present and future impact of cytogenetics on acute myeloid leukemia
DESCRIPTION
Cytogenetics is an advancement in which clinicians can look for specific genetic mutations of chromosomal DNA and use that information to determine patient prognosis and individualize therapy. In this presentation I cover what cytogenetics are, how they impact patient risk, what therapies to use based on risk, and how genetically targeted agents may be used in the future.TRANSCRIPT
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Marti Larriva
PharmD Candidate 2014
September 11, 2013
Present and future impact of cytogenetics on AML treatment
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Outline
Background AML Cytogenetics Molecular genetics
Current Practice Prognosis Treatment
Future Practice Novel therapeutics
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Question
What areas of AML therapy are most fluid and subject to change?
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BackgroundAML, Cytogenetics, Molecular Genetics
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Acute Myeloid Leukemia
Excessive production of immature myeloblast cells Anemia Thrombocytopenia Neutropenia
Symptoms Fatigue Infection
Estey EH. Am J Hematol. 2012;87(1):89-99.
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Cytogenetics
Examines abnormalities of chromosomes Inversions, translocations, deletion, monosomy
http://cnx.org/content/m45467/latest/
Estey EH. Am J Hematol. 2013;88(4):318-27.
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Molecular Genetics
Examines abnormalities of genes Most well studied:
NPM1 (27%) FLT3 (28%) CEBPA (6%) c-KIT(4%)
Less well studied: DNMT3A(26%) IDH 1 or 2 (20%)
Cancer Genome Atlas Research Network. N Engl J Med. 2013;368(22):2059-74.
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NPM1
Nucleophosmin Shuttle between cytoplasm and nucleus NPMc+ = mutation Better outcomes
NPMc+
Loss of function
Oncogene
Paolo S. Pediatric Reports. 2011;3(s2):11-13.
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FLT3
FMS-like tyrosine kinase 3 FLT3 – ITD = mutation Associated with poor outcomes
FLT3-ITD
Constitutive
Activation
Proliferation
Impaired Apoptosis
Leung AY, Man CH, Kwong YL. Leukemia. 2013;27(2):260-8.
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CEBPA
CCAAT enhancer binding protein alpha Transcription factor essential for myeloid differentiation Double mutation (both chromosomes) = better outcomes
CEBPA Mutation
Lack of transcription factor binding
Missing elements for
myeloid differentiation
Pabst T, Mueller BU. Clin Cancer Res. 2009;15(17):5303-7.
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c-KIT Receptor tyrosine kinase
Expressed on surface of hematopoietic progenitor cells More common in core binding factor (CBF) AML
inv (16) and t (8; 21) Poor outcomes
Proliferation and survival
c-KIT overexpressi
on
c-KIT mutation
Paschka P, Marcucci G, Ruppert AS et al.. J Clin Oncol. 2006;24(24):3904-11.
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DNMT3A and IDH 1/2
Enzymes involved in epigenetic regulation
DNA (cytosine-5) methyltransferase 3 alpha
IDH 1/2 – Isocitrate Dehydrogenase 1 and 2
DNMT3Amut Altered DNA methylation
Abnormal silencing and activation of
DNA transcription
IDH1/2 mut Neomorphic Activity
Depletion of
cofactors for
epigenetic machinery
Rakheja D, Konoplev S, Medeiros LJ et al Hum Pathol. 2012;43(10):1541-51.
Gaidzik VI, Schlenk RF, Paschka P et al. Blood. 2013;121(23):4769-77.
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Complex Heterogeneity
Patel JP, Gonen M, Figueroa ME et al. N Engl J Med. 2012;366(12):1079-89.
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Making sense of it all
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Current Impact of CytogeneticsPrognosis, Treatment
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Risk stratification and PrognosisRisk Cytogenetics Molecular
Abnormalities5-year Survival
Better Risk Inv (16)t(16;16)t(8;21)t(15,17)
Normal cytogenetics: NPM1 w/o FLT3-ITD or isolated double mutation CEBPA
55-65%
Intermediate Risk
Normal cytogenetics+8 onlyt(9;11)
CBF [t(8;21), inv(16), t(16;16)] with c-KIT mutation
24-40%
Poor Risk Complex (≥3 abnormalities)-5, -7, 5q-, 7q-Abnormalities of 11q23 excluding t(9;11)Inversion 3t(3;3), t(6;9), t(9;22)
Normal cytogenetics: with FLT3-ITD mutation
5-14%
National Comprehensive Cancer Network. Acute Myeloid Leukemia (version 2.2013)
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Treatment
Stratified based upon cytogenetics
Two stages Induction Consolidation
HSCT – CR1 vs. CR2
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Better Risk (Best) TreatmentBetter Risk
CBF AML [inv (16), t(16;16) or t(8;21)]
NK with NPM1 mutation and no FLT3-ITD
NK with double mutated CEBPA
Induction
7+3 (Cytarabine
+ Daunorubicin
)
Consolidation
CBF with c-KIT +?
Yes
Dasatinib in clinical trial
No
High Dose Cytarabine
Estey EH. Am J Hematol. 2013;88(4):318-27.
