small molecules

2026-08-11 | A Case of Acute Myeloid Leukemia, Myelodysplasia-Related (AML-MR) with Immunophenotypic Features Suggestive of B/Myeloid Mixed-Phenotype Acute Leukemia (MPAL), Harboring Multiple KMT2A Gene Amplifications

The amplification of KMT2A, a gene involved in hematopoietic stem cell function, is extremely rare in acute leukemias, especially in mixed-phenotype acute leukemia. We present the case of a 62-year-old patient diagnosed with acute myeloid leukemia, myelodysplasia-related (AML-MR) with immunophenotypic features suggestive of B/myeloid mixed-phenotype acute leukemia (MPAL), with the presence of multiple KMT2A gene amplifications and a very aggressive and complicated clinical course ending in failure despite intensive treatment. KMT2A amplification in MPAL could be a risk factor suggesting adverse outcomes.

Open article ↗

2026-05-18 | Isolated Neutropenia as a Sentinel of High-Risk Clonal Evolution: Acute Myeloid Leukemia With Myelodysplasia-Related Changes Harboring TP53 Deletion via Isochromosome 17q and Deletion 20q Mimicking a Myeloproliferative Neoplasm.

Isolated neutropenia is often deemed benign in elderly patients, frequently attributed to age-related marrow changes, medications, or nutritional deficiencies. However, persistent and unexplained neutropenia may signal early clonal hematopoiesis or evolving myeloid malignancy. While acute myeloid leukemia with myelodysplasia-related changes (AML-MRC) usually arises from multilineage cytopenia, presentation with isolated neutropenia and myeloproliferative neoplasia (MPN)-like features is exceedingly rare. This case underscores the importance of early, risk-adapted assessment in such scenarios. A 69-year-old woman presented with isolated mild neutropenia (absolute neutrophil count (ANC) 1,188/µL) and easy bruising. With no other cytopenias or symptoms, bone marrow biopsy was deferred. Six months later, she developed abdominal discomfort, anorexia, and massive splenomegaly. Laboratory tests revealed leukocytosis with left shift, anemia, thrombocytopenia, and nucleated red cells. Bone marrow biopsy showed > 40% myeloblasts, trilineage dysplasia, and mild fibrosis. JAK2 mutation and BCR-ABL were negative. Cytogenetics demonstrated i(17q) and del(20q); Fluorescence in situ hybridization (FISH) showed TP53 deletion in 81.91% of nuclei, establishing AML-MRC with high-risk features. She was started on azacitidine and venetoclax. Day 28 marrow showed minimal residual disease (blast 8%) but no metaphase growth prompting treatment continuation. She is currently on her fourth cycle with treatment-related transfusion-dependent cytopenias, prompting dose reduction. This case challenges the prevailing "watch-and-wait" paradigm in the evaluation of isolated neutropenia, particularly in older adults. It exposes the hidden risk of clinical inertia, where the absence of other overt cytopenias or symptoms may lead to missed opportunities for early diagnosis of high-risk clonal evolution. In resource-limited setting, this case underscores urgent need for heightened clinical vigilance. Likewise, it highlights the urgent need for a more risk-adapted approach to persistent isolated neutropenia and compels us to confront a critical question: how many patients are we failing to diagnose in time, and how many windows for potentially life-altering intervention are we silently allowing to close?

Open article ↗

2026-03-13 | Acute myeloid leukaemia (AML) harbouring KMT2A-PTD: should it be considered as a myelodysplasia-related abnormality?

Although acute myeloid leukaemia (AML), myelodysplasia-related (AML-MR), can be defined solely by molecular abnormalities, legacy studies did not analyse the KMT2A gene. The KMT2A-partial tandem duplication (KMT2A-PTD) is described in myelodysplastic neoplasms (MDS) as well as AML. We describe the clinical, morphological, immunophenotypic and molecular features of AML harbouring KMT2A-PTD. We studied 802 adult AML patients, for whom next-generation sequencing- based mutation and copy number analysis were available. For the patients harbouring KMT2A-PTD, the immunophenotypic analysis including measurable residual disease (MRD), mutational landscape and the patient outcomes were analysed. We identified 45 patients of de novo and secondary AML harbouring KMT2A-PTD. Morphological dysplasia and immunophenotypic abnormalities, described in MDS, were observed in 35.6% and 40% of de novo cases respectively. Furthermore, 44% of AML with KMT2A-PTD could be diagnosed as AML-MR based on cytogenetics or genomics. We observed progenitor abnormalities, commonly aberrant CD7 (33%) and CD15 (59%), and granulocytic abnormalities like loss of side scatter (50%), asynchronous maturation patterns and loss of CD177 in mature granulocytes. Frequent mutations involving IDH2 (30% of which were R172), FLT3 (32% each), RUNX1 (29%), DNMT3A and U2AF1 (24% each) were noted. We also found that more than 25% of patients did not achieve morphological remission, and the remaining 60% were MRD positive. The outcomes of AML with KMT2A-PTD with or without MR-associated abnormalities were similar. AML harbouring KMT2A-PTD frequently displays MR immunophenotypic abnormalities and is frequently associated with AML-MR type mutations. In addition, they have similar outcomes as compared with AML-MR.

Open article ↗

2026-02-19 | Biomarkers and advances in AML-MRC: from bench to bedside.

