bims-tremyl 2021-07-04 papers

bims-tremyl

Biomed News

on Therapy resistance biology in myeloid leukemia

Issue of 2021–07–04
thirty papers selected by
Paolo Gallipoli, Barts Cancer Institute, Queen Mary University of London

Outcomes in patients with newly diagnosed TP53-mutated acute myeloid leukemia with or without venetoclax-based therapy.
Distinguishing AML from MDS: a fixed blast percentage may no longer be optimal.
Driving CAR T Stem Cell Targeting in Acute Myeloid Leukemia: The Roads to Success.
Autophagy a Close Relative of AML Biology.
Integrated genomic-metabolic classification of acute myeloid leukemia defines a subgroup with NPM1 and cohesin/DNA damage mutations.
Polo-like kinase inhibition as a therapeutic target in acute myeloid leukemia.
Efficacy and Safety Profile of Ivosidenib in the Management of Patients with Acute Myeloid Leukemia (AML): An Update on the Emerging Evidence.
A Humanized Animal Model Predicts Clonal Evolution and Therapeutic Vulnerabilities in Myeloproliferative Neoplasms.
Neonatal heel prick mass spectrometry identifies metabolic predictors of AML latency.
Acute Myeloid Leukemia: Historical Perspective and Progress in Research and Therapy Over 5 Decades.
Increasing recognition and emerging therapies argue for dedicated clinical trials in chronic myelomonocytic leukemia.
Eradication of Measurable Residual Disease in AML: A Challenging Clinical Goal.
Network Analysis Reveals Synergistic Genetic Dependencies for Rational Combination Therapy in Philadelphia Chromosome-like Acute Lymphoblastic Leukemia.
Clonal Hematopoiesis after Autologous Stem Cell Transplantation Does Not Confer Adverse Prognosis in Patients with AML.
Acute promyelocytic leukemia current treatment algorithms.
Targeted and cytotoxic therapies as maintenance treatment for non-transplant eligible patients with acute myeloid leukemia.
Repeat to gene expression ratios in leukemic blast cells can stratify risk prediction in acute myeloid leukemia.
TET2 and DNMT3A Mutations Exert Divergent Effects on DNA Repair and Sensitivity of Leukemia Cells to PARP Inhibitors.
Interferon-α as maintenance therapy can significantly reduce relapse in patients with favorable-risk acute myeloid leukemia.
U2AF1 mutation promotes tumorigenicity through facilitating autophagy flux mediated by FOXO3a activation in myelodysplastic syndromes.
Cellular Metabolomics Profiles Associated With Drug Chemosensitivity in AML.
Myelodysplastic Syndromes in the Postgenomic Era and Future Perspectives for Precision Medicine.
Transcript-Level Dysregulation of BCL2 Family Genes in Acute Myeloblastic Leukemia.
High lactate dehydrogenase at time of admission for allogeneic hematopoietic transplantation associates to poor survival in acute myeloid leukemia and non-Hodgkin lymphoma.
Releasing the brake on protein synthesis in hematopoietic stem cells.
AF10 (MLLT10) prevents somatic cell reprogramming through regulation of DOT1L-mediated H3K79 methylation.
Daratumumab-Based Treatment for Immunoglobulin Light-Chain Amyloidosis.
Hierarchical distribution of somatic variants in newly diagnosed chronic myeloid leukaemia at diagnosis and early follow-up.
Dasatinib dose optimisation based on therapeutic drug monitoring reduces pleural effusion rates in chronic myeloid leukaemia patients.
Clonal hematopoiesis and its emerging effects on cellular therapies.

Cancer. 2021 Jun 28.

Outcomes in patients with newly diagnosed TP53-mutated acute myeloid leukemia with or without venetoclax-based therapy.

Sangeetha Venugopal, Mahran Shoukier, Marina Konopleva, Courtney D Dinardo, Farhad Ravandi, Nicholas J Short, Michael Andreeff, Gautam Borthakur, Naval Daver, Naveen Pemmaraju, Koji Sasaki, Guillermo Montalban-Bravo, Kayleigh R Marx, Sherry Pierce, Uday R Popat, Elizabeth J Shpall, Rashmi Kanagal-Shamanna, Guillermo Garcia-Manero, Hagop M Kantarjian, Tapan M Kadia.

   BACKGROUND: Venetoclax (VEN) in combination with a hypomethylating agent (HMA) has become the standard of care for patients aged >75 years and for those not eligible for intensive chemotherapy who have newly diagnosed acute myeloid leukemia (AML). The benefit of VEN-based therapy in patients who have newly diagnosed AML with mutations in the TP53 gene (TP53mut ) over standard therapy is undefined.
METHODS: In this single-institutional, retrospective analysis, the authors assessed the clinical outcomes of 238 patients with newly diagnosed TP53mut AML and compared the clinical characteristics, response to different therapies, and outcomes of those who received VEN-based (n = 58) and non-VEN-based (n = 180) regimens.
RESULTS: Patients who received VEN-based regimens were older (aged >65 years: 81% vs 65%; P = .02) and had higher response rates (complete remission, 43% vs 32%; P = .06) than those who received non-VEN-based regimens. Compared with patients who received non-VEN-based regimens, no difference in overall survival (median, 6.6 vs 5.7 months; P = .4) or relapse-free survival (median, 4.7 vs 3.5 months; P = .43) was observed in those who received VEN-based regimens, regardless of age or intensity of treatment.
CONCLUSIONS: The addition of VEN to standard treatment regimens did not improve outcomes in younger or older patients who had TP53mut AML. These data highlight the need for novel therapies beyond VEN to improve the outcome of patients with TP53mut AML.

Keywords:   TP53 ; acute myeloid leukemia (AML); hypomethylating agent; venetoclax (VEN)

DOI:  https://doi.org/10.1002/cncr.33675
Blood. 2021 06 10. pii: blood.2021011304. [Epub ahead of print]

Distinguishing AML from MDS: a fixed blast percentage may no longer be optimal.

Elihu H Estey, Robert P Hasserjian, Hartmut Döhner.

Patients with acute myeloid leukemia (AML) have conventionally received more "intense" therapy than patients with myelodysplastic syndromes (MDS). Although less intense therapies are being used more often in AML, the AML-MDS dichotomy remains, with the presence of ≥ 20% myeloblasts in marrow or peripheral blood generally regarded as defining AML. Consequently, patients with 19% blasts are typically ineligible for AML studies, with patients with 21% blasts ineligible for MDS studies. Here we cite biologic and clinical data to question this practice. Biologically, abnormalities in chromosome 3q26,and mutations in NPM1, and FLT3, regarded as AML-associated, also occur in MDS. The genetic signatures of MDS, particularly cases with 10-19% blasts (MDS-EB2), resemble those of AML following a preceding MDS ("secondary AML"). Mutationally, secondary AML appears at least as similar to MDS-EB2 as to de novo AML. Patients presenting with de novo AML but with secondary-type AML mutations, appear to have the same poor prognoses associated with clinically defined secondary AML. Seattle data indicate that after accounting for European LeukemiaNet (ELN) 2017 risk, age, performance status, clinically secondary AML, and treatment including allogeneic transplant, patients with WHO-defined AML (n=769) have similar rates of OS, EFS and CR/CRi as patients with MDS-EB2 (n=202). We suggest defining patients with 10-30% blasts ("AML/MDS") as eligible for either AML or MDS studies. This would permit empirical testing of the independent effect of blast percentage on outcome, allow patients access to more therapies, and potentially simplify the regulatory approval process.

