4.7 Review

Current status and future perspectives in targeted therapy of NPM1-mutated AML

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Menin Inhibitors in Acute Myeloid Leukemia-What Does the Future Hold?

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Summary: Menin inhibitors are a class of drugs targeting NPM1 mutant and KMT2Ar acute leukemias, with the aim of inducing differentiation, downregulating critical gene expression, and providing a survival advantage. Multiple clinical trials are ongoing, and preliminary results show promising effects and tolerable toxicity.

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Impact of FLT3 Mutation on Outcomes after Venetoclax and Azacitidine for Patients with Treatment-Naive Acute Myeloid Leukemia

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Summary: The efficacy and safety of venetoclax + azacitidine in patients with FLT3-mutant acute myeloid leukemia were evaluated. The results showed significant differences in composite complete remission rates and overall survival between patients treated with venetoclax + azacitidine and those treated with azacitidine alone. These findings suggest that venetoclax + azacitidine may be of importance in the treatment of patients with FLT3 mutations.

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Effective Menin inhibitor-based combinations against AML with MLL rearrangement or NPM1 mutation (NPM1c)

Warren Fiskus et al.

Summary: Treatment with Menin inhibitor disrupts the interaction between Menin and MLL1 or MLL1-fusion protein, inhibiting AML cell survival and inducing differentiation. Combining Menin inhibitor with other drugs enhances the therapeutic efficacy against AML cells.

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Pembrolizumab and decitabine for refractory or relapsed acute myeloid leukemia

Meghali Goswami et al.

Summary: This study aimed to investigate the feasibility and efficacy of the combination of PD-1 blockade and hypomethylating therapy in patients with R-AML. The results showed that this combination therapy achieved disease stability or better response in some patients. Moreover, clonal T cell expansions and immunological changes were observed during treatment, which may be associated with treatment-related adverse events.

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EAPB0503, an Imidazoquinoxaline Derivative Modulates SENP3/ARF Mediated SUMOylation, and Induces NPM1c Degradation in NPM1 Mutant AML

Hala Skayneh et al.

Summary: Nucleophosmin-1 (NPM1) is a pleiotropic protein involved in various cellular processes. In acute myeloid leukemia (AML), NPM1 frequently mutates and exhibits aberrant cytoplasmic localization. Therefore, finding therapeutic approaches to modulate NPM1c post-translational modifications is of great significance in the management of AML patients.

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Use of Venetoclax in Patients with Relapsed or Refractory Acute Myeloid Leukemia: The PETHEMA Registry Experience

Jorge Labrador et al.

Summary: The effectiveness of venetoclax (VEN) in relapsed or refractory acute myeloid leukemia (RR-AML) has not been well established. This study found that the combination of venetoclax with azacitidine had a higher complete remission rate compared to combination with decitabine and low-dose cytarabine. Mutated NPM1 was associated with increased complete remission rate.

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Enhanced stimulation of antigen-specific immune responses against nucleophosmin 1 mutated acute myeloid leukaemia by an anti-programmed death 1 antibody

Jochen Greiner et al.

Summary: This study investigated immune responses against NPM1 and other leukaemia-associated antigens (LAA) in AML patients and found that the anti-PD-1 antibody nivolumab enhances immune response against stem cell-like cells. It suggests that NPM1 mutated AML patients could benefit from treatment with anti-PD-1 and NPM1-specific immunotherapy.

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The 5th edition of the World Health Organization Classification of Haematolymphoid Tumours: Myeloid and Histiocytic/Dendritic Neoplasms

Joseph D. Khoury et al.

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Memory-like NK cells armed with a neoepitope-specific CAR exhibit potent activity against NPM1 mutated acute myeloid leukemia

Han Dong et al.

Summary: Acute myeloid leukemia (AML) is difficult to treat due to a lack of tumor-specific targets for immune-based therapies. Recent studies have shown that natural killer (NK) cells exhibit innate memory and enhanced antitumor activity when activated with IL-12 and IL-18. This study demonstrates that arming CIML NK cells with a neoepitope-specific CAR significantly improves their antitumor responses to NPM1-mutated AML and avoids off-target toxicity.

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Venetoclax induces rapid elimination of NPM1 mutant measurable residual disease in combination with low-intensity chemotherapy in acute myeloid leukaemia

Ing S. Tiong et al.

Summary: This study demonstrates the significant efficacy of venetoclax-based therapy in reducing the risk of relapse in patients with persistent or rising NPM1(mut) MRD.

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Venetoclax Increases Intratumoral Effector T Cells and Antitumor Efficacy in Combination with Immune Checkpoint Blockade

Frederick J. Kohlhapp et al.

Summary: Venetoclax, a selective BCL2 inhibitor, can enhance the anticancer efficacy of immune checkpoint inhibitors by increasing PD-1+ T effector memory cells in mouse models. It does not impair human T-cell function and can provide a survival advantage in effector T cells, indicating its potential in combination with ICIs for cancer therapy.

CANCER DISCOVERY (2021)

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CAR-T cells targeting a nucleophosmin neoepitope exhibit potent specific activity in mouse models of acute myeloid leukaemia

Guozhu Xie et al.

Summary: Therapies using CAR-T cells targeting tumor-specific driver gene mutations show potent and specific cytotoxic activity against acute myeloid leukemia, potentially avoiding harmful effects on normal tissues.

