CD20- und anti-BCR-Antikörper wurden an Lymphomzelllinien analysiert. Für die FLT3-Inhibition konnte gezeigt werden, dass die Vorhersagen zur Spezifität aus der Display-Technologie in vier von fünf Fällen tendenziell richtig waren. In einem mehrstufigen Verfahren wurden verschiedene Eigenschaften der Inhibitoren getestet: Hemmung der Phosphorylierung von rekombinanter FLT3-Kinase, Hemmung der zellulären Phosphorylierung der Wildtyp-FLT3-Kinase, Hemmung der Phosphorylierung von FLT3 mit der ITD-Mutation. So konnte für die Substanzen VX-680, CHIR-265 und RKI-1 eine FLT3-Hemmung als primärer Wirkmechanismus in einer Zelllinie mit FLT3-ITD ausgeschlossen werden. Für die kommerziell erhältlichen Inhibitoren Sorafenib, CFI-2 und CFI-3 sowie die neue Substanz RKI-3 konnte bestätigt bzw. gezeigt werden, dass sie FLT3 / FLT3-ITD in biochemischen und zellulären Testsystemen spezifisch hemmen können. Die Expressionsprofilierung erwies sich für die Klärung dieser Fragestellung nur als bedingt geeignet, da die Expressionsmuster der Behandlungen mit verschiedenen Inhibitoren untereinander trotz unterschiedlicher Wirkungsweisen funktionell stark übereinstimmten. In diesen Profilen zeichnete sich bereits nach vierstündiger Behandlung ein Zellzyklusarrest ab, und im weiteren Verlauf wurden sie von Expressionsänderungen aus dem Umfeld der Apoptose dominiert. Die Inhibitoren konnten jedoch hinsichtlich der FLT3-Hemmung relativ zu einander aufgrund der Übereinstimmung mit dem Muster der Behandlung mit FLT3-siRNAs eingeordnet werden. Aus den bei beiden Behandlungsarten übereinstimmend deregulierten Genen wurden zeitabhängige FLT3-Inhibitionssignaturen abgeleitet.Die Untersuchungen zum Wirkmechanismus von Typ I anti-CD20-Antikörpern zeigten, dass der Signalweg downstream von CD20 in den getesteten Zelllinien zumindest teilweise mit dem der BCR-Aktivierung identisch ist. Obgleich die Übereinstimmung der BCR-Aktivierungsmuster der verschiedenen Zelllinien verhältnismäßig gering war, konnte gezeigt werden, dass die Transkriptionsmuster der Behandlungen mit anti-CD20- bzw. anti-BCR-Antikörpern untereinander in großen Teilen übereinstimmten. Zwei der besonders schnell und stark induzierten Gene waren CCL3 und CCL4. Die Kinase SYK ist als Signalüberträger downstream des BCR bekannt. Die Induktion der Cytokine CCL3 und CCL4 konnte durch SYK-Hemmung mittels spezifischer Inhibitoren und das siRNA-vermittelte Stilllegen von SYK deutlich vermindert werden. Somit deuten die Ergebnisse dieser Arbeit darauf hin, dass SYK auch im Signalweg von CD20 eine wichtige Rolle spielt. Durch die Behandlung von NHL-Zelllinien mit anti-CD20-Antikörpern wie Rituximab oder LT20 wird demzufolge eine zelluläre Antwort ausgelöst, die einer BCR-Aktivierung ähnelt.