Acute myeloid leukemia with myelodysplasia-related changes (AML-MRC) represents a high-risk subtype of AML, characterized by poor prognosis and limited therapeutic options. Recent updates in the WHO and ICC classifications have redefined AML-MRC, emphasizing molecular and cytogenetic criteria over morphological features alone. This review provides a comprehensive overview of the pathogenesis, key biomarkers, and diagnostic innovations in AML-MRC, highlighting the role of genetic mutations (e.g., TP53, RUNX1, and splicing factors), cytogenetic abnormalities, and immune microenvironment alterations. We explore advanced diagnostic techniques such as next-generation sequencing (NGS), minimal residual disease (MRD) monitoring, and functional precision medicine (FPM), which are revolutionizing disease stratification and treatment selection. Additionally, we discuss emerging therapies, including CPX-351, hypomethylating agents (HMAs), targeted inhibitors (e.g., FLT3 and IDH1/2 inhibitors), and immunotherapies, while addressing the challenges of treatment resistance and relapse. The integration of multi-omics technologies and liquid biopsies offers promising avenues for personalized medicine, enabling dynamic monitoring and tailored therapeutic strategies. Finally, we outline future directions, emphasizing the potential of artificial intelligence and collaborative efforts to overcome current limitations and improve patient outcomes. This review underscores the importance of precision medicine in transforming the management of AML-MRC, bridging the gap between bench research and clinical application.

Open article ↗

2026-01-01 | Adverse karyotype amplifies risk in secondary acute myeloid leukemia (AML) and AML with myelodysplasia-related changes

Secondary acute myeloid leukemia (sAML) and AML with myelodysplasia-related changes (AML-MRC) are associated with poor prognosis, but the impact relative to de novo AML remains controversial. We investigated clinical and genetic features in a multicenter Japanese cohort before CPX-351 approval. We retrospectively analyzed 294 patients with newly diagnosed AML registered in the Hokkaido Leukemia Net between 2022 and 2023. Propensity score matching was used to adjust baseline variables. Genetic profiles were assessed in 160 matched patients. In the matched cohort, sAML/AML-MRC did not show inferior overall survival compared with non-sAML/non-AML-MRC (P = 0.90). Adverse karyotypes were the predominant determinant among sAML/AML-MRC. Among sAML/AML-MRC patients, adverse karyotypes were associated with poorer survival than those without adverse karyotypes (P = 0.0075). In contrast, non-sAML/non-AML-MRC groups did not affect survival regardless of adverse karyotypes (P = 0.51). Among 65 patients with ELN 2017 adverse-risk, those with TP53 mutations had markedly shorter survival than those with TP53 wild-type (P = 0.018). sAML/AML-MRC with an adverse karyotype had a dismal outcome. These findings provide a benchmark for risk stratification in the pre– CPX-351 era.

Open article ↗

cell therapies

2025-11-03 | Bzip in-frame mutations might abrogate the adverse prognosis of therapy-related CEBPA-mutated AML

Abstract Background：According to the 2022 WHO classification, acute myeloid leukemia (AML) with CEBPA mutations is considered a unique subtype that often has a better prognosis. Although previous studies have shown that the prognosis of therapy-related AML is usually worse than that of de novo AML, there is currently no research to clarify the prognosis of therapy-related CEBPA mutated AML (t- CEBPA AML). Aims：This study firstly investigated the clinical characteristics and prognosis of t-CEBPA AML by systematically comparing the differences between t-CEBPA AML, therapy-related AML with wild type CEBPA (t-AML), and de novo CEBPA mutated AML(dn-CEBPA AML). Methods： This study compared the genetics, clinical baseline and outcomes of t-CEBPA AML, dn-CEBPA AML and t-AML. The diagnosis of CEBPA mutated AML was based on the 2022 WHO classification. All patients were newly diagnosed AML and received treatment at the Hematology Institute of Peking University from January 2017 to December 2024. Results: In this study, we retrospectively compared and analyzed the clinical baseline and survival data of total 478 patients: 23 t-CEBPA AML patients, 153 t-AML patients and 302 dn-CEBPA AML patients. Our findings revealed that t-CEBPA AML and t-AML patients were older than dn-CEBPA AML (44 years vs 49 years vs 40 years, p<0.001) and exhibited a similar co-mutation spectrum, with lower incidences of GATA2 mutations (8.6% vs 1.9% vs 26.8%, p<0.001), and higher incidences of KIT (17.3% vs 14.4% vs 6.6%, p<0.001), TP53(12.9% vs 10.5% vs 0.6%) and AML-myelodysplasia-related (MR) gene mutations (21.7% vs 25.9% vs 12.5%, p<0.001). But for cytogenetics, t-CEBPA AML and dn-CEBPA AML showed the same high frequency of normal karyotype (73.9% of t-CEBPA; 73.9% of dn-CEBPA), unlike t-AML (28.8%; p <0 .001). Although t-CEBPA AML and dn-CEBPA AML demonstrated higher CRc rates after chemotherapy than t-AML (91.3% vs 96.0% vs 74.5%, p<0.001), t-CEBPA AML and t-AML had a higher relapse rate than dn-CEBPA (30.4% vs 28.7% vs 18.2%, p<0.001), which might result in poor 3-years-overall survival (OS) (50.3% vs 64.0% vs 76.1%, p<0.001) and 3-year-disease free survival (DFS) (46.1% vs 60.0% vs 70.0%, p=0.003). In addition, receiving allogeneic hematopoietic stem cell transplantation (allo-HSCT) significantly improved survival in t-CEBPA AML (3-year-OS:76.0% vs 38.1%, p=0.072; 3-year-DFS:66.8% vs 35.7%, p=0.041) and t-AML (3-year-OS:74.7% vs 36.5%, p<0.001; 3-year-DFS:69.4% vs 45.7%, p=0.018) patients, but this improvement was not significant in dn-CEBPA AML. Among t-CEBPA AML, multivariate analysis identified TET mutation (HR=1.78, p=0.032), AML-MR genes mutation (HR=1.36, p=0.047) and measurable residual disease (MRD) negative after induction therapy (HR=0.085, p=0.041) as independent risk factors for inferior OS. Moreover, by comparing the specific mutation information, we found that the proportion of basic leucine zipper domain (bZIP) in-frame mutations of dn-CEBPA is higher than that of t-CEBPA AML (91.1% vs 60%, p=0.031). Considering the difference in the proportion of bZIP-inf mutation, we compared the long-term survival of t-CEBPAbZIP-inf and dn-CEBPAbZIP-inf, and the results suggest that there seems to be little difference in survival between them (3-year-OS: 62.0 vs 76.3%, P=0.47; 3-year-DFS: 45.0% vs 72.1%, p=0.075). Summary/Conclusion: This study analyzed that t-CEBPA AML and t-AML have similar clinical features and poor prognosis compared with dn-CEBPA AML. T-CEBPA AML and t-AML should receive allo-HSCT to improve long-term survival. But among CEBPAbZIP-inf mutations patients, the poor prognosis caused by “therapy-related” is offset. Keywords acute myeloid leukemia, CEBPA, bZIP-inf, therapy-related