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Intermediate 1 TreatmentIntermediate 1 Risk
NK w/o NPM1 mutation or FLT3-ITD
Cytogenetic abnormalities other than best or
unfavorable
Induction
7+3 (Cytarabine + Daunorubicin)
Clinical Trial
Consolidation
Matched sibling donor (MSD) HCT
High dose Cytarabine
Estey EH. Am J Hematol. 2013;88(4):318-27.
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Intermediate 2 TreatmentIntermediate 2 Risk
FLT3-ITD+
Induction
Clinical Trial involving
FLT3 inhibitor
Consolidation
Matched sibling donor (MSD) or
matched unrelated donor (MUD) HCT
High dose Cytarabine
Clinical trial involving FLT3
inhibitor
Estey EH. Am J Hematol. 2013;88(4):318-27.
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Intermediate 3 TreatmentIntermediate 3 Risk
Unfavorable cytogenetics without monosomal
karyotype
Induction
Clinical Trial
Consolidation
Matched sibling donor (MSD) or
matched unrelated donor (MUD) HCT
Clinical trial for non-transplant
candidates
HCT clinical trial involving new preparative
regimen or means to prevent relapse
Estey EH. Am J Hematol. 2013;88(4):318-27.
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Poor Risk (Worst) TreatmentPoor Risk
Monosomal karyotype
Induction
Clinical Trial
Consolidation
Matched sibling donor (MSD) or
matched unrelated donor (MUD) HCT
Clinical trial for non-transplant
candidates
HCT clinical trial involving new preparative
regimen or means to prevent relapse
Estey EH. Am J Hematol. 2013;88(4):318-27.
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Treatment Summary
Prognostic Group
Subsets Induction Post-Remission
Best inv (16), t(16;16) or t(8;21) NK with NPM1 mutation and no FLT3-ITD
NK with double mutated CEBPA
7+3 Cytarabine at 1g/m2 BID daily x 6
Dasatinib in clinical trial if CBF with c-KIT mutation
Intermediate 1 NK w/o NPM mutation or FLT3-ITD
Cytogenetic abnormalities other than best of unfavorable
7+3
Clinical trial
HCT from matched sibling donor (MSD)
Cytarabine as above or clinical trial if not HCT candidate
Intermediate 2 FLT3-ITD+ Clinical trial involving FLT3 inhibitor
HCT from MSD or matched unrelated donor (MUD); consider trial with FLT3 inhibitor
Cytarabine as above or clinical trial if not HCT candidate
Intermediate 3 Unfavorable cytogenetics without monosomal karyotype
Clinical trial
HCT from MSD, MUD; consider trial involving new prep regimen or means to prevent relapse after HCT
Clinical trial if not HCT candidate
Worst Monosomal karyotype Clinical trial
As in intermediate 3Estey EH. Am J Hematol. 2013;88(4):318-27.
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Future Impact of CytogeneticsFLT3 inhibitors, c-KIT inhibitors, Hypomethylating agents
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Predicting the future…
“While theoretically and technically television may be feasible, commercially and financially I consider it an impossibility, a development of which we need waste little time dreaming.” – Lee DeForest, American radio pioneer, 1926.
“Well informed people know it is impossible to transmit the voice over wires, and that were it possible to do so, the thing would be of no practical value.” – Editorial in the Boston Post, 1865
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FLT3 inhibition No FDA approval yet
Efficacy and resistance issues Ongoing trials
Several multi-TKI inhibitors exist – tandutinib, sorafenib, sunitinib, midostaurin, lestaurtinib
Oral FLT3 specific inhibitor – quizartinib Monotherapy for relapsed/refractory disease after 2nd line
chemotherapy or HSCT
DLT – QT prolongation, myelosuppression
Patient group FLT3-ITD + FLT3-ITD -
All patients CRc 44%OS 23.1 weeks
CRc 34%OS 25.6 weeks
≥ 70 years old CRc 53%OS 21.0 weeks
CRc 43%OS 19 weeks
Grunwald MR, Levis MJ. Int J Hematol. 2013;97(6):683-94.Levis MJ, Perl AE, Dombret H, Dohner H et al. Blood (ASH Annual Meeting Abstracts). 2012; 120:Abstract 673.
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c-KIT inhibition
No clear clinical benefit, still in clinical trials c-KIT overexpression in CBF AML Case reports of success and failure
c-KIT inhibitors – midostaurin, dasatinib, imatinib, nilotinib Clinical trials evaluating:
monotherapy in relapsed/refractory disease combination with induction and salvage chemotherapy combination with low dose chemo for older patients
Smith CC, Shah NP. Am Soc Clin Oncol Educ Book. 2013;2013:313-8.
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Hypomethylation
Use of azacitadine and decitabine increasing
Older adults ≥ 65 + intermediate/poor risk disease Phase III trial decitabine vs. Treatment of choice
(supportive care or low dose cytarabine):
Stratification by IDH, TET2, or DNMT3A status?
Treatment group
Decitabine TC P-value
OS 7.7 months 5.0 months 0.108
CR 17.8% 7.8% 0.001
Kantarjian HM, Thomas XG, Dmoszynska A et al. J Clin Oncol. 2012;30(21):2670-7.