DOI: https://doi.org/10.1182/blood.2021011304
Cancers (Basel). 2021 Jun 05. pii: 2816. [Epub ahead of print]13(11):

Driving CAR T Stem Cell Targeting in Acute Myeloid Leukemia: The Roads to Success.

Ilaria M Michelozzi, Efstratios Kirtsios, Alice Giustacchini.

  Current treatment outcome for acute myeloid leukemia (AML) patients is unsatisfactory and characterized by high rates of relapse and poor overall survival. Increasing evidence points to a crucial role of leukemic stem cells (LSC) and the bone marrow (BM) leukemic niche, in which they reside, in AML evolution and chemoresistance. Thus, future strategies aiming at improving AML therapeutic protocols are likely to be directed against LSC and their niche. Chimeric antigen receptor (CAR) T-cells have been extremely successful in the treatment of relapsed/refractory acute lymphoblastic leukemia and B-cell non-Hodgkin lymphoma and comparable results in AML are highly desirable. At present, we are at the dawn of CAR T-cell application in AML, with several preclinical studies and few early phase clinical trials. However, the lack of leukemia-specific targets and the genetic and phenotypic heterogeneity of the disease combined with the leukemia-induced remodeling of the BM microenvironment are limiting CAR T-cell exploitation in AML. Here, we reviewed AML-LSC and AML-BM niche features in the context of their therapeutic targeting using CAR T-cells. We summarized recent progress in CAR T-cell application to the treatment of AML, and we discussed the remaining therapeutic challenges and promising novel strategies to overcome them.

Keywords:  acute myeloid leukemia; bone marrow niche; chimeric antigen receptor T-cells; leukemic stem cells

DOI:  https://doi.org/10.3390/cancers13112816
Biology (Basel). 2021 Jun 18. pii: 552. [Epub ahead of print]10(6):

Autophagy a Close Relative of AML Biology.

Carine Joffre, Charlotte Ducau, Laura Poillet-Perez, Charly Courdy, Véronique Mansat-De Mas.

  Autophagy, which literally means "eat yourself", is more than just a lysosomal degradation pathway. It is a well-known regulator of cellular metabolism and a mechanism implicated in tumor initiation/progression and therapeutic resistance in many cancers. However, whether autophagy acts as a tumor suppressor or promoter is still a matter of debate. In acute myeloid leukemia (AML), it is now proven that autophagy supports cell proliferation in vitro and leukemic progression in vivo. Mitophagy, the specific degradation of mitochondria through autophagy, was recently shown to be required for leukemic stem cell functions and survival, highlighting the prominent role of this selective autophagy in leukemia initiation and progression. Moreover, autophagy in AML sustains fatty acid oxidation through lipophagy to support mitochondrial oxidative phosphorylation (OxPHOS), a hallmark of chemotherapy-resistant cells. Nevertheless, in the context of therapy, in AML, as well as in other cancers, autophagy could be either cytoprotective or cytotoxic, depending on the drugs used. This review summarizes the recent findings that mechanistically show how autophagy favors leukemic transformation of normal hematopoietic stem cells, as well as AML progression and also recapitulates its ambivalent role in resistance to chemotherapies and targeted therapies.

Keywords:  AML; autophagy; hematopoiesis; mitophagy; therapy

DOI:  https://doi.org/10.3390/biology10060552
Leukemia. 2021 Jun 30.

Integrated genomic-metabolic classification of acute myeloid leukemia defines a subgroup with NPM1 and cohesin/DNA damage mutations.

Giorgia Simonetti, Carlo Mengucci, Antonella Padella, Eugenio Fonzi, Gianfranco Picone, Claudio Delpino, Jacopo Nanni, Rossella De Tommaso, Eugenia Franchini, Cristina Papayannidis, Giovanni Marconi, Martina Pazzaglia, Margherita Perricone, Emanuela Scarpi, Maria Chiara Fontana, Samantha Bruno, Michela Tebaldi, Anna Ferrari, Maria Teresa Bochicchio, Andrea Ghelli Luserna Di Rorà, Martina Ghetti, Roberta Napolitano, Annalisa Astolfi, Carmen Baldazzi, Viviana Guadagnuolo, Emanuela Ottaviani, Ilaria Iacobucci, Michele Cavo, Gastone Castellani, Torsten Haferlach, Daniel Remondini, Francesco Capozzi, Giovanni Martinelli.

Although targeting of cell metabolism is a promising therapeutic strategy in acute myeloid leukemia (AML), metabolic dependencies are largely unexplored. We aimed to classify AML patients based on their metabolic landscape and map connections between metabolic and genomic profiles. Combined serum and urine metabolomics improved AML characterization compared with individual biofluid analysis. At intracellular level, AML displayed dysregulated amino acid, nucleotide, lipid, and bioenergetic metabolism. The integration of intracellular and biofluid metabolomics provided a map of alterations in the metabolism of polyamine, purine, keton bodies and polyunsaturated fatty acids and tricarboxylic acid cycle. The intracellular metabolome distinguished three AML clusters, correlating with distinct genomic profiles: NPM1-mutated(mut), chromatin/spliceosome-mut and TP53-mut/aneuploid AML that were confirmed by biofluid analysis. Interestingly, integrated genomic-metabolic profiles defined two subgroups of NPM1-mut AML. One was enriched for mutations in cohesin/DNA damage-related genes (NPM1/cohesin-mut AML) and showed increased serum choline + trimethylamine-N-oxide and leucine, higher mutation load, transcriptomic signatures of reduced inflammatory status and better ex-vivo response to EGFR and MET inhibition. The transcriptional differences of enzyme-encoding genes between NPM1/cohesin-mut and NPM1-mut allowed in silico modeling of intracellular metabolic perturbations. This approach predicted alterations in NAD and purine metabolism in NPM1/cohesin-mut AML that suggest potential vulnerabilities, worthy of being therapeutically explored.

DOI: https://doi.org/10.1038/s41375-021-01318-x
Oncotarget. 2021 Jun 22. 12(13): 1314-1317

Polo-like kinase inhibition as a therapeutic target in acute myeloid leukemia.

Jan Philipp Bewersdorf, Amer M Zeidan.



Keywords:  AML; PLK-1 inhibitor; acute myeloid leukemia; onvansertib; volasertib

DOI:  https://doi.org/10.18632/oncotarget.27919
Blood Lymphat Cancer. 2021 ;11 41-54

Efficacy and Safety Profile of Ivosidenib in the Management of Patients with Acute Myeloid Leukemia (AML): An Update on the Emerging Evidence.

Galia Stemer, Jacob M Rowe, Yishai Ofran.

