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Treatment of Acute Myeloid Leukemia with the FLT3 Gene Mutation

  • Leukemia (A Aguayo, Section Editor)
  • Published:
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Abstract

In acute myeloid leukemia (AML), mutations of the Fms-like tyrosine kinase 3 receptor (FLT3) and its overexpression are related with hyperleukocytosis, higher risk of relapse, and decrease of both disease-free survival and overall survival. It has been suggested that this phenomenon confers proliferative and survival advantages to the malignant blast cells. As a consequence, it is an attractive therapeutic target. As the best treatment strategy for mutated FLT3 AML remains to be defined, the addition of FLT3 inhibitor drugs to chemotherapy or to the bone marrow transplant approach has become a growing strategy. With encouraging results, this combination seems to be an attractive option. Relevant data regarding the current treatment trends on mutated FLT3 AML is reviewed here.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Catherine C. Coombs, Martin S. Tallman and Ross L. Levine. Molecular therapy for acute myeloid leukaemia. Nature reviews. Clinical oncology. 2015. Advance on line publication. doi:10.1038/nrclinonc.2015.210

  2. Kottaridis PD, Gale RE, Frew ME, et al. The presence of a FLT3 internal tandem duplication in patients with acute myeloid leukemia (AML) adds important prognostic information to cytogenetic risk group and response to the first cycle of chemotherapy: analysis of 854 patients from the United Kingdom Medical Research Council AML10 and 12 trials. Blood. 2001;98(number 6):1752–9. doi:10.1182/blood.V98.6.1752.

    Article  CAS  PubMed  Google Scholar 

  3. Gary Gilliland D, Griffin JD. The roles of FLT3 in hematopoiesis and leukemia. Blood. 2002;100(number 5):1532–42. doi:10.1182/blood-2002-02-0492.

    Article  PubMed  Google Scholar 

  4. Nakao M, Yokota S, Iwai T, Kaneko H, Horiike S, Kashima K, et al. Internal tandem duplication of the FLT3 gene found in acute myeloid leukemia. Leukemia. 1996;10:1911–8.

    CAS  PubMed  Google Scholar 

  5. Iwai T, Yokota S, Nakao M, et al. Internal tandem duplication of the FLT3 gene and clinical evaluation in childhood acute myeloid leukemia. The Children’s cancer and leukemia study group, Japan. Leukemia. 1999;13:38–43.

    Article  CAS  PubMed  Google Scholar 

  6. Meshinchi S, Woods WG, Stirewalt DL, et al. Prevalence and prognostic significance of Flt3 internal tandem duplication in pediatric acute myeloid leukemia. Blood. 2001;97:89–94. doi:10.1182/blood.V97.1.89.

    Article  CAS  PubMed  Google Scholar 

  7. O’Brien SG, Guilhot F, Larson RA. Imatinib compared with interferon and low-dose cytarabine for newly diagnosed chronic-phase chronic myeloid leukemia. N Engl J Med. 2003;348:994–1004.

    Article  PubMed  Google Scholar 

  8. Kiyoi H. FLT3 inhibitors: recent advances and problems for clinical application. Nagoya J Med Sci. 2015;77:7–17.

    PubMed  PubMed Central  Google Scholar 

  9. Xu G, Mao L, Liu H, Yang M, Jin J, Qian W. Sorafenib in combination with low-dose-homoharringtonine as a salvage therapy in primary refractory FLT3-ITD-positive AML: a case report and review of literature. Int J Clin Exp Med. 2015;8(11):19891–4.

    PubMed  PubMed Central  Google Scholar 

  10. •• Stone RM, Mandrekar S, Sanford BL, et al. The multi-kinase inhibitor Midostaurin (M) prolongs survival compared with placebo (P) in combination with Daunorubicin (D)/Cytarabine (C) induction (ind), high-dose C consolidation (consol), and as maintenance (maint) therapy in newly diagnosed acute myeloid leukemia (AML) patients (pts) age 18–60 with FLT3 mutations (muts): an international prospective randomized (rand) P-controlled double-blind trial (CALGB 10603/RATIFY [alliance]). Blood. 2015;126(23):6. August 29, 2016. Established the feasibility and efficacy of the combination of chemotherapy and Midostaurin in one of the most extensive cohorts of patients studied to date.