Bei Patienten mit AML und MDS hat die Identifikation von zytogenetischen und molekularen Aberrationen eine herausragende Bedeutung. Als wichtige unabhängige Prognoseparameter nehmen sie einen entscheidenden Einfluss auf die Planung der Therapiestrategie und sind darüber hinaus zum genetischen Monitoring der Krankheitsaktivität geeignet. In der vorliegenden Arbeit konnte die Effektivität des FLAMSA-RIC-Protokolls in zytogenetisch und molekulargenetisch definierten Subgruppen herausgearbeitet werden. Im ersten Teil der Analyse wurden 141 Patienten mit normalem Karyotyp und bekanntem Mutationsstatus für NPM1 und FLT3 untersucht. Dabei konnten vielversprechende Resultate bei Transplantation im primären Induktionsversagen beobachtet werden. Bei Patienten, die jenseits der ersten kompletten Remission transplantiert wurden, konnte die prognostische Relevanz der molekularen Subgruppen bestätigt werden, was sich sowohl in den unterschiedlichen Eigenschaften der Patienten im Rezidiv und bei Transplantation als auch in den unterschiedlichen Ergebnissen der Patienten mit verschiedenen Genotypen zeigte. Bei Transplantation jenseits der ersten kompletten Remission, zeigten Patienten mit einem günstigen Genotyp (NPM1mut/FLT3wt) signifikant bessere Ergebnisse nach Transplantation als Patienten mit einem ungünstigen Genotyp (NPM1wt/FLT3wt und FLT3-ITD mit oder ohne NPM1-Mutation). Der prognostische Wert der günstigen molekularen Marker blieb auch bei Transplantation jenseits der ersten kompletten Remission erhalten. So waren die Ergebnisse in der Gruppe von Pateinten mit günstigem Genotyp bei einer Transplantation in erster kompletter Remission und jenseits der ersten kompletten Remission vergleichbar. Dagegen zeigten Patienten mit einem ungünstigen Genotyp signifikant schlechtere Ergebnisse, wenn die Transplantation jenseits der ersten kompletten Remission erfolgte. Im zweiten Teil der Arbeit wurden die Ergebnisse von 173 Patienten mit AML und MDS und einer Hochrisiko-Zytogenetik analysiert. Die Resultate unterstreichen die Bedeutung des FLAMSA-RIC-Regimes als hocheffektives Konditionierungsprotokoll bei der allogenen Stammzelltransplantation von Patienten mit MDS und AML und einer ungünstigen Zytogenetik. Für MDS-Patienten konnte eindrucksvoll gezeigt werden, dass eine Transplantation vor dem Übergang in eine sekundäre AML signifikant bessere Überlebensraten erzielt als nach der Transformation in eine akute Leukämie. Des Weiteren wurden zytogenetisch definierte Subgruppen innerhalb der klassischen ungünstigen Prognosegruppe identifiziert, die eine differenziertere Abschätzung der Prognose ermöglichen.

Dr Levis talks to ecancertv at ASH 2013 about novel agents for FLT3-ITD positive acute myeloid leukaemia (AML) The relapse rate for FLT3-ITD positive AML is worse than normal AML, and when relapse does occur cure is near to impossible. Activating mutations in the receptor tyrosine kinase FLT3 occur in roughly 30% of acute myeloid leukemia patients, implicating FLT3 as a potential target for kinase inhibitor therapy. The multi-targeted kinase inhibitor midostaurin (PKC412) shows potent activity against FLT3 as a single agent but also in combination with intensive chemotherapy. Besides its mere presence, the allelic ratio as well as ITD insertion site within the FLT3 gene had been reported as prognostic factors in FLT3-ITD positive AML. Pharmacokinetic analyses revealed clinically important interactions between potent CYP3A4 inhibitors, such as azoles, and midostaurin. Allogeneic transplant remains the best option.

This is a commentary on a report from the EBMT demonstrating a higher relapse rate after allogeneic transplantation in AML patients with FLT3 ITD mutations.

Activating mutations in the juxtamembrane domain of FLT3 (FLT3-internal tandem duplications, FLT3-ITDs) represent the most frequent genetic alterations in acute myeloid leukemia (AML). FLT3-internal tandem duplications (FLT3-ITDs) are a heterogenous group of mutations in patients with acute leukemias that are prognostically important. To characterize the mechanism of transformation by FLT3-ITDs, we sequenced the juxtamembrane region (JM) of FLT3 from 284 patients with acute leukemias. The length of FLT3-ITDs varied from 2 to 42 amino acids (AA) with a median of 17 AA. The analysis of duplicated AAs showed that in the majority of patients, the duplications localize between AA 591 to 599 (YVDFREYEY). Arginine 595 (R595) within this region is duplicated in 77% of patients. Single duplication of R595 in FLT3 conferred factor-independent growth to Ba/F3 cells and activated STAT5. Moreover, deletion or substitution of the duplicated R595 in two FLT3-ITD constructs as well as the deletion of wildtype-R595 in FLT3-ITD substantially reduced the transforming potential, pointing to a critical role of the positive charge of R595 in stabilizing the active confirmation of FLT3-ITDs. Deletion of R595 in the FLT3-WT inhibited the growth of cells upon FL stimulation and the STAT5 activation. In this study we could also show that the tyrosine residues 589 and 591 of the FLT3-ITDs could be important phosphorylation sites and are very crucial for the activation of FLT3- ITDs. Simultaneous substitution of these two tyrosine residues with phenyalanine showed complete inhibition of the transforming potential of FLT3-ITDs and STAT5 activation. The substitution of tyrosine residues 597 and 599 did not show any effect on the transforming potential of FLT3-ITDs, supporting the previous hypothesis that these tyrosines may be only important to maintain the integrity of FLT3-WT in its inactive state. Our data provide important insights into the role of the juxtamembrane domain in the mechanism of transformation by FLT3-ITDs.