  The isocitrate dehydrogenase enzyme, catalyzing isocitrate conversion to α-ketoglutarate (αKG) in both the cell cytoplasm and mitochondria, contributes to the production of dihydronicotinamide-adenine dinucleotide phosphate (NADPH) as a reductive potential in various cellular processes. IDH1 gene mutations are revealed in up to 20% of the patients with acute myeloid leukemia (AML). A mutant IDH enzyme, existing in the cell cytoplasm and possessing neomorphic activity, converts αKG into oncometabolite R-2-hydroxyglutarate (R-2-HG) that accumulates in high amounts in the cell and inhibits αKG-dependent enzymes, including epigenetic regulators. The resultant alteration in gene expression and blockade of differentiation ultimately lead to leukemia development. Myeloid differentiation capacity can be restored by obstruction of the mutant enzyme, inducing substantial reduction in R-2-HG levels. Ivosidenib, a potent selective inhibitor of mutant IDH1, is a differentiating agent shown to be clinically effective in newly diagnosed AML (ND-AML) and relapsed/refractory (R/R) AML harboring this mutation. The drug is approved by the Food and Drug Administration (FDA) as a single-agent treatment for R/R AML. Significance of mutated IDH1 targeting and a potential role of ivosidenib in AML management, when used either as a single agent or as part of combination therapies, will be reviewed herein.

Keywords:  acute myeloid leukemia; ivosidenib; mutant IDH1

DOI:  https://doi.org/10.2147/BLCTT.S236446
Cancer Discov. 2021 Jun 30. pii: candisc.1652.2020. [Epub ahead of print]

A Humanized Animal Model Predicts Clonal Evolution and Therapeutic Vulnerabilities in Myeloproliferative Neoplasms.

Hamza Celik, Ethan Krug, Christine R Zhang, Wentao Han, Nancy Issa, Won Kyun Koh, Hassan Bjeije, Ostap Kukhar, Maggie Allen, Tiandao Li, Daniel Ac Fisher, Jared S Fowles, Terrence N Wong, Matthew C Stubbs, Holly K Koblish, Stephen T Oh, Grant A Challen.

Myeloproliferative neoplasms (MPNs) are chronic blood diseases with significant morbidity and mortality. While sequencing studies have elucidated the genetic mutations that drive these diseases, MPNs remain largely incurable with a significant proportion of patients progressing to rapidly fatal secondary acute myeloid leukemia (sAML). Therapeutic discovery has been hampered by the inability of genetically-engineered mouse models to generate key human pathologies such as bone marrow fibrosis. To circumvent these limitations, here we present a humanized animal model of myelofibrosis (MF) patient-derived xenografts (PDXs). These PDXs robustly engrafted patient cells that recapitulated the patient's genetic hierarchy and pathologies such as reticulin fibrosis and propagation of MPN-initiating stem cells. The model can select for engraftment of rare leukemic subclones to identify MF patients at-risk for sAML transformation, and can be used as a platform for genetic target validation and therapeutic discovery. We present a novel but generalizable model to study human MPN biology.

DOI: https://doi.org/10.1158/2159-8290.CD-20-1652
Leuk Res. 2021 Jun 15. pii: S0145-2126(21)00145-4. [Epub ahead of print]109 106644

Neonatal heel prick mass spectrometry identifies metabolic predictors of AML latency.

Kelly Lim, Chloe Thompson-Peach, Daniel Thomas.

  Ongoing research efforts that consider cancer as a disease of dramatically altered cellular metabolism have accelerated interest in snapshot metabolomics in various human tissues. In this issue of Leukemia Research, Petrick et al performed metabolomic analysis on newborn blood spots and found a number of unexpected ceramide and sphingolipid compounds that may play a role in the development and latency of pediatric acute myeloid leukemia (AML). The chemical complexity and range of cellular metabolites massively exceeds the relatively limited building blocks of the transcriptome or the proteome and has high potential to find novel leukemia-specific macromolecular synthesis pathways, metabolic vulnerabilities and biomarkers.

Keywords:  AML; Dried blood spots; Heel prick; Leukemia; Mass spectrometry; Metabolic predictors; Metabolomics

DOI:  https://doi.org/10.1016/j.leukres.2021.106644
Clin Lymphoma Myeloma Leuk. 2021 May 29. pii: S2152-2650(21)00203-2. [Epub ahead of print]

Acute Myeloid Leukemia: Historical Perspective and Progress in Research and Therapy Over 5 Decades.

Hagop M Kantarjian, Nicholas J Short, Amir T Fathi, Guido Marcucci, Farhad Ravandi, Martin Tallman, Eunice S Wang, Andrew H Wei.

  With the Food and Drug Administration approval of 9 agents for different acute myeloid leukemia (AML) indications, the prognosis and management of AML is evolving rapidly. Herein, we review the important milestones in the history of AML research and therapy, discuss insights regarding prognostic assessment and prediction of treatment outcome, detail practical supportive care measures, and summarize the current treatment landscape and areas of evolving research.

Keywords:  AML; Biology; Prognosis; Targeted therapy; Therapy

DOI:  https://doi.org/10.1016/j.clml.2021.05.016
Leukemia. 2021 Jun 26.

Increasing recognition and emerging therapies argue for dedicated clinical trials in chronic myelomonocytic leukemia.

Aline Renneville, Mrinal M Patnaik, Onyee Chan, Eric Padron, Eric Solary.

Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping features of myelodysplastic syndromes (MDS) and myeloproliferative neoplasms (MPN). Median overall survival of this aggressive myeloid malignancy is only 2-3 years, with a 15-30% risk of acute leukemic transformation. The paucity of clinical trials specifically designed for CMML has made therapeutic management of CMML patients challenging. As a result, treatment paradigms for CMML patients are largely borrowed from MDS and MPN. The standard of care still relies on hydroxyurea, hypomethylating agents (HMA), and allogeneic stem cell transplantation, this latter option remaining the only potentially curative therapy. To date, approved drugs for CMML treatment are HMA, including azacitidine, decitabine, and more recently the oral combination of decitabine and cedazuridine. However, HMA treatment does not meaningfully alter the natural course of this disease. New treatment approaches for improving CMML-associated cytopenias or targeting the CMML malignant clone are emerging. More than 25 therapeutic agents are currently being evaluated in phase 1 or phase 2 clinical trials for CMML and other myeloid malignancies, often in combination with a HMA backbone. Several novel agents, such as sotatercept, ruxolitinib, lenzilumab, and tagraxofusp have shown promising clinical efficacy in CMML. Current evidence supports the idea that effective treatment in CMML will likely require combination therapy targeting multiple pathways, which emphasizes the need for additional new therapeutic options. This review focuses on recent therapeutic advances and innovative treatment strategies in CMML, including global and molecularly targeted approaches. We also discuss what may help to make progress in the design of rationally derived and disease-modifying therapies for CMML.

DOI: https://doi.org/10.1038/s41375-021-01330-1
Cancers (Basel). 2021 Jun 25. pii: 3170. [Epub ahead of print]13(13):

Eradication of Measurable Residual Disease in AML: A Challenging Clinical Goal.

Paolo Bernasconi, Oscar Borsani.

