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Acute myeloid leukemia

The combination of FLT3 and DNA methyltransferase inhibition is synergistically cytotoxic to FLT3/ITD acute myeloid leukemia cells

Leukemia volume 30, pages 1025–1032 (2016)Cite this article

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Abstract

Effective treatment regimens for elderly acute myeloid leukemia (AML) patients harboring internal tandem duplication mutations in the FMS-like tyrosine kinase-3 (FLT3) gene (FLT3/ITD) are lacking and represent a significant unmet need. Recent data on the effects of FLT3 tyrosine kinase inhibitors on FLT3/ITD+ AML showed promising clinical activity, including in elderly patients. DNA methyltransferase (DNMT) inhibitors such as decitabine (5-aza-2-deoxycytidine, DEC) and 5-azacitidine (AZA) demonstrated clinical benefit in AML, are well tolerated and are associated with minimal increases in FLT3 ligand, which can represent a potential resistance mechanism to FLT3 inhibitors. In addition, both FLT3 and DNMT inhibition are associated with the induction of terminal differentiation of myeloid blasts. Consequently, there is a strong theoretical rationale for combining FLT3 and DNMT inhibition for FLT3/ITD+ AML. We therefore sought to study the anti-leukemic effects of DEC, AZA and FLT3 inhibitors, either as single agents or in combination, on AML cell lines and primary cells derived from newly diagnosed and relapsed AML patients. Our studies indicate that combined treatment using FLT3 inhibition and hypomethylation confers synergistic anti-leukemic effects, including apoptosis, growth inhibition and differentiation. The simultaneous administration of AZA and FLT3 inhibition appears to be the most efficacious combination in this regard. These drugs may provide a novel therapeutic approach for FLT3/ITD+ AML, in particular for older patients.

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References

  1. Levis M, Small D . FLT3: ITDoes matter in leukemia. Leukemia 2003; 17: 1738–1752.

    Article  CAS  PubMed  Google Scholar 

  2. Konig H, Levis M . Targeting FLT3 to treat leukemia. Expert Opin Ther Targets. 2015; 19: 37–54.

    Article  CAS  PubMed  Google Scholar 

  3. Zhang W, Konopleva M, Shi YX, McQueen T, Harris D, Ling X et al. Mutant FLT3: a direct target of sorafenib in acute myelogenous leukemia. J Natl Cancer Inst. 2008; 100: 184–198.

    Article  CAS  PubMed  Google Scholar 

  4. Zarrinkar PP, Gunawardane RN, Cramer MD, Gardner MF, Brigham D, Belli B et al. AC220 is a uniquely potent and selective inhibitor of FLT3 for the treatment of acute myeloid leukemia (AML). Blood 2009; 114: 2984–2992.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Sexauer A, Perl A, Yang X, Borowitz M, Gocke C, Rajkhowa T et al. Terminal myeloid differentiation in vivo is induced by FLT3 inhibition in FLT3/ITD AML. Blood 2012; 120: 4205–4214.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Zheng R, Friedman AD, Levis M, Li L, Weir EG, Small D . Internal tandem duplication mutation of FLT3 blocks myeloid differentiation through suppression of C/EBPalpha expression. Blood 2004; 103: 1883–1890.

    Article  CAS  PubMed  Google Scholar 

  7. Man CH, Fung TK, Ho C, Han HH, Chow HC, Ma AC et al. Sorafenib treatment of FLT3-ITD(+) acute myeloid leukemia: favorable initial outcome and mechanisms of subsequent nonresponsiveness associated with the emergence of a D835 mutation. Blood 2012; 119: 5133–5143.

    Article  CAS  PubMed  Google Scholar 

  8. Fathi AT, Le L, Hasserjian RP, Sadrzadeh H, Levis M, Chen YB . FLT3 inhibitor-induced neutrophilic dermatosis. Blood 2013; 122: 239–242.