Open article ↗

2024-11-05 | Allogeneic Hematopoietic Cell Transplantation in Newly Diagnosed and Relapse/Refractory AML Patients Post Venetoclax-Azacitidine Treatment: A Multicenter Real-Life Analysis By the French Auraml Group

Allogeneic hematopoietic stem cell transplantation (ASCT) remains the most effective curative treatment for patients with high-risk acute myeloid leukemia (AML). However, patients ineligible for intensive chemotherapy (IC) due to age or comorbidities have typically not been viable candidates. The therapeutic landscape of AML has recently evolved with the integration of the 5-azacitidine and venetoclax (AZA/VEN) combination regimen in newly diagnosed (ND) patients unfit for IC. Off-label use of AZA/VEN is also prevalent in the relapsed/refractory (R/R) setting. However, data regarding the safety and outcomes of ASCT in AZA/VEN-treated patients remain limited. In this study, we aimed to evaluate the safety and efficacy of ASCT in AML patients treated with AZA/VEN in both ND and R/R settings. We conducted a multicenter retrospective cohort study using data from the VENAURA registry, which includes 585 AML patients from 12 centers in the Auvergne Rhône Alpes (AURA) region of France treated with AZA/VEN between 2019 and 2024. This study analyzed 80 AML patients who underwent ASCT after receiving AZA/VEN in either ND (25; 31%) or R/R (55; 69%) settings. The cohort included 40 patients (52%) with de novo AML, 13 (17%) with secondary AML, 10 (13%) with AML with Myelodysplasia-Related Changes (AML-MRC), and 14 (18%) with MDS/AML. The median age was 57 years (y) (range 18-73). Besides age (61 y vs. 56 y, p=0.048), there were no significant differences between the ND and R/R groups in other clinical characteristics, molecular features, or ELN 2022 risk groups. No significant differences were observed between the groups for median number of AZA/VEN cycles before HSCT (2 cycles, range 1-6, p=1), median time from AZA/VEN initiation to ASCT (3 months, range 1-14, p=0.85), pre-ASCT response (complete remission (CR) in 61 patients, 76%; CR with incomplete hematologic recovery (CRi) in 7 patients, 9%; morphologic leukemia-free state (MLFS) in 7 patients, 9%; no response (NR) in 5 patients, 6%, p=0.75), or minimal residual disease (MRD) status (36 MRD-negative, 60%; 24 MRD-positive, 40%, p=0.58). With a median follow-up period of 13 months (IQR 11-16), no significant differences were observed between ND and R/R groups regarding 1-year overall survival (72 vs 79%, p=0.34), non-relapse mortality at 1 year (4.3 vs 6.2%, p=0.86), or relapse rate at 1 year (21% vs 25%, p=0.91). No significant differences were observed between groups regarding acute graft-versus-host disease (GVHD) (28% overall, 37% ND, 23% R/R, p=0.12), severe acute GVHD (9.6% overall, 8.1% ND, 10% R/R, p=0.98), or chronic GVHD incidence at 1 year (22% overall, 18% ND, 23% R/R, p=0.97). In multivariate overall survival analysis, factors significantly associated with worse survival were age (HR 1.08 per y, 95% CI: 1.00-1.15, p=0.043), higher HCT-CI score (≥3) (HR 8.69, 95% CI: 2.27-33.3, p=0.002) and ELN 2022 adverse risk classification (HR 12.5, 95% CI: 1.52-103, p=0.019). Concerning cumulative incidence of relapse, MRD positivity pre-ASCT remained significant (HR 4.53, 95% CI: 1.34-15.3, p=0.015), and donor type (matched vs mismatched) was nearly significant (HR 3.03, 95% CI: 0.99-9.35, p=0.053) in multivariate analysis. In conclusion, our data suggest that ASCT for AZA/VEN treated AML patients is feasible, with promising transplant outcomes and an encouraging post-ASCT treatment-related mortality. Additionally, it is important to note that our results, collected in a real-world setting, involve older patients with inherently poor leukemia characteristics and a high number of mismatched donors. To establish the benefit of AZA/VEN pre-ASCT, a matching comparison with a CIBMTR historical control cohort treated with conventional IC will be presented during the meeting.

Open article ↗

2024-09-04 | Risk Stratification in Older Intensively Treated Patients With AML.