    Google Scholar 

  11. Chen Y-B, Li S, Lane AA, et al. Phase I trial of maintenance sorafenib after allogeneic hematopoietic stem cell transplantation for FLT3-ITD AML. Biol Blood Marrow Transplant. 2014 December;20(12):2042–8. doi:10.1016/j.bbmt.2014.09.007.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Sandmaier BM, Khaled SK, Oran B, Gammon G, Trone D, Frankfurt O. Results of a phase 1 study of quizartinib (AC220) as maintenance therapy in subjects with acute myeloid leukemia in remission following allogeneic hematopoietic cell transplantation. Blood. 2014;124:428.

    Google Scholar 

  13. Strati P, Kantarjian H, Ravandi F. Phase I/II trial of the combination of midostaurin (PKC412) and 5-azacytidine for patients with acute myeloid leukemia and myelodysplastic syndrome. Am J Hematol. 2015 April;90(4):276–81. doi:10.1002/ajh.23924.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Ravandi F, Cortes JE, Jones D, Faderl S, Garcia-Manero G, et al. Phase I/II study of combination therapy with Sorafenib, Idarubicin, and cytarabine in younger patients with acute myeloid leukemia. J Clin Oncol. 2010;28(Number 11) doi:10.1200/JCO.2009.25.4888.

  15. Rombouts WJC, Blokland I, Löwenberg B, Ploemacher RE. Biological characteristics and prognosis of adult acute myeloid leukemia with internal tandem duplications in the Flt3 gene. Leukemia. 2000;14:675–83.

    Article  CAS  PubMed  Google Scholar 

  16. Hassanein M, Almahayni MH, Gaballa S, Ahmed SO, Fakih RE. FLT3 inhibitors for treating acute myeloid leukemia, clinical lymphoma. Myeloma and Leukemia. 2016; doi:10.1016/j.clml.2016.06.002.

    Google Scholar 

  17. Burnett AK, et al. Higher Daunorubicin exposure benefits FLT3 mutated acute myeloid leukemia. Blood. 2016;128(Number 3):449–52. doi:10.1182/blood-2016-04-712091.

    Article  CAS  PubMed  Google Scholar 

  18. • Talha B, Kantarjian Hagop M, Nogueras-Gonzalez Graciela M, et al. Improvement in clinical outcome of FLT3 ITD mutated acute myeloid leukemia over the last one and half decade. Am J Hematol. 90(11) doi:10.1002/ajh.24140. Describes the evolution of treatment and results over 6 eras along 14 years in a single institution.

  19. Carow CE, Levenstein M, Kaufmann SH, Chen J, Amin S, Rockwell P, et al. Expression of the hematopoietic growth factor receptor FLT3 (STK-UFIk2) in human Leukemias. Blood. 1996;87(3):1089–96.

    CAS  PubMed  Google Scholar 

  20. Pawar R, Bali OPS, Malhotra BK, Lamba G. Recent advances and novel agents for FLT3 mutated acute myeloid leukemia. Stem Cell Investig. 2014;1:7. doi:10.3978/j.issn.2306-9759.2014.03.03.

    PubMed  PubMed Central  Google Scholar 

  21. Kase H, Iwahashi K, Matsuda Y. K-252a, a potent inhibitor of protein kinase C from microbial origin. J Antibiot (Tokyo). 1986;39(8):1059–65.

    Article  CAS  Google Scholar 

  22. • Francisco Alejandro Lagunas-Rangel, Carlos Cortes-Penagos, Martha Eva Viveros-Sandoval. FLT3: beyond good and evil. Hematol Oncol 2016; 1–9. DOI 10.1002/hon.2330 A concise review of pharmacology of FLT3ID and physiology of FLT3 mutations.

  23. • Seth A. Wander, Mark J. Levis and Amir T. Fathi. The evolving role of FLT3 inhibitors in acute myeloid leukemia: Quizartinib and beyond. 2014, Vol. 5(3) 65–77. DOI: 10.1177/2040620714532123 Describes the experience and future perspectives of FLT3ID.

  24. Fiedler W, Serve H, Dohner H, Schwittay M, Ottmann OG, O’Farrell A-M. A phase 1 study of SU11248 in the treatment of patients with refractory or resistant acute myeloid leukemia (AML) or not amenable to conventional therapy for the disease. Blood. 2005;105(Number 3) doi:10.1182/blood-2004-05-1846.

  25. Fiedler W, Kayser S, Kebenko M, Janning M, Krauter J, et al. A phase I/II study of Sunitinib and intensive chemotherapy in patients over 60 years of age with acute myeloid leukaemia and activating FLT3 mutations. Br J Haematol. 2015;169:694–700. doi:10.1111/bjh.13353.