    Article  CAS  PubMed  Google Scholar 

  9. Smith CC, Wang Q, Chin CS, Salerno S, Damon LE, Levis MJ et al. Validation of ITD mutations in FLT3 as a therapeutic target in human acute myeloid leukaemia. Nature 2012; 485: 260–263.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Grunwald MR, Levis MJ . FLT3 inhibitors for acute myeloid leukemia: a review of their efficacy and mechanisms of resistance. Int J Hematol 2013; 97: 683–694.

    Article  CAS  PubMed  Google Scholar 

  11. Levis M, Ravandi F, Wang ES, Baer MR, Perl A, Coutre S et al. Results from a randomized trial of salvage chemotherapy followed by lestaurtinib for patients with FLT3 mutant AML in first relapse. Blood 2011; 117: 3294–3301.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Serve H, Krug U, Wagner R, Sauerland MC, Heinecke A, Brunnberg U et al. Sorafenib in combination with intensive chemotherapy in elderly patients with acute myeloid leukemia: results from a randomized, placebo-controlled trial. J Clin Oncol 2013; 31: 3110–3118.

    Article  CAS  PubMed  Google Scholar 

  13. Chen YB, Li S, Lane AA, Connolly C, Del Rio C, Valles B et al. Phase I trial of maintenance sorafenib after allogeneic hematopoietic stem cell transplantation for fms-like tyrosine kinase 3 internal tandem duplication acute myeloid leukemia. Biol Blood Marrow Transplant 2014; 20: 2042–2048.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Plimack ER, Kantarjian HM, Issa JP . Decitabine and its role in the treatment of hematopoietic malignancies. Leuk Lymphoma 2007; 48: 1472–1481.

    Article  CAS  PubMed  Google Scholar 

  15. Pollyea DA, Kohrt HE, Gallegos L, Figueroa ME, Abdel-Wahab O, Zhang B et al. Safety, efficacy and biological predictors of response to sequential azacitidine and lenalidomide for elderly patients with acute myeloid leukemia. Leukemia 2012; 26: 893–901.

    Article  CAS  PubMed  Google Scholar 

  16. Sudan N, Rossetti JM, Shadduck RK, Latsko J, Lech JA, Kaplan RB et al. Treatment of acute myelogenous leukemia with outpatient azacitidine. Cancer 2006; 107: 1839–1843.

    Article  CAS  PubMed  Google Scholar 

  17. Lubbert M, Ruter BH, Claus R, Schmoor C, Schmid M, Germing U et al. A multicenter phase II trial of decitabine as first-line treatment for older patients with acute myeloid leukemia judged unfit for induction chemotherapy. Haematologica 2012; 97: 393–401.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Cashen AF, Schiller GJ, O'Donnell MR, DiPersio JF . Multicenter phase II study of decitabine for the first-line treatment of older patients with acute myeloid leukemia. J Clin Oncol 2010; 28: 556–561.

    Article  CAS  PubMed  Google Scholar 

  19. Saunthararajah Y, Triozzi P, Rini B, Singh A, Radivoyevitch T, Sekeres M et al. p53-Independent, normal stem cell sparing epigenetic differentiation therapy for myeloid and other malignancies. Semin Oncol 2012; 39: 97–108.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Ravandi F, Alattar ML, Grunwald MR, Rudek MA, Rajkhowa T, Richie MA et al. Phase 2 study of azacytidine plus sorafenib in patients with acute myeloid leukemia and FLT-3 internal tandem duplication mutation. Blood 2013; 121: 4655–4662.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Aimiuwu J, Wang H, Chen P, Xie Z, Wang J, Liu S et al. RNA-dependent inhibition of ribonucleotide reductase is a major pathway for 5-azacytidine activity in acute myeloid leukemia. Blood 2012; 119: 5229–5238.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Fenaux P, Mufti GJ, Hellstrom-Lindberg E, Santini V, Gattermann N, Germing U et al. Azacitidine prolongs overall survival compared with conventional care regimens in elderly patients with low bone marrow blast count acute myeloid leukemia. J Clin Oncol. 2010; 28: 562–569.