AML is a genetically heterogeneous disease, particularly in older patients. In patients older than 60 years, survival rates are variable after the most important curative approach, intensive chemotherapy followed by allogeneic hematopoietic cell transplantation (allo-HCT). Thus, there is an urgent need in clinical practice for a prognostic model to identify older patients with AML who benefit from curative treatment. We studied 1,910 intensively treated patients older than 60 years with AML and high-risk myelodysplastic syndrome (HR-MDS) from two cohorts (NCRI-AML18 and HOVON-SAKK). The median patient age was 67 years. Using a random survival forest, clinical, molecular, and cytogenetic variables were evaluated in an AML development cohort (n = 1,204) for association with overall survival (OS). Relative weights of selected variables determined the prognostic model, which was validated in AML (n = 491) and HR-MDS cohorts (n = 215). The complete cohort had a high frequency of poor-risk features, including 2022 European LeukemiaNet adverse-risk (57.3%), mutated TP53 (14.4%), and myelodysplasia-related genetic features (65.1%). Nine variables were used to construct four groups with highly distinct 4-year OS in the (1) AML development, (2) AML validation, and (3) HR-MDS test cohorts ([1] favorable: 54% ± 4%, intermediate: 38% ± 2%, poor: 21% ± 2%, very poor: 4% ± 1%; [2] 54% ± 9%, 43% ± 4%, 27% ± 4%, 4% ± 3%; and [3] 54% ± 10%, 33% ± 6%, 14% ± 5%, 0% ± 3%, respectively). This new AML60+ classification improves current prognostic classifications. Importantly, patients within the AML60+ intermediate- and very poor-risk group significantly benefited from allo-HCT, whereas the poor-risk patients showed an indication, albeit nonsignificant, for improved outcome after allo-HCT. The new AML60+ classification provides prognostic information for intensively treated patients 60 years and older with AML and HR-MDS and identifies patients who benefit from intensive chemotherapy and allo-HCT.

Open article ↗

2024-04-11 | Strategies to reduce relapse risk in patients undergoing allogeneic stem cell transplantation for acute myeloid leukaemia

Allogeneic stem cell transplantation is a centrally important curative strategy in adults with acute myeloid leukaemia; however, relapse occurs in a significant proportion of patients and remains the leading cause of treatment failure. The prognosis for patients who relapse post-transplant remains poor, and the development of new strategies with the ability to reduce disease recurrence without increasing transplant toxicity remains a priority. In this review, within the context of our understanding of disease biology and the graft-versus-leukaemia (GVL) effect, we will discuss established, evolving and novel approaches for increasing remission rates, decreasing measurable residual disease pretransplant, future methods to augment the GVL effect and the opportunities for post-transplant maintenance. Future progress depends upon the development of innovative trials and networks, which will ensure the rapid assessment of emerging therapies in prospective clinical trials.

Open article ↗

2024-01-23 | Dysregulated immune and metabolic pathways are associated with poor survival in adult acute myeloid leukemia with CEBPA bZIP in-frame mutations

Abstract Acute myeloid leukemia (AML) with CEBPA bZIP in-frame mutations ( CEBPA bZIP-inf ) is classified within the favorable-risk group by the 2022 European LeukemiaNet (ELN-2022). However, heterogeneous clinical outcomes are still observed in these patients. In this study, we aimed to investigate the mutation profiles and transcriptomic patterns associated with poor outcomes in patients with CEBPA bZIP-inf . One hundred and thirteen CEBPA bZIP-inf patients were identified in a cohort of 887 AML patients homogeneously treated with intensive chemotherapy. Concurrent WT1 or DNMT3A mutations significantly predicted worse survival in AML patients with CEBPA bZIP-inf . RNA-sequencing analysis revealed an enrichment of interferon (IFN) signaling and metabolic pathways in those with a shorter event-free survival (EFS). CEBPA bZIP-inf patients with a shorter EFS had higher expression of IFN-stimulated genes ( IRF2, IRF5, OAS2 , and IFI35 ). Genes in mitochondrial complexes I ( NDUFA12 and NDUFB6 ) and V ( ATP5PB and ATP5IF1 ) were overexpressed and were associated with poorer survival, and the results were independently validated in the TARGET AML cohort. In conclusion, concurrent WT1 or DNMT3A mutations and a dysregulated immune and metabolic state were correlated with poor survival in patients with CEBPA bZIP-inf , and upfront allogeneic transplantation may be indicated for better long-term disease control.

Open article ↗

antibodies

2026-03-20 | Diagnostic updates and research advances in AML-MR: Integrating molecular genetics and immune mechanisms.

Acute myeloid leukaemia, myelodysplasia-related (AML-MR) is a distinct subtype of acute myeloid leukemia defined in the 2022 WHO classification. It is characterized by specific molecular genetic abnormalities and immunological features. In recent years, with the continuous refinement of AML classification criteria and the incorporation of more precise molecular biomarkers into the diagnostic system, the accuracy of diagnosis and the precision of risk stratification have been significantly improved, laying the foundation for personalized treatment. Studies have shown that the development of AML-MR is closely associated with clonal hematopoietic abnormalities and dysregulation of the bone marrow immune microenvironment. This immunosuppressive state not only promotes leukemic progression but also affects therapeutic responses. In terms of treatment, emerging immunotherapies have shown promising advances in AML-MR, offering new directions for improving the prognosis of high-risk patients. This review systematically summarizes recent progress in the classification criteria, molecular genetic mechanisms, immune microenvironment characteristics, and targeted therapeutic strategies of AML-MR, aiming to provide insights for optimizing clinical management and guiding future research.