  In non-promyelocytic (non-M3) AML measurable residual disease (MRD) detected by multi-parameter flow cytometry and molecular technologies, which are guided by Consensus-based guidelines and discover very low leukemic cell numbers far below the 5% threshold of morphological assessment, has emerged as the most relevant predictor of clinical outcome. Currently, it is well-established that MRD positivity after standard induction and consolidation chemotherapy, as well as during the period preceding an allogeneic hematopoietic stem cell transplant (allo-HSCT), portends to a significantly inferior relapse-free survival (RFS) and overall survival (OS). In addition, it has become absolutely clear that conversion from an MRD-positive to an MRD-negative state provides a favorable clinical outcome similar to that associated with early MRD negativity. Thus, the complete eradication of MRD, i.e., the clearance of the few leukemic stem cells-which, due to their chemo-radiotherapy resistance, might eventually be responsible of disease recurrence-has become an un-met clinical need in AML. Nowadays, this goal might potentially be achieved thanks to the development of novel innovative treatment strategies, including those targeting driver mutations, apoptosis, methylation patterns and leukemic proteins. The aim of this review is to analyze these strategies and to suggest any potential combination able to induce MRD negativity in the pre- and post-HSCT period.

Keywords:  AML; MFC; MRD; RT-qPCR

DOI:  https://doi.org/10.3390/cancers13133170
Clin Cancer Res. 2021 Jul 01. pii: clincanres.0553.2021. [Epub ahead of print]

Network Analysis Reveals Synergistic Genetic Dependencies for Rational Combination Therapy in Philadelphia Chromosome-like Acute Lymphoblastic Leukemia.

Yang-Yang Ding, Hannah Kim, Kellyn Madden, Joseph P Loftus, Gregory M Chen, David Hottman Allen, Ruitao Zhang, Jason Xu, Chia-Hui Chen, Yuxuan Hu, Sarah K Tasian, Kai Tan.

PURPOSE: Systems biology approaches can identify critical targets in complex cancer signaling networks to inform new therapy combinations that may overcome conventional treatment resistance.
EXPERIMENTAL DESIGN: We performed integrated analysis of 1,046 childhood B-ALL cases and developed a data-driven network controllability-based approach to identify synergistic key regulator targets in Philadelphia chromosome-like B-acute lymphoblastic leukemia (Ph-like B-ALL), a common high-risk leukemia subtype associated with hyperactive signal transduction and chemoresistance.
RESULTS: We identified 14 dysregulated network nodes in Ph-like ALL involved in aberrant JAK/STAT, Ras/MAPK, and apoptosis pathways and other critical processes. Genetic co-targeting of the synergistic key regulator pair STAT5B and BCL2-associated athanogene 1 (BAG1) significantly reduced leukemia cell viability in vitro Pharmacologic inhibition with dual small molecule inhibitor therapy targeting this pair of key nodes further demonstrated enhanced anti-leukemia efficacy of combining the BCL-2 inhibitor venetoclax with the tyrosine kinase inhibitors ruxolitinib or dasatinib in vitro in human Ph-like ALL cell lines and in vivo in multiple childhood Ph-like ALL patient-derived xenograft models. Consistent with network controllability theory, co-inhibitor treatment also shifted the transcriptomic state of Ph-like ALL cells to become less like kinase-activated BCR-ABL1-rearranged (Ph+) B-ALL and more similar to prognostically-favorable childhood B-ALL subtypes.
CONCLUSIONS: Our study represents a powerful conceptual framework for combinatorial drug discovery based on systematic interrogation of synergistic vulnerability pathways with pharmacologic inhibitor validation in preclinical human leukemia models.

DOI: https://doi.org/10.1158/1078-0432.CCR-21-0553
Cancers (Basel). 2021 Jun 25. pii: 3190. [Epub ahead of print]13(13):

Clonal Hematopoiesis after Autologous Stem Cell Transplantation Does Not Confer Adverse Prognosis in Patients with AML.

Alexander D Heini, Naomi Porret, Reinhard Zenhaeusern, Annette Winkler, Ulrike Bacher, Thomas Pabst.

   INTRODUCTION: Despite a 50% cure rate, relapse remains the main cause of death in patients with acute myeloid leukemia (AML) consolidated with autologous stem cell transplantation (ASCT) in first remission (CR1). Clonal hematopoiesis of indeterminate potential (CH) increases the risk for hematological and cardiovascular disorders and death. The impact of CH persisting after ASCT in AML patients is unclear.
MATERIALS AND METHODS: We retrospectively investigated the prognostic value of persisting DNMT3A, TET2, or ASXL1 (DTA) mutations after ASCT. Patients underwent stratification depending on the presence of DTA mutations.
RESULTS: We investigated 110 consecutive AML patients receiving ASCT in CR1 after two induction cycles at our center between 2007 and 2020. CH-related mutations were present in 31 patients (28.2%) after ASCT. The baseline characteristics were similar between patients with or without persisting DTA mutations after ASCT. The median progression free survival was 26.9 months in patients without DTA mutations and 16.7 months in patients with DTA mutations (HR 0.75 (0.42-1.33), p = 0.287), and the median overall survival was 80.9 and 54.4 months (HR 0.79 (0.41-1.51), p = 0.440), respectively.
CONCLUSION: We suggest that DTA-CH after ASCT is not associated with an increased risk of relapse or death. The persistence of DTA mutations after induction should not prevent AML patients in CR1 from ASCT consolidation. Independent studies should confirm these data.

Keywords:  acute myeloid leukemia (AML); autologous stem cell transplantation (ASCT); clonal hematopoiesis (CH); outcome; prognosis

DOI:  https://doi.org/10.3390/cancers13133190
Blood Cancer J. 2021 Jun 30. 11(6): 123

Acute promyelocytic leukemia current treatment algorithms.

Musa Yilmaz, Hagop Kantarjian, Farhad Ravandi.

In 1957, Hillestad et al. defined acute promyelocytic leukemia (APL) for the first time in the literature as a distinct type of acute myeloid leukemia (AML) with a "rapid downhill course" characterized with a severe bleeding tendency. APL, accounting for 10-15% of the newly diagnosed AML cases, results from a balanced translocation, t(15;17) (q22;q12-21), which leads to the fusion of the promyelocytic leukemia (PML) gene with the retinoic acid receptor alpha (RARA) gene. The PML-RARA fusion oncoprotein induces leukemia by blocking normal myeloid differentiation. Before using anthracyclines in APL therapy in 1973, no effective treatment was available. In the mid-1980s, all-trans retinoic acid (ATRA) monotherapy was used with high response rates, but response durations were short. Later, the development of ATRA, chemotherapy, and arsenic trioxide combinations turned APL into a highly curable malignancy. In this review, we summarize the evolution of APL therapy, focusing on key milestones that led to the standard-of-care APL therapy available today and discuss treatment algorithms and management tips to minimize induction mortality.

DOI: https://doi.org/10.1038/s41408-021-00514-3
Blood Rev. 2021 Jun 21. pii: S0268-960X(21)00069-2. [Epub ahead of print] 100863

Targeted and cytotoxic therapies as maintenance treatment for non-transplant eligible patients with acute myeloid leukemia.

Shyam A Patel, Mark R Litzow, Jan Cerny.

  In the recent years, there have been multiple approvals by the Food and Drug Administration (FDA) for therapeutics for acute myeloid leukemia (AML). The role of maintenance therapy in AML has been rather unrealized mostly due to lack of efficacy and increased toxicity of classical chemotherapy agents. Many clinical trials have demonstrated a disease-free survival benefit for various therapeutics in the maintenance setting for patients with AML who are ineligible for stem cell transplant. Notably, oral hypomethylating agent therapy has recently shown an overall survival and disease-free survival benefit in the maintenance setting for AML. In this review, we summarize the relevant data on maintenance therapy with a specific focus on cytotoxic antimetabolite chemotherapeutics, hypomethylating agents, targeted agents, and immunotherapeutics. We discuss our approach to maintenance therapy in AML in 2021 and propose a measurable residual disease (MRD)-adapted, personalized approach based on the best available evidence.