    Article  CAS  PubMed  Google Scholar 

  23. Hollenbach PW, Nguyen AN, Brady H, Williams M, Ning Y, Richard N et al. A comparison of azacitidine and decitabine activities in acute myeloid leukemia cell lines. PLoS One 2010; 5: e9001.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Kantarjian HM, Thomas XG, Dmoszynska A, Wierzbowska A, Mazur G, Mayer J 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: 2670–2677.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Borthakur G, Kantaranjan HM, O'Brien S, Garcia-Manero G, Jabbour E, Daver N et al The Combination of Quizartinib with Azacitidine or Low Dose Cytarabine Is Highly Active in Patients (Pts) with FLT3-ITD Mutated Myeloid Leukemias: Interim Report of a Phase I/II Trial. Blood. 2014; 56th ASH Annual Meeting (abstract #388).

  26. Pratz KW, Sato T, Murphy KM, Stine A, Rajkhowa T, Levis M . FLT3-mutant allelic burden and clinical status are predictive of response to FLT3 inhibitors in AML. Blood 2010; 115: 1425–1432.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Levis M, Pham R, Smith BD, Small D . In vitro studies of a FLT3 inhibitor combined with chemotherapy: sequence of administration is important to achieve synergistic cytotoxic effects. Blood 2004; 104: 1145–1150.

    Article  CAS  PubMed  Google Scholar 

  28. Yang X, Sexauer A, Levis M . Bone marrow stroma-mediated resistance to FLT3 inhibitors in FLT3-ITD AML is mediated by persistent activation of extracellular regulated kinase. Br J Haematol 2014; 164: 61–72.

    Article  CAS  PubMed  Google Scholar 

  29. Matsuo Y, MacLeod RA, Uphoff CC, Drexler HG, Nishizaki C, Katayama Y et al. Two acute monocytic leukemia (AML-M5a) cell lines (MOLM-13 and MOLM-14) with interclonal phenotypic heterogeneity showing MLL-AF9 fusion resulting from an occult chromosome insertion, ins(11;9)(q23;p22p23). Leukemia 1997; 11: 1469–1477.

    Article  CAS  PubMed  Google Scholar 

  30. Burton EWB, Zhang J, West B, Bollag G, Habets G, Galanis A et al The Novel Inhibitor PLX3397 Effectively Inhibits FLT3-Mutant AML. Blood. 2011; 53rd ASH Annual Meeting (abstract #3632).

  31. Flotho C, Claus R, Batz C, Schneider M, Sandrock I, Ihde S et al. The DNA methyltransferase inhibitors azacitidine, decitabine and zebularine exert differential effects on cancer gene expression in acute myeloid leukemia cells. Leukemia 2009; 23: 1019–1028.

    Article  CAS  PubMed  Google Scholar 

  32. Wong YF, Jakt LM, Nishikawa S . Prolonged treatment with DNMT inhibitors induces distinct effects in promoters and gene-bodies. PLoS One 2013; 8: e71099.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Saunthararajah Y, Sekeres M, Advani A, Mahfouz R, Durkin L, Radivoyevitch T et al. Evaluation of noncytotoxic DNMT1-depleting therapy in patients with myelodysplastic syndromes. J Clin Invest 2015; 125: 1043–1055.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Agrawal S, Hofmann WK, Tidow N, Ehrich M, van den Boom D, Koschmieder S et al. The C/EBPdelta tumor suppressor is silenced by hypermethylation in acute myeloid leukemia. Blood 2007; 109: 3895–3905.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

This work was supported by the NCI Leukemia SPORE P50 CA100632-11.

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Authors and Affiliations

  1. Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA

    E Chang, S Ganguly, T Rajkhowa & M Levis

  2. Division of Molecular Pathology, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    C D Gocke

  3. Division of Hematology/Oncology, Department of Medicine, Melvin and Bren Simon Cancer Center, Indiana University, Indianapolis, IN, USA

    H Konig

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  1. E Chang
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  2. S Ganguly
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  4. C D Gocke
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Correspondence to H Konig.

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Chang, E., Ganguly, S., Rajkhowa, T. et al. The combination of FLT3 and DNA methyltransferase inhibition is synergistically cytotoxic to FLT3/ITD acute myeloid leukemia cells. Leukemia 30, 1025–1032 (2016). https://doi.org/10.1038/leu.2015.346

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