In der akuten myeloischen Leukämie (AML) sind zwei Cluster aktivierender Mutationen im ´FMS-like tyrosine kinase-3´ (FLT3)-Gen bekannt: FLT3-´internal tandem duplications´ (FLT3-ITD) in der juxtamembranösen (JM)-Domäne in 20 - 25 % der Patienten und FLT3-Punktmutationen in der Tyrosinkinasedomäne (FLT3-TKD) in 7 – 10 % der Patienten. In dieser Studie haben wir eine neue Klasse aktivierender Punktmutationen (PM) charakterisiert, die in einem 16-Aminosäuren-Abschnitt der JM-Domäne von FLT3 (FLT3-JM-PM) lokalisiert sind. Die Expression von vier FLT3-JM-PM in IL-3-abhängigen Ba/F3-Zellen führte zu wachstumsfaktor-unabhängigem Wachstum, Hyperproliferation in Gegenwart von FL und Resistenz gegenüber apoptotischem Zelltod. FLT3-JM-PM-Rezeptoren waren autophosphoryliert und zeigten verglichen mit FLT3-WT-Rezeptoren eine höhere konstitutive Dimerisierungsrate. Als einen molekularen Mechanismus konnten wir die Aktivierung von STAT5 und eine erhöhte Expression von Bcl-x(L) in allen FLT3-JM-PM-exprimierenden Zellen im Vergleich zu FLT3-WT-Zellen zeigen. Der FLT3-Inhibitor PKC412 inhibierte das wachstumsfaktor-unabhängige Wachstum der FLT3-JM-PM-Zellen. Verglichen mit FLT3-ITD- und FLT3-TKD-Zellen, zeigten die FLT3-JM-PM-Zellen ein schwächeres Transformationspotential, verbunden mit geringerer Autophosphorylierung des Rezeptors und dessen nachgeordneten Ziel-Protein STAT5. Die Kartierung der FLT3-JM-PM auf die Kristallstruktur des FLT3-Proteins zeigte, dass diese Punktmutationen wahrscheinlich die Stabilität der autoinhibitorischen JM-Domäne reduzieren. Dies liefert eine strukturelle Erklärung für das transformierende Potential dieser neuen Klasse aktivierender Mutationen von FLT3. Die defekte Negativ-Regulation aktivierter Rezeptortyrosinkinasen (RTKs) ist ein bekannter Mechanismus der Onkogenese. Die RTK FLT3 wird in frühen myeloischen und lymphoiden Progenitorzellen exprimiert und ist an der Pathogenese der AML beteiligt. Das ´Casitas B-lineage lymphoma´ (CBL)-Protein ist in der Evolution stark konserviert und übernimmt wichtige Funktionen in der Negativ-Regulation der Signalübertragung verschiedener Zelloberflächenrezeptoren. Zwei CBL-Deletionsmutanten, die in vitro Fibroblasten transformieren, wurden aus murinen Retroviren isoliert, die Vorläufer-B-Zelllymphome induzieren. In dieser Arbeit konnte gezeigt werden, dass CBL nach FL-Stimulierung von FLT3-WT-exprimierenden Ba/F3-Zellen phosphoryliert wird und damit in die FLT3-nachgeordnete Signaltransduktion involviert ist. Die Koexpression der CBL-Deletionsmutanten CBL-70Z oder v-CBL mit FLT3 führt zur Transformation von Ba/F3-Zellen. Das transformierende Potential wird durch den FLT3-Rezeptor vermittelt, da die selektiven FLT3-PTK-Inhibitoren SU5614 und PKC412 die Proliferation der FLT3-WT/CBL-mutanten-Zellen vollständig aufheben. Die Aktivierung des PI3K/mTOR/AKT-Signalweges, jedoch nicht der SRC-Kinasen und MAPK, trägt wesentlich zum hyperproliferierenden Phänotyp der FLT3-WT/CBL-mutanten Zellen nach Ligandenstimulierung bei. Die Koexpression von CBL-70Z oder v-CBL mit FLT3 führt zur konstitutiven Aktivierung der FLT3-Rezeptoren sowie STAT5 und AKT. Nach FL-Stimulierung konnten wir eine Hyperaktivierung von STAT5 und AKT in FLT3-WT/CBL-70Z und FLT3-WT/v-CBL-Zellen beobachten. An der Interaktion von CBL und FLT3 sind die TKB-Domäne des CBL-Proteins und die JM-Tyrosine Y589 und Y599 des FLT3-Rezeptors beteiligt. Die Internalisierung der FLT3-Rezeptoren wird durch die Koexpression von CBL-70Z nicht verändert. Allerdings ist CBL an der Ubiquitinierung und Degradierung von Rezeptoren beteiligt und wir konnten zeigen, dass CBL-WT die Dephosphorylierung und Degradierung des FLT3-Rezeptors fördert. Es wurde vorgeschlagen, dass die CBL-Deletionsmutanten in dominant-negativer Weise agieren und die negativ-regulatorische Funktion von CBL-WT blockieren. Wir haben eine CBL-Deletionsmutante in den AML Zelllinie MOLM-13 und MOLM-14 identifiziert. Dieser CBL-Mutante fehlt Exon 8, das für Teile der Linker- und RING-Finger-Domäne kodiert, und erinnert an CBL-70Z. Die Entdeckung einer möglicherweise transformierenden CBL-Mutante in AML-Zellen unterstützt die Hypothese, dass CBL zum malignen Phänotyp der AML beiträgt. Zusammenfassend haben wir gezeigt, dass die strukturelle oder funktionelle Inaktivierung negativ-regulatorischer Mechanismen das transformierende Potential von FLT3 aktivieren kann: 1. Der Verlust der Autoinhibition durch Punktmutationen, die die geordnete Konformation der autoinhibitorischen JM-Domäne stören. 2. Die funktionelle Inaktivierung eines negativ-regulatorischen Proteins durch ´loss-of-function´-Mutationen. Diese Daten unterstreichen die zentrale Rolle von FLT3 in der Leukämogenese und als ein Zielprotein für therapeutische Ansätze.