    Article  CAS  PubMed  Google Scholar 

  26. Gallogly MM, Lazarus HM. Midostaurin: an emerging treatment for acute myeloid leukemia patients. Journal of Blood Medicine. 2016;7:73–83. doi:10.2147/JBM.S100283.

    PubMed  PubMed Central  Google Scholar 

  27. Stone RM, DeAngelo DJ, Klimek V, Galinsky I, Estey E, Nimer SD. Patients with acute myeloid leukemia and an activating mutation in FLT3 respond to a small-molecule FLT3 tyrosine kinase inhibitor, PKC412. Blood. 2005;105(Number 1):54–60. doi:10.1182/blood-2004-03-0891.

    Article  CAS  PubMed  Google Scholar 

  28. Shabbir M, Stuart R. Lestaurtinib, a multitargeted tyrosinse kinase inhibitor: from bench to bedside. Expert Opin Investig Drugs. 2010;19(3):427–36. doi:10.1517/13543781003598862.

    Article  CAS  PubMed  Google Scholar 

  29. Douglas Smith B, Levis M, Beran M, Giles F, Kantarjian H, Berg K. Single-agent CEP-701, a novel FLT3 inhibitor, shows biologic and clinical activity in patients with relapsed or refractory acute myeloid leukemia. Blood. 2004;103(Number 10):3669–76. doi:10.1182/blood-2003-11-3775.

    Article  PubMed  Google Scholar 

  30. Burnett AK, Bowen D, Russell N, Knapper S, Milligan D, Hunter AE, et al. AC220 (Quizartinib) can be safely combined with conventional chemotherapy in older patients with newly diagnosed acute myeloid leukaemia: experience from the AML18 pilot trial. Blood. 2013;122:622.

    Article  Google Scholar 

  31. Jorge E. Cortes, Hagop Kantarjian, James M. Foran, Darejan Ghirdaladze, Mamia Zodelava. Phase I study of quizartinib administered daily to patients with relapsed or refractory acute myeloid leukemia irrespective of FMS-like tyrosine kinase 3–internal tandem duplication status. J Clin Oncol 31:3681–3687. DOI: 10.1200/JCO.2013.48.8783.

  32. Tood M. Cooper, Jeannette Cassar, Elena Eckroth, Jemily Malvar, Richard Sposto, Paul Gaynon, Bill H. Chang, Lia Gore, Keith August. Et. al. A Phase I study of quizartinib combined with chemotherapy in relapsed childhood leukemia: therapeutic advances in childhood leukemia & lymphoma (TACL) study. February 27, American Association for Cancer Reserch. DOI: 10.1158/1078-0432.CCR-15-1998.

  33. Wilhelm SM, Carter C, Tang LY, et al. BAY 43-9006 exhibits broad Spectrum oral antitumor activity and targets the RAF/MEK/ERK pathway and receptor tyrosine kinases involved in tumor progression and angiogenesis. Cancer Res. 2004;64:7099–109.

    Article  CAS  PubMed  Google Scholar 

  34. Zhang W, Konopleva M, Shi Y-x, et al. Mutant FLT3: a direct target of sorafenib in acute Myelogenous leukemia. J Natl Cancer Inst. 2008;100:184–98. doi:10.1093/jnci/djm328.

    Article  CAS  PubMed  Google Scholar 

  35. Williams CB, Kambhampati S, Fiskus W, Wick J, Dutreix C, Ganguly S. Preclinical and phase I results of decitabine in combination with midostaurin (PKC412) for newly diagnosed elderly or relapsed/refractory adult patients with acute myeloid leukemia. Pharmacotherapy. 2013;33(12):1341–52. doi:10.1002/phar.1316.

    Article  CAS  PubMed  Google Scholar 

  36. • Linblad O, Cordero E, Puissant A, et al. Aberrant activation of the PI3K/mTOR pathway promotes resistance to Sorafenib in AML. Oncogene. 2016; doi:10.1038/onc.2016.41. Describes the aberrant activation of cell survival and proliferative pathways as a mechanism to overcome inhibition of FLT3.

    Google Scholar 

  37. Grimm D, Lieb J, Weyer V et al. Organic Cation Transporter 1 (OCT1) mRNA expression in hepatocellular carcinoma as a biomarker for Sorafenib treatment. BMC Cancer. 2016.1–8. DOI 10.1186/s12885-016-2150-3.