Open article ↗

2023-09-09 | The Association between Immune Checkpoint Proteins and Therapy Outcomes in Acute Myeloid Leukaemia Patients

The development of novel drugs with different mechanisms of action has dramatically changed the treatment landscape of AML patients in recent years. Considering a significant dysregulation of the immune system, inhibitors of immune checkpoint (ICI) proteins provide a substantial therapeutic option for those subjects. However, use of ICI in haematological malignancies remains very limited, in contrast to their wide use in solid tumours. Here, we analysed expression patterns of the most promising selected checkpoint-based therapeutic targets in AML patients. Peripheral blood of 72 untreated AML patients was used for flow cytometric analysis. Expression of PD-1, PD-L1, CTLA-4, and B7-H3 was assessed within CD4+ (Th) lymphocytes and CD33+ blast cells. Patients were stratified based on therapy outcome and cytogenetic molecular risk. AML non-responders (NR) showed a higher frequency of PD-1 in Th cells compared to those with complete remission (CR). Reduced blast cell level of CTLA-4 was another factor differentiating CR from NR subjects. Elevated levels of PD-1 were associated with a trend for poorer patients' survival. Additionally, prognosis for AML patients was worse in case of a higher frequency of B7-H3 in Th lymphocytes. In summary, we showed the significance of selected ICI as outcome predictors in AML management. Further, multicentre studies are required for validation of those data.

Open article ↗

2023-03-08 | Magrolimab in Combination With Azacitidine in Patients With Higher-Risk Myelodysplastic Syndromes: Final Results of a Phase Ib Study

PURPOSE Magrolimab is a monoclonal antibody that blocks cluster of differentiation 47, a don't-eat-me signal overexpressed on cancer cells. Cluster of differentiation 47 blockade by magrolimab promotes macrophage-mediated phagocytosis of tumor cells and is synergistic with azacitidine, which increases expression of eat-me signals. We report final phase Ib data in patients with untreated higher-risk myelodysplastic syndromes (MDS) treated with magrolimab and azacitidine (ClinicalTrials.gov identifier: NCT03248479 ). PATIENTS AND METHODS Patients with previously untreated Revised International Prognostic Scoring System intermediate-/high-/very high-risk MDS received magrolimab intravenously as a priming dose (1 mg/kg) followed by ramp-up to a 30 mg/kg once‐weekly or once‐every-2-week maintenance dose. Azacitidine 75 mg/m 2 was administered intravenously/subcutaneously once daily on days 1-7 of each 28-day cycle. Primary end points were safety/tolerability and complete remission (CR) rate. RESULTS Ninety-five patients were treated. Revised International Prognostic Scoring System risk was intermediate/high/very high in 27%, 52%, and 21%, respectively. Fifty-nine (62%) had poor-risk cytogenetics and 25 (26%) had TP53 mutation. The most common treatment-emergent adverse effects included constipation (68%), thrombocytopenia (55%), and anemia (52%). Median hemoglobin change from baseline to first postdose assessment was −0.7 g/dL (range, −3.1 to +2.4). CR rate and overall response rate were 33% and 75%, respectively. Median time to response, duration of CR, duration of overall response, and progression-free survival were 1.9, 11.1, 9.8, and 11.6 months, respectively. Median overall survival (OS) was not reached with 17.1-month follow-up. In TP53-mutant patients, 40% achieved CR with median OS of 16.3 months. Thirty-four patients (36%) had allogeneic stem-cell transplant with 77% 2-year OS. CONCLUSION Magrolimab + azacitidine was well tolerated with promising efficacy in patients with untreated higher-risk MDS, including those with TP53 mutations. A phase III trial of magrolimab/placebo + azacitidine is ongoing (ClinicalTrials.gov identifier: NCT04313881 [ENHANCE]).

Open article ↗

2023-01-30 | Biological therapy in elderly patients with acute myeloid leukemia

Introduction The introduction of target molecules and immunological therapies is changing the treatment landscape of acute myeloid leukemia (AML).Areas covered We recapitulate the biological therapies that can be employed in the treatment of elderly patients with AML. Alongside small molecules inhibitors that target specific gene mutations, antibodies, tumor microenvironment modulators, and cellular therapies are being developed for the cure of the disease. Here, we report the biological activities, the efficacy and toxicities of humanized antibodies and antibody-drug conjugates that targets surface antigens as CD33 (gemtuzumab ozogamicine) or CD123 (pivekimab sunirine). We further explore mechanisms and effectiveness of medications that modify the microenvironment, such as glasdegib, or that harness the immune system against leukemia, such as CD47 antibody magrolimab, PD1/PDL1 inhibitors pembrolizumab and nivolumab, TIM3 inhibitor sabatolimab, T-cell and NK-cell engagers. Cellular therapies are considered, even if a large trial is still pending for the feasibility of the approach. In this scenario, a brief overview of the mechanism of action of target agents is provided, particularly with respect to their biological mechanisms.Expert opinion Overall, this therapeutic armamentarium will constitute the basis for multimodal and personalized combinations that, in the idea of precision medicine, will enormously benefit elderly AML patients.

Open article ↗

2023-01-20 | A potential area of use for immune checkpoint inhibitors: Targeting bone marrow microenvironment in acute myeloid leukemia

Acute myeloid leukemia (AML) arises from the cells of myeloid lineage and is the most frequent leukemia type in adulthood accounting for about 80% of all cases. The most common treatment strategy for the treatment of AML includes chemotherapy, in rare cases radiotherapy and stem cell and bone marrow transplantation are considered. Immune checkpoint proteins involve in the negative regulation of immune cells, leading to an escape from immune surveillance, in turn, causing failure of tumor cell elimination. Immune checkpoint inhibitors (ICIs) target the negative regulation of the immune cells and support the immune system in terms of anti-tumor immunity. Bone marrow microenvironment (BMM) bears various blood cell lineages and the interactions between these lineages and the noncellular components of BMM are considered important for AML development and progression. Administration of ICIs for the AML treatment may be a promising option by regulating BMM. In this review, we summarize the current treatment options in AML treatment and discuss the possible application of ICIs in AML treatment from the perspective of the regulation of BMM.