Flt3 is the most recently discovered member of the platelet-derived growth factor receptor (PDGFR) subfamily of receptor tyrosine kinases (RTKs). It is expressed on early hematopoietic progenitor cells and is involved in their growth. Activating mutations of Flt3, such as internal tandem duplications (ITD) in the juxtamembrane (JM) region of Flt3, are among the most common genetic alterations found in patients with acute myeloid leukemia (AML). For this reason Flt3 is an attractive target for specific tyrosine kinase inhibitors, and a number of such compounds are currently being tested in clinical trials. However, the mechanisms of Flt3-mediated signal transduction are poorly understood. Src family tyrosine kinases (SFKs) are involved in the signaling processes of various RTKs, including those of the PDGFR subfamily . Most SFKs are expressed predominantly or exclusively in hematopoietic cells, and at least Hck and Lyn were found to be activated in AML patients. These observations indicate that SFKs could also be involved in Flt3 signaling. In this work the role of SFKs in signal transduction of the Flt3 receptor was investigated. A panel of Hck and Flt3 mutants was used in biochemical and biological assays to deduce the contribution of kinase activity, SH2 and SH3 binding domains and tyrosine phosphorylation status to Flt3-SFK interaction. The work presented shows that SFKs interfere with the maturation of wild type and Flt3 ITD receptors in human embryonic kidney 293 (HEK- 293) cells in a kinase-dependent manner. The SFK-mediated effect on receptor maturation is reflected by accumulation of the immature, intracellular form of Flt3 at the expense of the mature, plasma membrane-inserted form of the receptor. This effect of SFK kinase activity on receptor maturation is not limited to Flt3, because analogous results were also obtained for the Kit receptor, another member of the PDGFR subfamily. The demonstration of the role of SFKs in regulation of receptor maturation is novel and the exact mechanism underlying this effect requires further investigation. Using the HEK-293 cells it was also shown that Hck is able to phosphorylate Flt3 on tyrosine residues and to associate with autophosphorylated Flt3 in an SH2 domain-dependent manner. Hck-mediated tyrosine phosphorylation occurs in the JM region of Flt3. Tyrosine residues 589 and 591 in the JM region, when phosphorylated, were also identified as the docking sites for Hck. Although Hck phosphorylation and binding sites on Flt3 overlap, Hck-mediated phosphorylation of Flt3 is not sufficient for Flt3-Hck association. In contrast to the situation in HEK-293 cells, Hck neither interferes with Flt3 maturation nor phosphorylates Flt3 on tyrosine residues, and does not detectably associate with the Flt3 receptor in the hematopoietic murine cell line 32D clone 3 (32D cl.3). However, the level of the ectopic expression of Hck in 32D cl.3 cells was lower than in HEK-293 cells. This difference in Hck expression level probably accounts for both the lack of the Hck-mediated phosphorylation of Flt3 and the interference with its maturation in 32D cl.3 cells. The lower Hck expression level, however, does not account for the lack of detectable association of Hck with Flt3 in 32D cl.3 cells. Using biological assays in which activation of Flt3 can partially overcome the requirement for cytokine stimulation in 32D cl.3 survival and proliferation, it was shown that Hck is not involved in Flt3 signal transduction leading to Flt3-mediated cell survival and Flt3 ITD-dependent cell growth. Therefore, biological relevance of SFKs in Flt3 signaling remains unclear. In summary, although the binding and phosphorylation of Flt3 by Hck can be shown, the biological relevance of Hck in Flt3 signaling remains to be formally demonstrated. This research led to the novel finding that, at least when over-expressed or hyperactivated, SFKs interfere with the maturation process of RTKs. Various studies have shown that the ligandindependent activation of RTKs as well as their premature phosphorylation can interfere with maturation of RTKs. This study reveals that, by virtue of their phosphorylating of Flt3, Kit and possibly other RTKs, SFKs can regulate maturation of these RTKs and consequently alter their transport to the plasma membrane. Further studies are required to investigate the biological relevance of this function of SFKs.