Keywords:  Acute myeloid leukemia; Maintenance therapy; Measurable residual disease; Stem cell transplantation; Targeted therapy

DOI:  https://doi.org/10.1016/j.blre.2021.100863
BMC Med Genomics. 2021 Jun 26. 14(1): 166

Repeat to gene expression ratios in leukemic blast cells can stratify risk prediction in acute myeloid leukemia.

M Onishi-Seebacher, G Erikson, Z Sawitzki, D Ryan, G Greve, M Lübbert, T Jenuwein.

BACKGROUND: Repeat elements constitute a large proportion of the human genome and recent evidence indicates that repeat element expression has functional roles in both physiological and pathological states. Specifically for cancer, transcription of endogenous retrotransposons is often suppressed to attenuate an anti-tumor immune response, whereas aberrant expression of heterochromatin-derived satellite RNA has been identified as a tumor driver. These insights demonstrate separate functions for the dysregulation of distinct repeat subclasses in either the attenuation or progression of human solid tumors. For hematopoietic malignancies, such as Acute Myeloid Leukemia (AML), only very few studies on the expression/dysregulation of repeat elements were done.
METHODS: To study the expression of repeat elements in AML, we performed total-RNA sequencing of healthy CD34 + cells and of leukemic blast cells from primary AML patient material. We also developed an integrative bioinformatic approach that can quantify the expression of repeat transcripts from all repeat subclasses (SINE/ALU, LINE, ERV and satellites) in relation to the expression of gene and other non-repeat transcripts (i.e. R/G ratio). This novel approach can be used as an instructive signature for repeat element expression and has been extended to the analysis of poly(A)-RNA sequencing datasets from Blueprint and TCGA consortia that together comprise 120 AML patient samples.
RESULTS: We identified that repeat element expression is generally down-regulated during hematopoietic differentiation and that relative changes in repeat to gene expression can stratify risk prediction of AML patients and correlate with overall survival probabilities. A high R/G ratio identifies AML patient subgroups with a favorable prognosis, whereas a low R/G ratio is prevalent in AML patient subgroups with a poor prognosis.
CONCLUSIONS: We developed an integrative bioinformatic approach that defines a general model for the analysis of repeat element dysregulation in physiological and pathological development. We find that changes in repeat to gene expression (i.e. R/G ratios) correlate with hematopoietic differentiation and can sub-stratify AML patients into low-risk and high-risk subgroups. Thus, the definition of a R/G ratio can serve as a valuable biomarker for AML and could also provide insights into differential patient response to epigenetic drug treatment.

DOI: https://doi.org/10.1186/s12920-021-01003-z
Cancer Res. 2021 Jul 02. pii: canres.3761.2020. [Epub ahead of print]

TET2 and DNMT3A Mutations Exert Divergent Effects on DNA Repair and Sensitivity of Leukemia Cells to PARP Inhibitors.

Silvia Maifrede, Bac Viet Le, Margaret Nieborowska-Skorska, Konstantin Golovine, Katherine Sullivan-Reed, Wangisa M B Dunuwille, Joseph Nacson, Michael Hulse, Kelsey Keith, Jozef Madzo, Lisa Beatrice Caruso, Zachary Gazze, Zhaorui Lian, Antonella Padella, Kumaraswamy N Chitrala, Boris A Bartholdy, Ksenia Matlawska-Wasowska, Daniela Di Marcantonio, Giorgia Simonetti, Georg Greiner, Stephen M Sykes, Peter Valent, Elisabeth M Paietta, Martin S Tallman, Hugo F Fernandez, Mark R Litzow, Mark D Minden, Jian Huang, Giovanni Martinelli, George S Vassiliou, Italo Tempera, Katarzyna Piwocka, Neil Johnson, Grant A Challen, Tomasz Skorski.

Somatic variants in TET2 and DNMT3A are founding mutations in hematological malignancies that affect the epigenetic regulation of DNA methylation. Mutations in both genes often co-occur with activating mutations in oncogenic tyrosine kinases such as FLT3ITD, BCR-ABL1, JAK2V617F, and MPLW515L, or with mutations affecting related signaling pathways such as NRASG12D and CALRdel52. Here we show that TET2 and DNMT3A mutations exert divergent roles in regulating DNA repair activities in leukemia cells expressing these oncogenes. Malignant TET2-deficient cells displayed downregulation of BRCA1 and LIG4, resulting in reduced activity of BRCA1/2-mediated homologous recombination (HR) and DNA-PK -mediated non-homologous end-joining (D-NHEJ), respectively. TET2-deficient cells relied on PARP1-mediated alternative NHEJ (Alt-NHEJ) for protection from the toxic effects of spontaneous and drug-induced DNA double-strand breaks. Conversely, DNMT3A-deficient cells favored HR/D-NHEJ owing to downregulation of PARP1 and reduction of Alt-NHEJ. Consequently, malignant TET2-deficient cells were sensitive to PARP inhibitor (PARPi) treatment in vitro and in vivo, whereas DNMT3A-deficient cells were resistant. Disruption of TET2 dioxygenase activity or TET2 - Wilms tumor 1 (WT1) binding ability were responsible for DNA repair defects and sensitivity to PARPi associated with TET2 deficiency. Moreover, mutation or deletion of WT1 mimicked the effect of TET2 mutation on DSB repair activity and sensitivity to PARPi. Collectively, these findings reveal that TET2 and WT1 mutations may serve as biomarkers of synthetic lethality triggered by PARPi, which should be explored therapeutically.

DOI: https://doi.org/10.1158/0008-5472.CAN-20-3761
Leuk Lymphoma. 2021 Jul 01. 1-8

Interferon-α as maintenance therapy can significantly reduce relapse in patients with favorable-risk acute myeloid leukemia.

Hao Jiang, Xiao-Hong Liu, Jun Kong, Jing Wang, Jin-Song Jia, Sheng-Ye Lu, Li-Zhong Gong, Xiao-Su Zhao, Qian Jiang, Ying-Jun Chang, Yu Wang, Guo-Rui Ruan, Ya-Zhen Qin, Kai-Yan Liu, Xiao-Jun Huang.

  To evaluate the efficacy of interferon-α (IFN-α) as maintenance therapy in patients with favorable-risk acute myeloid leukemia (AML), this retrospective study enrolled 84 patients with favorable-risk AML: 42 patients who received IFN-α maintenance therapy and 42 patients who did not (control). The median follow-up time and duration of IFN-α treatment was 26 (6-54) months and 18 (2-24) months, respectively. The 4-year estimated relapse-free survival (RFS) after the last consolidation chemotherapy was 86.8% (95% confidence interval (CI), 75.8-97.8%) in the IFN-α group and 55.7% (95% CI, 37.2-74.3%) in the control group (p=.007). The 4-year estimated overall survival was 94.4% (95% CI, 86.8-102%) and 76.4% (95% CI, 61.9-90.9%) in IFN-α and control groups, respectively (p=.040). The Cox regression analysis showed that IFN-α treatment was the only independent factor affecting RFS (p=.004). Maintenance therapy with IFN-α may prevent relapse in favorable-risk AML after consolidation chemotherapy.