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A Box of Chemistry to Inhibit the MEN1 Tumor Suppressor Gene Promoting Leukemia

Ezgi Ozyerli-Goknar et al.

Summary: The study introduces a new class of PPI inhibitors targeting the interaction between Menin and MLL proteins to treat MLL/KMT2A-rearranged leukemia, with thienopyrimidine compounds showing promising results in late-phase clinical trials. These compounds exhibit good tolerability and minimal side effects, suggesting a potential novel targeted therapy for leukemia patients.

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Dactinomycin induces complete remission associated with nucleolar stress response in relapsed/refractory NPM1-mutated AML

Ilaria Gionfriddo et al.

Summary: Relapsed or refractory AML patients with NPM1 mutations face challenges in treatment, particularly in elderly and unfit individuals. Dactinomycin, a low-cost chemotherapeutic agent, shows potential as an alternative treatment option, possibly through its association with nucleolar stress. Further investigation in larger clinical studies is warranted.

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Biyu Zhang et al.

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CD123 Is Consistently Expressed on NPM1-Mutated AML Cells

Vincenzo Maria Perriello et al.

Summary: One-third of adult AML patients have NPM1 mutations, with high expression of CD123 identified as a potential target for therapy in NPM1-mutated leukemic cells, particularly in CD34(+)CD38(-) cells. Targeting CD123 may be effective for treating NPM1-mutated AML, especially in combination with FLT3 mutations.

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Clinical and molecular predictors of response and survival following venetoclax therapy in relapsed/refractory AML

Maximilian Stahl et al.

Summary: Combination therapy of venetoclax is effective in many patients with relapsed or refractory AML, with azacitidine+venetoclax showing higher response rates compared to low-dose cytarabine+venetoclax. Clinical and molecular characteristics of patients may predict treatment outcomes in this population.

BLOOD ADVANCES (2021)

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Venetoclax enhances T cell-mediated antileukemic activity by increasing ROS production

Jong Bok Lee et al.

Summary: The combination therapy of Venetoclax and azacytidine directly activates T cells, increases reactive oxygen species generation, and enhances cytotoxicity against AML cells. Azacytidine also activates the STING/cGAS pathway, rendering AML cells more susceptible to T cell-mediated cytotoxicity.
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An HLA-A*11:01-Binding Neoantigen from Mutated NPM1 as Target for TCR Gene Therapy in AML

Dyantha I. van der Lee et al.

Summary: AML is an aggressive hematological malignancy with a poor prognosis, requiring new and effective therapies; approximately 30-35% of AML cases have a frameshift mutation in the dNPM1 gene, potentially creating targets for immunotherapy.

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Brunangelo Falini et al.

Summary: Mutations of Nucleophosmin (NPM1) are common in adult AML and are recognized as a distinct entity. Evaluation of NPM1 and FLT3 status is important for risk stratification and monitoring of MRD. Combining MRD monitoring with the ELN prognostication model can help guide therapeutic decisions for NPM1-mutated AML.

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A phase 1b/2 study of azacitidine with PD-L1 antibody avelumab in relapsed/refractory acute myeloid leukemia

Kapil Saxena et al.

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CANCER (2021)

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Venetoclax Combined With FLAG-IDA Induction and Consolidation in Newly Diagnosed and Relapsed or Refractory Acute Myeloid Leukemia

Courtney D. DiNardo et al.

Summary: The combination of fludarabine, cytarabine, granulocyte colony-stimulating factor, and idarubicin with venetoclax showed to be an effective treatment regimen in both newly diagnosed and relapsed or refractory AML patients, resulting in deep remissions and high rates of successful transplantation.

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Therapeutic implications of menin inhibition in acute leukemias

Ghayas C. Issa et al.

Summary: Menin inhibitors are novel targeted agents currently being developed for the treatment of genetically defined subsets of acute leukemia, showing promising early results in specific leukemia types, such as NPM1 mutations. These inhibitors target various gene regulatory roles of menin in leukemogenesis and are being investigated in clinical studies for relapsed acute leukemias.

LEUKEMIA (2021)

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A 2:1 randomized, open-label, phase II study of selinexor vs. physician's choice in older patients with relapsed or refractory acute myeloid leukemia

Kendra Sweet et al.

Summary: Selinexor, a selective inhibitor of nuclear export, showed promising activity in patients with acute myeloid leukemia (AML). However, in patients aged >= 60 years with relapsed/refractory (R/R) AML, there was no significant difference in overall survival between selinexor and physician's choice treatment. Despite some patients responding well to selinexor, there was a higher incidence of adverse events in the selinexor group.

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Actinomycin D Targets NPM1c-Primed Mitochondria to Restore PML-Driven Senescence in AML Therapy

Hsin-Chieh Wu et al.

Summary: NPM1c mutation affects mitochondrial biogenesis and PML NBs, while ActD targets mitochondria to generate ROS, promoting PML NB biogenesis and restoring senescence. Dual targeting of mitochondria with ActD and venetoclax enhances their anti-AML activities.

CANCER DISCOVERY (2021)

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Phase II Trial of Pembrolizumab after High-Dose Cytarabine in Relapsed/Refractory Acute Myeloid Leukemia

Joshua F. Zeidner et al.

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Lei Zhong et al.

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