  38. Smith CC, Lin K, Stecula A. FLT3 D835 mutations confer differential resistance to type II FLT3 inhibitors. Leukemia. 2015 December;29(12):2390–2. doi:10.1038/leu.2015.165.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Chen F, Ishikawa Y, Akashi A, et al. Co-expression of wild-type FLT3 attenuates the inhibitory effect of FLT3 inhibitor on FLT3 mutated leukemia cells. Oncotarget. 2016;7(30):47018–32.

    PubMed  PubMed Central  Google Scholar 

  40. Huang A, Huaiqiang J, Liu K, et al. Metabolic alterations and drug sensitivity of tyrosine kinase inhibitor resistant leukemia cells with a FLT3/ITD mutation. Cancer Lett. 2016;1-9 doi:10.1016/j.canlet.2016.04.040.

  41. • Galanis A, Ma H, Rajkhowa T, Ramachandran A, Small D, Cortes J, Levis M. Crenolanib is a potent inhibitor of FLT3 with activity against resistance-conferring point mutants. Blood. 2014;123(1):94–100. doi:10.1182/blood-2013-10-529313. Describes the potential capacity of Crenolanib to overcome acquired resistance to FLT3ID.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Meshinchi S, Arceci RJ, Sanders JE, et al. Role of allogeneic stem cell transplantation in FLT3/ITD-positive AML. Blood. 2006;108:400.

    Article  CAS  PubMed  Google Scholar 

  43. Bornhauser M, Illmer T, Schaich M, et al. Improved outcome after stem-cell transplantation in FLT3/ITD-positive AML. Blood. 2007;109:2265–6.

    Article  Google Scholar 

  44. Brunet S, Perea G, Esteve J, et al. Adverse impact of FLT3 internal tandem duplication in patients with poor-risk acute myeloid leukaemia allocated to autologous transplantation. Bone Marrow Transpl. 2004;33:S3. (Suppl 1; abstr 71)

    Article  Google Scholar 

  45. Gale R, Hills R, Kottaridis P, et al. No evidence that FLT3 status should be considered as an indicator for transplantation in acute myeloid leukemia (AML): an analysis of 1135 patients, excluding acute promyelocytic leukemia, from the UK MRC AML10 and 12 trials. Blood. 2005;106:3658–65. doi:10.1182/blood-2005-03-1323.

    Article  CAS  PubMed  Google Scholar 

  46. Brunet S, Labopin M, Esteve J, et al. Impact of FLT3 internal tandem duplication on the outcome of related and unrelated hematopoietic transplantation for adult acute myeloid leukemia in first remission: a retrospective analysis. J Clin Oncol. 2012;30:735–41. doi:10.1200/JCO.2011.36.9868.

    Article  PubMed  Google Scholar 

  47. •• De Freitas T, Marktel S, Piemontese S, et al. High rate of hematological responses to Sorafenib in FLT3-ITD acute myeloid leukemia relapsed after allogeneic hematopoietic stem cell transplantation. Eur J Haematol. 2015; doi:10.1111/ejh.12647. Explores the feasibility of Sorafenib as maintenance therapy following allogenic BMT in FLT3-ITD AML patients.

    PubMed  Google Scholar 

  48. Alvarado Y, Kantarjian H, Luthra R, Ravandi F, Borthakur G. Treatment with FLT3 inhibitor in patients with FLT3-mutated AML is associated with development of secondary FLT3-TKD mutations. Cancer. 2014;120(14):2142–9. doi:10.1002/n28705.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Acknowledgments

The authors wish to thank Dr. Mónica Vazquez del Mercado (CUCS, Universidad de Guadalajara) for her invaluable support in English grammar review.

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Correspondence to Carlos Best-Aguilera.

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Conflict of Interest

Carlos Best-Aguilera has received compensation from Avillion Development 1, Ltd., Novartis, AbbVie Farmacéuticos S.A. de C.V., and Celgene for service as a consultant.

O Rodrigo Gómez-Vázquez declares that he has no conflict of interest.

A. Elizabeth Guzmán-Hernández declares that she has no conflict of interest.

R. Monserrat Rojas-Sotelo has received compensation from Janssen and Avillion Development 1, Ltd. for service as a consultant.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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Best-Aguilera, C., Rodrigo Gómez-Vázquez, O., Elizabeth Guzmán-Hernández, A. et al. Treatment of Acute Myeloid Leukemia with the FLT3 Gene Mutation. Curr Oncol Rep 19, 21 (2017). https://doi.org/10.1007/s11912-017-0573-x

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