Keywords:  Acute myeloid leukemia; interferon-α; maintenance therapy; relapse

DOI:  https://doi.org/10.1080/10428194.2021.1948027
Cell Death Dis. 2021 Jun 28. 12(7): 655

U2AF1 mutation promotes tumorigenicity through facilitating autophagy flux mediated by FOXO3a activation in myelodysplastic syndromes.

Yuqian Zhu, Dandan Song, Juan Guo, Jiacheng Jin, Ying Tao, Zheng Zhang, Feng Xu, Qi He, Xiao Li, Chunkang Chang, Lingyun Wu.

Mutations in the U2 small nuclear RNA auxiliary factor 1 (U2AF1) gene are the common feature of a major subset in myelodysplastic syndromes (MDS). However, the genetic landscape and molecular pathogenesis of oncogenic U2AF1S34F mutation in MDS are not totally understood. We performed comprehensive analysis for prognostic significance of U2AF1 mutations in acute myeloid leukemia (AML) cohort based on The Cancer Genome Atlas (TCGA) database. Functional analysis of U2AF1S34F mutation was performed in vitro. Differentially expressed genes (DEGs) and significantly enriched pathways were identified by RNA sequencing. The forkhead box protein O3a (FOXO3a) was investigated to mediate the function of U2AF1S34F mutation in cell models using lentivirus. Chromatin immunoprecipitation, immunoblotting analyses, and immunofluorescence assays were also conducted. U2AF1 mutations were associated with poor prognosis in MDS and AML samples, which significantly inhibited cell proliferation and induced cellular apoptosis in cell models. Our data identified that U2AF1-mutant cell lines undergo FOXO3a-dependent apoptosis and NLRP3 inflammasome activation, which induces pyroptotic cell death. Particularly, an increase in the level of FOXO3a promoted the progression of MDS in association with restored autophagy program leading to NLRP3 inflammasome activation in response to U2AF1S34F mutation. Based on the result that U2AF1S34F mutation promoted the transcriptional activity of Bim through upregulating FOXO3a with transactivation of cell cycle regulators p21Cip1 and p27Kip1, FOXO3a, a potentially cancer-associated transcription factor, was identified as the key molecule on which these pathways converge. Overall, our studies provide new insights that U2AF1S34F mutation functions the crucial roles in mediating MDS disease progression via FOXO3a activation, and demonstrate novel targets of U2AF1 mutations to the pathogenesis of MDS.

DOI: https://doi.org/10.1038/s41419-021-03573-3
Front Oncol. 2021 ;11 678008

Cellular Metabolomics Profiles Associated With Drug Chemosensitivity in AML.

Bradley Stockard, Neha Bhise, Miyoung Shin, Joy Guingab-Cagmat, Timothy J Garrett, Stanley Pounds, Jatinder K Lamba.

   Background: Acute myeloid leukemia (AML) is a hematological malignancy with a dismal prognosis. For over four decades, AML has primarily been treated by cytarabine combined with an anthracycline. Although a significant proportion of patients achieve remission with this regimen, roughly 40% of children and 70% of adults relapse. Over 90% of patients with resistant or relapsed AML die within 3 years. Thus, relapsed and resistant disease following treatment with standard therapy are the most common clinical failures that occur in treating this disease. In this study, we evaluated the relationship between AML cell line global metabolomes and variation in chemosensitivity.
Methods: We performed global metabolomics on seven AML cell lines with varying chemosensitivity to cytarabine and the anthracycline doxorubicin (MV4.11, KG-1, HL-60, Kasumi-1, AML-193, ME1, THP-1) using ultra-high performance liquid chromatography - mass spectrometry (UHPLC-MS). Univariate and multivariate analyses were performed on the metabolite peak intensity values from UHPLC-MS using MetaboAnalyst to identify cellular metabolites associated with drug chemosensitivity.
Results: A total of 1,624 metabolic features were detected across the leukemic cell lines. Of these, 187 were annotated to known metabolites. With respect to doxorubicin, we observed significantly greater abundance of a carboxylic acid (1-aminocyclopropane-1-carboxylate) and several amino acids in resistant cell lines. Pathway analysis found enrichment of several amino acid biosynthesis and metabolic pathways. For cytarabine resistance, nine annotated metabolites were significantly different in resistance vs. sensitive cell lines, including D-raffinose, guanosine, inosine, guanine, aldopentose, two xenobiotics (allopurinol and 4-hydroxy-L-phenylglycine) and glucosamine/mannosamine. Pathway analysis associated these metabolites with the purine metabolic pathway.
Conclusion: Overall, our results demonstrate that metabolomics differences contribute toward drug resistance. In addition, it could potentially identify predictive biomarkers for chemosensitivity to various anti-leukemic drugs. Our results provide opportunity to further explore these metabolites in patient samples for association with clinical response.

Keywords:  AML; cytarabine; doxorubicin; drug resistance; leukemia; metabolomics

DOI:  https://doi.org/10.3389/fonc.2021.678008
Cancers (Basel). 2021 Jun 30. pii: 3296. [Epub ahead of print]13(13):

Myelodysplastic Syndromes in the Postgenomic Era and Future Perspectives for Precision Medicine.

Ioannis Chanias, Kristina Stojkov, Gregor Th Stehle, Michael Daskalakis, Helena Simeunovic, Linet Muthoni Njue, Annatina S Schnegg-Kaufmann, Naomi A Porret, Ramanjaneyulu Allam, Tata Nageswara Rao, Rudolf Benz, Axel Ruefer, Adrian Schmidt, Marcel Adler, Alicia Rovo, Stefan Balabanov, Georg Stuessi, Ulrike Bacher, Nicolas Bonadies, On Behalf Of The Swiss Mds Study Group.

  Myelodysplastic syndromes (MDS) represent a heterogeneous group of clonal disorders caused by sequential accumulation of somatic driver mutations in hematopoietic stem and progenitor cells (HSPCs). MDS is characterized by ineffective hematopoiesis with cytopenia, dysplasia, inflammation, and a variable risk of transformation into secondary acute myeloid leukemia. The advent of next-generation sequencing has revolutionized our understanding of the genetic basis of the disease. Nevertheless, the biology of clonal evolution remains poorly understood, and the stochastic genetic drift with sequential accumulation of genetic hits in HSPCs is individual, highly dynamic and hardly predictable. These continuously moving genetic targets pose substantial challenges for the implementation of precision medicine, which aims to maximize efficacy with minimal toxicity of treatments. In the current postgenomic era, allogeneic hematopoietic stem cell transplantation remains the only curative option for younger and fit MDS patients. For all unfit patients, regeneration of HSPCs stays out of reach and all available therapies remain palliative, which will eventually lead to refractoriness and progression. In this review, we summarize the recent advances in our understanding of MDS pathophysiology and its impact on diagnosis, risk-assessment and disease monitoring. Moreover, we present ongoing clinical trials with targeting compounds and highlight future perspectives for precision medicine.