Open article ↗

oligonucleotides

2023-07-27 | MicroRNA-765 is upregulated in myelodysplastic syndromes and induces apoptosis via PLP2 inhibition in leukemia cells

Epigenetic studies, particularly research on microRNA (miRNA), have flourished. The abnormal expression of miRNA contributes to the development of hematologic malignancies. miR-765 has been reported to inhibit cell proliferation by downregulating proteolipid protein 2 (PLP2), which causes apoptosis. We investigated miR-765 dysregulation in myelodysplastic syndromes (MDS).We compared the expression profiles of miR-765 in 65 patients with MDS and 11 controls. Cell proliferation and apoptosis assays were performed to determine the in vitro effects of miR-765 on leukemia cells transfected with the miR-765 mimic. Reverse transcription quantitative PCR (RT-qPCR) and western blotting were performed to examine the targets of miR-765.We found that miR-765 levels were upregulated 10.2-fold in patients with MDS compared to controls. In refractory cytopenia with multilineage dysplasia, the percentage of patients with elevated miR-765 levels was significantly higher than in other forms of MDS. Experiments with leukemia cells revealed that transfection with a miR-765 mimic inhibited cell proliferation and induced apoptosis. RT-qPCR and western blotting demonstrated that the target of miR-765 was PLP2.These findings imply that upregulation of miR-765 induces apoptosis via downregulation of PLP2 and may have a role in MDS pathogenesis.

Open article ↗

2021-10-28 | Blast cells surviving acute myeloid leukemia induction therapy are in cycle with a signature of FOXM1 activity

Abstract Background Disease relapse remains common following treatment of acute myeloid leukemia (AML) and is due to chemoresistance of leukemia cells with disease repopulating potential. To date, attempts to define the characteristics of in vivo resistant blasts have focused on comparisons between leukemic cells at presentation and relapse. However, further treatment responses are often seen following relapse, suggesting that most blasts remain chemosensitive. We sought to characterise in vivo chemoresistant blasts by studying the transcriptional and genetic features of blasts from before and shortly after induction chemotherapy using paired samples from six patients with primary refractory AML. Methods Leukemic blasts were isolated by fluorescence-activated cell sorting. Fluorescence in situ hybridization (FISH), targeted genetic sequencing and detailed immunophenotypic analysis were used to confirm that sorted cells were leukemic. Sorted blasts were subjected to RNA sequencing. Lentiviral vectors expressing short hairpin RNAs were used to assess the effect of FOXM1 knockdown on colony forming capacity, proliferative capacity and apoptosis in cell lines, primary AML cells and CD34+ cells from healthy donors. Results Molecular genetic analysis revealed early clonal selection occurring after induction chemotherapy. Immunophenotypic characterisation found leukemia-associated immunophenotypes in all cases that persisted following treatment. Despite the genetic heterogeneity of the leukemias studied, transcriptional analysis found concerted changes in gene expression in resistant blasts. Remarkably, the gene expression signature suggested that post-chemotherapy blasts were more proliferative than those at presentation. Resistant blasts also appeared less differentiated and expressed leukemia stem cell (LSC) maintenance genes. However, the proportion of immunophenotypically defined LSCs appeared to decrease following treatment, with implications for the targeting of these cells on the basis of cell surface antigen expression. The refractory gene signature was highly enriched with targets of the transcription factor FOXM1. shRNA knockdown experiments demonstrated that the viability of primary AML cells, but not normal CD34+ cells, depended on FOXM1 expression. Conclusions We found that chemorefractory blasts from leukemias with varied genetic backgrounds expressed a common transcriptional program. In contrast to the notion that LSC quiescence confers resistance to chemotherapy we find that refractory blasts are both actively proliferating and enriched with LSC maintenance genes. Using primary patient material from a relevant clinical context we also provide further support for the role of FOXM1 in chemotherapy resistance, proliferation and stem cell function in AML.

Open article ↗

2021-02-19 | Reduced miR-16 levels are associated with VEGF upregulation in high-risk myelodysplastic syndromes

Objective: Overexpression of vascular endothelial growth factor (VEGF), a major angiogenic factor, was found in myelodysplastic syndromes (MDS) and showed different expression statuses in different risk groups of MDS.We aimed to investigate the possible role of microRNA (miR)-15a and miR-16 on the regulation of VEGF expression and their effect on angiogenesis in lower-and higher-risk MDS.Methods: We studied peripheral blood and bone marrow samples of MDS patients or several leukaemia and MDS cell lines by enzyme-linked immunosorbent assay, immunohistochemical staining, immunofluorescence and quantitative PCR for expression levels of VEGF, miR-15a and miR-16.MiRNA transfection and Luciferase reporter assays were conducted to investigate whether VEGF is a target of miR-16.Migration and tube formation assays were performed in cells exposed to medium from cells with overexpressed or knockdown miR-16.Results: It showed a significantly lower level of miR-16 in higher-risk MDS patients, while the VEGF levels were upregulated.Inverse correlation between VEGF and miR-16 were determined in cells lines including SKM-1, THP-1, and K562 cells.Overexpression of miR-16 in SKM-1 cells resulted in reduced VEGF secretion and cell protein levels.Direct binding of miR-16 to the 3' untranslated region (3'-UTR) of VEGF was confirmed by luciferase reporter assays.The migration and tube formation of human umbilical vein endothelial cells decreased in the presence of medium from SKM-1 cells with overexpressed miR-16.Conclusion: These data suggest that miR-16 may play a role in angiogenesis in higher-risk MDS by targeting VEGF and therefore modulating MDS progression.MiR-16 might be a novel therapeutic target in higher-risk MDS.