Aktivierende Mutationen in der juxtamembranösen Region (FLT3-Längenmutationen, FLT3-LM; FLT3- Interne Tandemduplikation, FLT3-ITD) und der Tyrosinkinase-Domäne (FLT3-TKD, FLT3-D835) von FLT3 stellen die häufigsten genetischen Alterationen in der AML dar und definieren eine klinisch-prognostische-Subgruppe in der AML. In der vorliegenden Arbeit wurden zwei neue Mutationen in FLT3 identifiziert und charakterisiert. Die erste Mutation (FLT3-840GS) wurde in zwei Patientenproben nachgewiesen. Moleculargenetisch stellte diese eine Längenmutation in Exon 20 dar, und war durch eine 6 bp-grosse Insertion bzw. Glycin+Serin Insertion in der Aktivierungsschleife der katalytischen Domäne zwischen den Kodons 840 und 841 nahe der Aktivierungsschleife verursacht. Die zweite Mutation, eine aktivierende Punktmutation in der JM-Region von FLT3 (FLT3-V592A) wurde in den AML-Zelllinien MonoMac 6 und MonoMac 1 identifiziert. Die funktionelle Analyse ergab, dass diese Mutanten eine konstitutive Tyrosinphosphorylierung aufweisen und zu einem IL-3 unabhängigem Wachstum in Ba/F3 Zellen führen, welches durch einen spezifischen Proteintyrosinekinase (PTK) Inhibitor gehemmt werden konnte. Diese Ergebnisse zeigen, dass neben den bisher beschriebenen noch weitere aktivierende Mutationen in der JM- und der katalytischen Domäne in FLT3 Gen existieren. Die weiteren Untersuchungen zeigten, dass verschiedene FLT3-TKD (D835) Mutationen eine deutlich unterschiedliche Empfindlichkeit gegenüber selektiven FLT3 PTK Inhibitoren aufwiesen. Weiter wurde gezeigt, dass durch kontinuierliche Exposition von FLT3-ITD transformierten Leukämiezellen mit dem FLT3 PTK Inhibitor SU5614 in vitro resistente Mutanten generiert werden können. Die molekulare und funktionelle Charakterisierung dieser SU5614-resistenten Zelllinien (Ba/F3 FLT3-ITDR1-4) ergab, dass spezifische Mutationen in der TKD-Domäne ursächlich für die Inhibitorresistenz verantwortlich waren. Die FLT3-ITD-R1-4 Zellen wiesen somit Doppelmutationen im FLT3-Gen (LM + TKD) auf und waren durch eine 7-26-fach höhere IC50 gegenüber dem Inhibitor gekennzeichnet. Solche Doppelmutanten von FLT3 wurden mittels in- vitro- Mutagenese generiert und rekapitulieren in Ba/F3 Zellen den SU5614-resistenten Phänotyp. Diese Ergebnisse zeigen, dass prä-existierende oder erworbene FLT3-TKD Mutationen Resistenzen gegenüber FLT3-PTK Inhibitoren in vitro induzieren können. Diese Befunde stellen die molekulare Basis für zelluläre Resistenzen gegenüber FLT3-PTK Inhibitoren bei Patienten mit AML dar.