Keywords:  future perspectives; myelodysplastic syndromes; postgenomic era; precision medicine; targeted therapies

DOI:  https://doi.org/10.3390/cancers13133296
Cancers (Basel). 2021 Jun 25. pii: 3175. [Epub ahead of print]13(13):

Transcript-Level Dysregulation of BCL2 Family Genes in Acute Myeloblastic Leukemia.

Luiza Handschuh, Pawel Wojciechowski, Maciej Kazmierczak, Krzysztof Lewandowski.

  The expression of apoptosis-related BCL2 family genes, fine-tuned in normal cells, is dysregulated in many neoplasms. In acute myeloid leukemia (AML), this problem has not been studied comprehensively. To address this issue, RNA-seq data were used to analyze the expression of 26 BCL2 family members in 27 AML FAB M1 and M2 patients, divided into subgroups differently responding to chemotherapy. A correlation analysis, analysis of variance, and Kaplan-Meier analysis were applied to associate the expression of particular genes with other gene expression, clinical features, and the presence of mutations detected by exome sequencing. The expression of BCL2 family genes was dysregulated in AML, as compared to healthy controls. An upregulation of anti-apoptotic and downregulation of pro-apoptotic genes was observed, though only a decrease in BMF, BNIP1, and HRK was statistically significant. In a group of patients resistant to chemotherapy, overexpression of BCL2L1 was manifested. In agreement with the literature data, our results reveal that BCL2L1 is one of the key players in apoptosis regulation in different types of tumors. An exome sequencing data analysis indicates that BCL2 family genes are not mutated in AML, but their expression is correlated with the mutational status of other genes, including those recurrently mutated in AML and splicing-related. High levels of some BCL2 family members, in particular BIK and BCL2L13, were associated with poor outcome.

Keywords:  AML; BCL2 family; RNA-seq; apoptosis; correlation; exome sequencing; gene expression; mutation; response to therapy; splicing

DOI:  https://doi.org/10.3390/cancers13133175
Bone Marrow Transplant. 2021 Jun 29.

High lactate dehydrogenase at time of admission for allogeneic hematopoietic transplantation associates to poor survival in acute myeloid leukemia and non-Hodgkin lymphoma.

Mika Geva, Angharad Pryce, Roni Shouval, Joshua A Fein, Ivetta Danylesko, Noga Shem-Tov, Ronit Yerushalmi, Avichai Shimoni, Richard Szydlo, Jiri Pavlu, Arnon Nagler.

Risk stratification is important for balancing potential risks and benefits of allogeneic hematopoietic stem cell transplantation (HSCT) for hematological malignancies. We retrospectively studied 1119 patients undergoing allogenic-HSCT in a single center for five hematological indications assessing the prognostic role of LDH at admission for survival (OS), progression-free survival (PFS), relapse incidence (RI), and nonrelapse mortality (NRM). In non-Hodgkin lymphoma (NHL) and acute myeloid leukemia (AML), higher than median LDH had an adverse effect on survival. The prognostic significance was strongest in AML, with higher LDH levels having lower 1-and 3-year survival 69.2% vs. 50.8%, P < 0.001 and 51.9% vs. 39.2%, P < 0.001, respectively, reduced 1-and 3-year PFS 62.4% vs. 42.1%, P < 0.001 48% vs. 35.2%, P < 0.001, respectively, higher cumulative incidence of 1-and 3-year NRM 11% vs. 17.3%, p = 0.01 and 15.7% vs. 19.6%, P = 0.04, and higher 1-and 3-year relapse incidence (RI) 26.7% vs. 40.7%, p < .0001 36.2% vs. 40.7%, respectively, P < 0.0001). In multivariate analysis LDH maintained significant prognostic capacity in OS, PFS and RI. These findings in AML, validated in an independent cohort, suggest that LDH is a readily available tool that could be integrated into transplant risk assessments to aid decision-making and identify high-risk patients who may benefit from post-transplant pharmacological or cellular strategies.

DOI: https://doi.org/10.1038/s41409-021-01377-9
Cell Stem Cell. 2021 Jul 01. pii: S1934-5909(21)00266-6. [Epub ahead of print]28(7): 1183-1185

Releasing the brake on protein synthesis in hematopoietic stem cells.

Craig M Forester, Davide Ruggero.

Protein synthesis regulation constitutes a key node in directing decisions between hematopoietic stemness and differentiation. In this issue of Cell Stem Cell, Lv et al. (2021) describe a mechanism by which HSCs fine-tune translation rates by controlling 60S and 40S ribosomal subunit joining through targeted degradation of ZNF622 in response to stress.

DOI: https://doi.org/10.1016/j.stem.2021.06.003
Epigenetics Chromatin. 2021 Jul 02. 14(1): 32

AF10 (MLLT10) prevents somatic cell reprogramming through regulation of DOT1L-mediated H3K79 methylation.

Deniz Uğurlu-Çimen, Deniz Odluyurt, Kenan Sevinç, Nazlı Ezgi Özkan-Küçük, Burcu Özçimen, Deniz Demirtaş, Eray Enüstün, Can Aztekin, Martin Philpott, Udo Oppermann, Nurhan Özlü, Tamer T Önder.

   BACKGROUND: The histone H3 lysine 79 (H3K79) methyltransferase DOT1L is a key chromatin-based barrier to somatic cell reprogramming. However, the mechanisms by which DOT1L safeguards cell identity and somatic-specific transcriptional programs remain unknown.
RESULTS: We employed a proteomic approach using proximity-based labeling to identify DOT1L-interacting proteins and investigated their effects on reprogramming. Among DOT1L interactors, suppression of AF10 (MLLT10) via RNA interference or CRISPR/Cas9, significantly increases reprogramming efficiency. In somatic cells and induced pluripotent stem cells (iPSCs) higher order H3K79 methylation is dependent on AF10 expression. In AF10 knock-out cells, re-expression wild-type AF10, but not a DOT1L binding-impaired mutant, rescues overall H3K79 methylation and reduces reprogramming efficiency. Transcriptomic analyses during reprogramming show that AF10 suppression results in downregulation of fibroblast-specific genes and accelerates the activation of pluripotency-associated genes.
CONCLUSIONS: Our findings establish AF10 as a novel barrier to reprogramming by regulating H3K79 methylation and thereby sheds light on the mechanism by which cell identity is maintained in somatic cells.

Keywords:  AF10; BioID; DOT1L; H3K79 methylation; Reprogramming; iPSC

DOI:  https://doi.org/10.1186/s13072-021-00406-7
N Engl J Med. 2021 07 01. 385(1): 46-58

Daratumumab-Based Treatment for Immunoglobulin Light-Chain Amyloidosis.