Open article ↗

2020-10-22 | Hyperglycemia cooperates with Tet2 heterozygosity to induce leukemia driven by proinflammatory cytokine–induced lncRNA Morrbid

Diabetes mellitus (DM) is a risk factor for cancer. The role of DM-induced hyperglycemic (HG) stress in blood cancer is poorly understood. Epidemiologic studies show that individuals with DM are more likely to have a higher rate of mutations in genes found in pre-leukemic hematopoietic stem and progenitor cells (pre-LHSPCs) including TET2. TET2-mutant pre-LHSPCs require additional hits to evolve into full-blown leukemia and/or an aggressive myeloproliferative neoplasm (MPN). Intrinsic mutations have been shown to cooperate with Tet2 to promote leukemic transformation. However, the extrinsic factors are poorly understood. Using a mouse model carrying Tet2 haploinsufficiency to mimic the human pre-LHSPC condition and HG stress, in the form of an Ins2Akita/+ mutation, which induces hyperglycemia and type 1 DM, we show that the compound mutant mice developed a lethal form of MPN and/or acute myeloid leukemia (AML). RNA-Seq revealed that this was due in part to upregulation of proinflammatory pathways, thereby generating a feed-forward loop, including expression of the antiapoptotic, long noncoding RNA (lncRNA) Morrbid. Loss of Morrbid in the compound mutants rescued the lethality and mitigated MPN/AML. We describe a mouse model for age-dependent MPN/AML and suggest that hyperglycemia acts as an environmental driver for myeloid neoplasms, which could be prevented by reducing expression levels of the inflammation-related lncRNA Morrbid.

Open article ↗

2020-04-17 | Detection of Novel t(12;17)(p12;p13) in Relapsed Refractory Acute Myeloid Leukemia by Anchored Multiplex PCR(AMP)-based Next-Generation Sequencing.

Although several technologies can be used to detect gene fusions, anchored multiplex PCR next-generation sequencing (AMP-NGS) offers the advantage of novel fusion detection and the ability to multiplex multitudinous genes. We applied AMP-NGS technology in the evaluation of a 56-year-old gentleman with myelodysplastic syndrome transformed acute myeloid leukemia (AML). Patient was initially diagnosed with low-risk myelodysplastic syndrome-refractory cytopenias and multilineage dysplasia (MDS-RCMD), progressed to AML after failing hypomethylating agent therapy. At progression patients had normal cytogenetics but NGS profiling showed ETV6 c.416_417del CT frame shift and U2AF1 S34F mutations. Patient attains brief remission of 2 months after induction chemotherapy and then he was refractory to 2 salvage chemotherapy regimens. Reassessment after failing second salvage, identified t(12;17)(p13;p13)[20] by karyotype. It was postulated that the 12p13 locus might represent a new rearrangement of ETV6. AMP-NGS confirmed involvement of the ETV6 with discovery of a novel fusion partner, HIC1. The detection of the novel fusion partners was supported by the breakpoints originally observed by karyotype. This discovery of ETV6-HIC1 gene fusion by AMP-NGS technology provided new insight into a leukemogenic pathway in AML. Future use of this technology can serve as an adjunct tool in workup of patients with AML and can also help in formulating therapeutic strategies.

Open article ↗

other

2021-09-28 | Off-Label Use of Thrombopoietin Receptor Agonists: Case Series and Review of the Literature

Since their license in 2008, studies on thrombopoietin receptor agonists (TPO-RAs) are proceeding at a fast pace. Their favorable efficacy and safety profile makes them good candidates for the management of thrombocytopenia in different settings, even beyond their current indications. In the last 10 years, we faced patients with refractory thrombocytopenia that required treatment with off-label TPO-RA, despite the paucity of data in the literature and the possible risks, particularly that of thrombosis. We hereby report our 10-year real-life single-center experience of TPO-RA used off-label. Fourteen patients were divided into three groups according to the etiology of thrombocytopenia: myelodysplastic syndromes, post-transplantation, and lymphoproliferative diseases. Clinical features and results are reported within each group. Overall, TPO-RA proved effective in all these conditions achieving responses also in heavily pretreated patients. The overall response rate (ORR) was 100% in patients with thrombocytopenia after transplantation and in those with lymphoproliferative diseases and 75% in patients with myelodysplastic syndromes. The median duration of therapy was 285 days (range 93–1,513 days). Four patients (29%) discontinued treatment because of lack of response (n=2) or a sustained response (n=2). No grade 3–4 adverse events occurred, particularly no thrombosis. In our real-life experience, TPO-RAs were effective and safe and proved of value in the challenging management of patients with refractory thrombocytopenia associated with different conditions.

Open article ↗

2019-02-18 | A phase 2 clinical trial of eltrombopag for treatment of patients with myelodysplastic syndromes after hypomethylating-agent failure

Hypomethylating agents (HMA) are the standard of care for treatment of myelodysplastic syndromes (MDS). HMA-failure MDS has extremely poor prognosis. This study was designed to explore the utility of eltrombopag in post-HMA failure MDS patients. Patients were treated in one of two arms: eltrombopag as monotherapy (Arm A), or with continuation of HMA (Arm B). The starting eltrombopag dose was 200 mg orally daily. Twenty-nine patients with a median age of 72 years (42–84) were enrolled. The median number of prior treatment was 1 (1–5). Seven (24%) patients were enrolled in cohort A and 22 (76%) in cohort B. One early death (<30 days) occurred in cohort B due to infection/sepsis. Of 28 evaluable patients, 3 (11%) in cohort B experienced platelet improvement. Median overall survival was 12 months. This study demonstrated modest platelet improvement in some, without evidently increased toxicity or increased risk of leukemia progression.Trial registration: ClinicalTrials.gov identifier: NCT01893372.