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Combination Regimens
AML Heterogeneity
Multiple mechanisms of therapy
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AML Clinical trials at Mayo
c-KIT overexpression: Nilotinib and 7+3 (DATA) – Phase II
Hypomethylation Clofarabine OR 7+3 followed by decitabine OR Observation (Older
patients with newly diagnosed AML) SGI-110 in intermediate or poor risk MDS or AML- Phase I/II
FLT3-ITD Midostaurin + SOC vs. SOC post HSCT to prevent relapse- Phase II Bortezomib + Sorafenib for De Novo AML with high allelic ratio
FLT3-ITD – Phase III
http://www.mayo.edu/research/clinical-trials/search-results?keyword=acute%20myeloid%20leukemia
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Summary & ConclusionsTried and true vs. room for something new
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Summary
FLT3-ITD and c-KIT Bad prognostic markers Alternative therapies, HSCT in CR1 Maybe future drug targets
NPM1, double CEBPA Better prognostic markers Standard therapy is an option, HSCT in CR2
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Summary & Conclusions
Tried & true
7+3 induction for better risk disease and HiDAC consolidation
HSCT for worst risk disease after first CR
Something new?
Molecular targeted therapies (FLT3, c-KIT) Combination regimens Bridge to HSCT
Hypomethylating agents Particularly in elderly
population Characterization of
epigenetics for prognosis?
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References
1. Cancer Genome Atlas Research Network. Genomic and epigenomic landscapes of adult de novo acute myeloid leukemia. N Engl J Med. 2013;368(22):2059-74.
2. Dohner H, Estey EH, Amadori S et al. Diagnosis and management of acute myeloid leukemia in adults: Recommendations from an international expert panel, on behalf of the european LeukemiaNet. Blood. 2010;115(3):453-74.
3. Estey EH. Acute myeloid leukemia: 2013 update on risk-stratification and management. Am J Hematol. 2013;88(4):318-27.
4. Estey EH. Acute myeloid leukemia: 2012 update on diagnosis, risk stratification, and management. Am J Hematol. 2012;87(1):89-99.
5. Ferrara F, Schiffer CA. Acute myeloid leukaemia in adults. Lancet. 2013;381(9865):484-95.
6. Gaidzik VI, Schlenk RF, Paschka P et al. Clinical impact of DNMT3A mutations in younger adult patients with acute myeloid leukemia: Results of the AML study group (AMLSG). Blood. 2013;121(23):4769-77.
7. Grunwald MR, Levis MJ. FLT3 inhibitors for acute myeloid leukemia: A review of their efficacy and mechanisms of resistance. Int J Hematol. 2013;97(6):683-94.
8. Kantarjian HM, Thomas XG, Dmoszynska A et al. Multicenter, randomized, open-label, phase III trial of decitabine versus patient choice, with physician advice, of either supportive care or low-dose cytarabine for the treatment of older patients with newly diagnosed acute myeloid leukemia. J Clin Oncol. 2012;30(21):2670-7.
9. Leung AY, Man CH, Kwong YL. FLT3 inhibition: A moving and evolving target in acute myeloid leukaemia. Leukemia. 2013;27(2):260-8.
10. Levis MJ, Perl AE, Dombret H, Dohner H et al. Blood (ASH Annual Meeting Abstracts). 2012; 120:Abstract 673.
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References
11. Magenau J, Couriel DR. Hematopoietic stem cell transplantation for acute myeloid leukemia: To whom, when, and how. Curr Oncol Rep. 2013.
12. Mrozek K, Marcucci G, Nicolet D et al. Prognostic significance of the european LeukemiaNet standardized system for reporting cytogenetic and molecular alterations in adults with acute myeloid leukemia. J Clin Oncol. 2012;30(36):4515-23.
13. National Comprehensive Cancer Network. Acute Myeloid Leukemia (version 2.2013). Accessed 9/8/13. http://www.nccn.org/professionals/physician_gls/pdf/aml.pdf
14. Pabst T, Mueller BU. Complexity of CEBPA dysregulation in human acute myeloid leukemia. Clin Cancer Res. 2009;15(17):5303-7.
15. Paolo S. How does the NPM1 mutant induce leukemia? Pediatric Reports. 2011;3(s2):11-13.
16. Paschka P, Marcucci G, Ruppert AS et al. Adverse prognostic significance of KIT mutations in adult acute myeloid leukemia with inv(16) and t(8;21): A cancer and leukemia group B study. J Clin Oncol. 2006;24(24):3904-11.
17. Patel JP, Gonen M, Figueroa ME et al. Prognostic relevance of integrated genetic profiling in acute myeloid leukemia. N Engl J Med. 2012;366(12):1079-89.
18. Rakheja D, Konoplev S, Medeiros LJ et al. IDH mutations in acute myeloid leukemia. Hum Pathol. 2012;43(10):1541-51.
19. Smith CC, Shah NP. The role of kinase inhibitors in the treatment of patients with acute myeloid leukemia. Am Soc Clin Oncol Educ Book. 2013;2013:313-8.
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Questions?