ANDROMEDA Trial Investigators

BACKGROUND: Systemic immunoglobulin light-chain (AL) amyloidosis is characterized by deposition of amyloid fibrils of light chains produced by clonal CD38+ plasma cells. Daratumumab, a human CD38-targeting antibody, may improve outcomes for this disease.
METHODS: We randomly assigned patients with newly diagnosed AL amyloidosis to receive six cycles of bortezomib, cyclophosphamide, and dexamethasone either alone (control group) or with subcutaneous daratumumab followed by single-agent daratumumab every 4 weeks for up to 24 cycles (daratumumab group). The primary end point was a hematologic complete response.
RESULTS: A total of 388 patients underwent randomization. The median follow-up was 11.4 months. The percentage of patients who had a hematologic complete response was significantly higher in the daratumumab group than in the control group (53.3% vs. 18.1%) (relative risk ratio, 2.9; 95% confidence interval [CI], 2.1 to 4.1; P<0.001). Survival free from major organ deterioration or hematologic progression favored the daratumumab group (hazard ratio for major organ deterioration, hematologic progression, or death, 0.58; 95% CI, 0.36 to 0.93; P = 0.02). At 6 months, more cardiac and renal responses occurred in the daratumumab group than in the control group (41.5% vs. 22.2% and 53.0% vs. 23.9%, respectively). The four most common grade 3 or 4 adverse events were lymphopenia (13.0% in the daratumumab group and 10.1% in the control group), pneumonia (7.8% and 4.3%, respectively), cardiac failure (6.2% and 4.8%), and diarrhea (5.7% and 3.7%). Systemic administration-related reactions to daratumumab occurred in 7.3% of the patients. A total of 56 patients died (27 in the daratumumab group and 29 in the control group), most due to amyloidosis-related cardiomyopathy.
CONCLUSIONS: Among patients with newly diagnosed AL amyloidosis, the addition of daratumumab to bortezomib, cyclophosphamide, and dexamethasone was associated with higher frequencies of hematologic complete response and survival free from major organ deterioration or hematologic progression. (Funded by Janssen Research and Development; ANDROMEDA ClinicalTrials.gov number, NCT03201965.).

DOI: https://doi.org/10.1056/NEJMoa2028631
Br J Haematol. 2021 Jul 01.

Hierarchical distribution of somatic variants in newly diagnosed chronic myeloid leukaemia at diagnosis and early follow-up.

Marianna Romzova, Dagmar Smitalova, Jakub Hynst, Nikola Tom, Tomas Loja, Zdenka Herudkova, Tomas Jurcek, Lukas Stejskal, Daniela Zackova, Jiri Mayer, Zdenek Racil, Martin Culen.

  There is an emerging body of evidence that patients with chronic myeloid leukaemia (CML) may carry not only breakpoint cluster region-Abelson murine leukaemia viral oncogene homologue 1 (BCR-ABL1) kinase domain mutations (BCR-ABL1 KD mutations), but also mutations in other genes. Their occurrence is highest during progression or at failure, but their impact at diagnosis is unclear. In the present study, we prospectively screened for mutations in 18 myeloid neoplasm-associated genes and BCR-ABL1 KD in the following populations: bulk leucocytes, CD34+ CD38+ progenitors and CD34+ CD38- stem cells, at diagnosis and early follow-up. In our cohort of chronic phase CML patients, nine of 49 patients harboured somatic mutations in the following genes: six ASXL1 mutations, one SETBP1, one TP53, one JAK2, but no BCR-ABL1 KD mutations. In seven of the nine patients, mutations were detected in multiple hierarchical populations including bulk leucocytes at diagnosis. The mutation dynamics reflected the BCR-ABL1 transcript decline induced by treatment in eight of the nine cases, suggesting that mutations were acquired in the Philadelphia chromosome (Ph)-positive clone. In one patient, the JAK2 V617F mutation correlated with a concomitant Ph-negative myeloproliferative neoplasm and persisted despite a 5-log reduction of the BCR-ABL1 transcript. Only two of the nine patients with mutations failed first-line therapy. No correlation was found between the mutation status and survival or response outcomes.

Keywords:  ASXL1; CML; NGS; leukaemic stem cells; progenitors; somatic mutations

DOI:  https://doi.org/10.1111/bjh.17659
Br J Haematol. 2021 Jun 30.

Dasatinib dose optimisation based on therapeutic drug monitoring reduces pleural effusion rates in chronic myeloid leukaemia patients.

Philippe Rousselot, Luigina Mollica, Joëlle Guilhot, Agnès Guerci, Franck E Nicolini, Gabriel Etienne, Laurence Legros, Aude Charbonnier, Valérie Coiteux, Caroline Dartigeas, Martine Escoffre-Barbe, Lydia Roy, Pascale Cony-Makhoul, Viviane Dubruille, Martine Gardembas, Françoise Huguet, Delphine Réa, Emilie Cayssials, François Guilhot, Anne Bergeron, Mathieu Molimard, Francois-Xavier Mahon, Jean-Michel Cayuela, Lambert Busque, Stéphane Bouchet.

  Dasatinib is a second-generation BCR-ABL1 tyrosine kinase inhibitor approved for patients with chronic myeloid leukaemia (CML). Dasatinib 100 mg per day is associated with an increased risk of pleural effusion (PlEff). We randomly evaluated whether therapeutic drug monitoring (TDM) may reduce dasatinib-associated significant adverse events (AEs) by 12 months (primary endpoint). Eligible patients started dasatinib at 100 mg per day followed by dasatinib (C)min assessment. Patients considered overdosed [(C)min ≥ 3 nmol/l) were randomised between a dose-reduction strategy (TDM arm) and standard of care (control arm). Out of 287 evaluable patients, 80 patients were randomised. The primary endpoint was not met due to early haematological AEs occurring before effective dose reduction. However, a major reduction in the cumulative incidence of PlEff was observed in the TDM arm compared to the control arm (4% vs. 15%; 11% vs. 35% and 12% vs. 39% at one, two and three years, respectively (P = 0·0094)). Molecular responses were superimposable in all arms. Dasatinib TDM during treatment initiation was feasible and resulted in a significant reduction of the incidence of PlEff in the long run, without impairing molecular responses. (NCT01916785; https://clinicaltrials.gov).

Keywords:  chronic leukaemia; pharmacology; tyrosine kinases

DOI:  https://doi.org/10.1111/bjh.17654
Leukemia. 2021 Jul 02.

Clonal hematopoiesis and its emerging effects on cellular therapies.

Malte von Bonin, Helena Klara Jambor, Raphael Teipel, Friedrich Stölzel, Christian Thiede, Frederik Damm, Frank Kroschinsky, Johannes Schetelig, Triantafyllos Chavakis, Martin Bornhäuser.

The accumulation of somatic mutations in hematopoietic stem cells during aging, leading to clonal expansion, is linked to a higher risk of cardiovascular mortality and hematologic malignancies. Clinically, clonal hematopoiesis is associated with a pro-inflammatory phenotype of hematopoietic cells and their progeny, inflammatory conditions and a poor outcome for patients with hematologic neoplasms and solid tumors. Here, we review the relevance and complications of clonal hematopoiesis for the treatment of hematologic malignancies with cell therapeutic approaches. In autologous and allogeneic hematopoietic stem cell transplantation native hematopoietic and immune effector cells of clonal origin are transferred, which may affect outcome of the procedure. In chimeric antigen receptor modified T-cell therapy, the effectiveness may be altered by preexisting somatic mutations in genetically modified effector cells or by unmodified bystander cells harboring clonal hematopoiesis. Registry studies and carefully designed prospective trials will be required to assess the relative roles of donor- and recipient-derived individual clonal events for autologous and allogeneic cell therapies and to incorporate novel insights into therapeutic strategies.

DOI: https://doi.org/10.1038/s41375-021-01337-8