Open article ↗

2014-10-09 | Thrombopoietin/MPL signaling confers growth and survival capacity to CD41-positive cells in a mouse model of Evi1 leukemia

Ecotropic viral integration site 1 (Evi1) is a transcription factor that is highly expressed in hematopoietic stem cells and is crucial for their self-renewal capacity. Aberrant expression of Evi1 is observed in 5% to 10% of de novo acute myeloid leukemia (AML) patients and predicts poor prognosis, reflecting multiple leukemogenic properties of Evi1. Here, we show that thrombopoietin (THPO) signaling is implicated in growth and survival of Evi1-expressing cells using a mouse model of Evi1 leukemia. We first identified that the expression of megakaryocytic surface molecules such as ITGA2B (CD41) and the THPO receptor, MPL, positively correlates with EVI1 expression in AML patients. In agreement with this finding, a subpopulation of bone marrow and spleen cells derived from Evi1 leukemia mice expressed both CD41 and Mpl. CD41(+) Evi1 leukemia cells induced secondary leukemia more efficiently than CD41(-) cells in a serial bone marrow transplantation assay. Importantly, the CD41(+) cells predominantly expressing Mpl effectively proliferated and survived on OP9 stromal cells in the presence of THPO via upregulating BCL-xL expression, suggesting an essential role of the THPO/MPL/BCL-xL cascade in enhancing the progression of Evi1 leukemia. These observations provide a novel aspect of the diverse functions of Evi1 in leukemogenesis.

Open article ↗

2010-01-15 | High-dose RHAMM-R3 peptide vaccination for patients with acute myeloid leukemia, myelodysplastic syndrome and multiple myeloma

Background Recently, we demonstrated immunological and clinical responses to a RHAMM-R3 peptide vaccine in patients with acute myeloid leukemia, myelodysplastic syndrome and multiple myeloma. To improve the outcome of the vaccine, a second cohort was vaccinated with a higher dose of 1,000 μg peptide.Design and Methods Nine patients received four vaccinations subcutaneously at a biweekly interval. Immunomonitoring of cytotoxic CD8+ as well as regulatory CD4+ T cells was performed by flow cytometry as well as by enzyme-linked immunospot (ELISpot) assays. Parameters of clinical response were assessed.Results In 4 of 9 patients (44%) we detected positive immunological responses. These patients showed an increase of CD8+RHAMM-R3_tetramer+/CD45RA+/CCR7−/CD27−/CD28− effector T cells and an increase of R3-specific CD8+ T cells. Two of these patients showed a significant decrease of regulatory T cells (Tregs). In one patient without response Tregs frequency increased from 5 to 16%. Three patients showed clinical effects: one patient with myelodysplastic syndrome RAEB-1 showed a reduction of leukemic blasts in the bone marrow, another myelodysplastic syndrome patient an improvement of peripheral blood counts and one patient with multiple myeloma a reduction of free light chains. Clinical and immunological reactions were lower in this cohort than in the 300 μg cohort.Conclusions High-dose RHAMM-R3 peptide vaccination induced immunological responses and positive clinical effects. Therefore, RHAMM constitutes a promising structure for further targeted immunotherapies in patients with different hematologic malignancies. However, higher doses of peptide did not improve the frequency and intensity of immune responses in this trial. (This study is registered at http://ISRCTN.org as ISRCTN32763606)

Open article ↗

2004-12-14 | Low-dose interleukin-11 in patients with bone marrow failure: update of the M. D. Anderson Cancer Center experience

Recombinant interleukin (IL)-11 is a thrombopoietic growth factor. The purpose of this study was to assess the toxicity, safety and efficacy of low-dose recombinant IL-11 in patients with bone marrow failure (BMF).Patients with BMF due to myelodysplastic syndromes (MDS), graft failure, chemotherapy or aplastic anemia (AA) were treated. Patients were required to have a platelet count of <20 x 10(9)/l, or a platelet count of <50 x 10(9)/l with an absolute neutrophil count <1 x 10(9)/l, or a hemoglobin value <10 g/dl. Treatment consisted of daily IL-11 at a dose of 10 mug/kg subcutaneously followed by a 2-week rest period. Two induction courses were given. Responders could receive maintenance therapy.Thirty-three patients (MDS, n=14; AA, n=16; prolonged thrombocytopenia following stem cell transplantation or chemotherapy, n=3) were evaluable. Their median age was 58 years (range 5-85). Three patients (9%) had poor risk cytogenetics. Nine patients (27%) responded to IL-11 (six MDS, three AA). Of these, three patients treated with IL-11 alone (n=1) or IL-11 together with other growth factors (n=2) showed multilineage recovery. The median time to response was 0.9 months (range 0.3-11). Factors associated with higher response rates in univariate analysis were age >50 years (P=0.008), diagnosis of MDS versus AA (P=0.025) and creatinine level >1 mg/dl (P=0.0004). The median response duration was 3 months (range 1.4-34.5+). Amongst responders, the median increment in platelet count was 111 x 10(9)/l (range 43-165). The most common side-effects were grade 1-2 lower extremity edema, conjunctival injections and fatigue. Grade 3 toxicities included arrhythmia (n=1) and transient ischemic attack (n=1). Ten patients (30%) had no side-effects.Low-dose IL-11 has activity in patients with BMF and is generally well tolerated.

Open article ↗