Impact of FLT3 Mutation on Outcomes after Venetoclax and Azacitidine for Patients with Treatment-Naïve Acute Myeloid Leukemia
Marina Konopleva, Michael J Thirman, Keith W Pratz, Jacqueline S Garcia, Christian Recher, Vinod Pullarkat, Hagop M Kantarjian, Courtney D DiNardo, Monique Dail, Yinghui Duan, Brenda Chyla, Jalaja Potluri, Catherine L Miller, Andrew H Wei, Marina Konopleva, Michael J Thirman, Keith W Pratz, Jacqueline S Garcia, Christian Recher, Vinod Pullarkat, Hagop M Kantarjian, Courtney D DiNardo, Monique Dail, Yinghui Duan, Brenda Chyla, Jalaja Potluri, Catherine L Miller, Andrew H Wei
Abstract
Purpose: To evaluate efficacy and safety of venetoclax + azacitidine among treatment-naïve patients with FLT3-mutant acute myeloid leukemia.
Patients and methods: Data were pooled from patients enrolled in a phase III study (NCT02993523) that compared patients treated with venetoclax + azacitidine or placebo + azacitidine and a prior phase Ib study (NCT02203773) where patients were treated with venetoclax + azacitidine. Enrolled patients were ineligible for intensive therapy due to age ≥75 years and/or comorbidities. Patients on venetoclax + azacitidine received venetoclax 400 mg orally (days 1-28) and azacitidine (75 mg/m2; days 1-7/28-day cycle). FLT3 mutation was analyzed centrally on pretreatment bone marrow aspirates.
Results: In the biomarker evaluable population, FLT3 mutation was detected in 42 (15%) and 22 (19%) patients in the venetoclax + azacitidine and azacitidine groups. Composite complete remission [CRc; complete remission (CR) + CR with incomplete hematologic recovery (CRi)] rates (venetoclax + azacitidine/azacitidine) for FLT3-mutant patients were 67%/36%, median duration of remission (DoR) was 17.3/5.0 months, and median OS was 12.5/8.6 months. The CRc rates among FLT3 wild-type patients were 67%/25%, median DoR 18.4/13.4 months, and median OS 14.7/10.1 months. In patients treated with venetoclax + azacitidine, CRc in patients with FLT3-ITD and FLT3-TKD was 63% and 77% and median OS was 9.9 and 19.2 months, and in comutated FLT3-ITD + NPM1 patients, CRc was 70%, median DoR was not reached, and median OS was 9.1 months. There were no unexpected toxicities in the venetoclax + azacitidine group.
Conclusions: When treated with venetoclax + azacitidine, patients with FLT3 mutations and FLT3 wild-type had similar outcomes. Future analyses in larger patient populations may further define the impact of venetoclax + azacitidine in patients harboring FLT3-ITD. See related commentary by Perl and Vyas, p. 2719.
©2022 The Authors; Published by the American Association for Cancer Research.
Figures
References
- Papaemmanuil E, Gerstung M, Bullinger L, Gaidzik VI, Paschka P, Roberts ND, et al. . Genomic classification and prognosis in acute myeloid leukemia. N Engl J Med 2016;374:2209–21.
- Schneider F, Hoster E, Schneider S, Dufour A, Benthaus T, Kakadia PM, et al. . Age-dependent frequencies of NPM1 mutations and FLT3-ITD in patients with normal karyotype AML (NK-AML). Ann Hematol 2012;91:9–18.
- Grafone T, Palmisano M, Nicci C, Storti S. An overview on the role of FLT3-tyrosine kinase receptor in acute myeloid leukemia: biology and treatment. Oncol Rev 2012;6:e8.
- Bacher U, Haferlach C, Kern W, Haferlach T, Schnittger S. Prognostic relevance of FLT3-TKD mutations in AML: the combination matters—an analysis of 3082 patients. Blood 2008;111:2527–37.
- Gale RE, Green C, Allen C, Mead AJ, Burnett AK, Hills RK, et al. . The impact of FLT3 internal tandem duplication mutant level, number, size, and interaction with NPM1 mutations in a large cohort of young adult patients with acute myeloid leukemia. Blood 2008;111:2776–84.
- Kayser S, Schlenk RF, Londono MC, Breitenbuecher F, Wittke K, Du J, et al. . Insertion of FLT3 internal tandem duplication in the tyrosine kinase domain-1 is associated with resistance to chemotherapy and inferior outcome. Blood 2009;114:2386–92.
- Schlenk RF, Kayser S, Bullinger L, Kobbe G, Casper J, Ringhoffer M, et al. . Differential impact of allelic ratio and insertion site in FLT3-ITD–positive AML with respect to allogeneic transplantation. Blood 2014;124:3441–9.
- Huang Y, Hu J, Lu T, Luo Y, Shi J, Wu W, et al. . Acute myeloid leukemia patient with FLT3-ITD and NPM1 double mutation should undergo allogeneic hematopoietic stem cell transplantation in CR1 for better prognosis. Cancer Manag Res 2019;11:4129–42.
- Döhner H, Estey E, Grimwade D, Amadori S, Appelbaum FR, Büchner T, et al. . Diagnosis and management of AML in adults: 2017 ELN recommendations from an international expert panel. Blood 2017;129:424–47.
- National Comprehensive Cancer Network. NCCN Guidelines for patients with Acute Myeloid Leukemia, Version 3.2021. 2021.
- Stone RM, Mandrekar SJ, Sanford BL, Laumann K, Geyer S, Bloomfield CD, et al. . Midostaurin plus chemotherapy for acute myeloid leukemia with a FLT3 Mutation. N Engl J Med 2017;377:454–64.
- Perl AE, Martinelli G, Cortes JE, Neubauer A, Berman E, Paolini S, et al. . Gilteritinib or chemotherapy for relapsed or refractory FLT3-mutated AML. N Engl J Med 2019;381:1728–40.
- Cortes J, Perl AE, Döhner H, Kantarjian H, Martinelli G, Kovacsovics T, et al. . Quizartinib, an FLT3 inhibitor, as monotherapy in patients with relapsed or refractory acute myeloid leukaemia: an open-label, multicentre, single-arm, phase 2 trial. Lancet Oncol 2018;19:889–903.
- Maiti A, DiNardo CD, Daver NG, Rausch CR, Ravandi F, Kadia TM, et al. . Triplet therapy with venetoclax, FLT3 inhibitor and decitabine for FLT3-mutated acute myeloid leukemia. Blood Cancer J 2021;11:25.
- Astellas. Astellas reports XOSPATA® (gilteritinib) in combination with azacitidine did not meet endpoint of overall survival in newly diagnosed FLT3 mutation-positive acute myeloid leukemia patients ineligible for intensive induction chemotherapy Tokyo 2020.
- Adams JM, Cory S. The Bcl-2 apoptotic switch in cancer development and therapy. Oncogene 2007;26:1324–37.
- Gilliland DG, Griffin JD. The roles of FLT3 in hematopoiesis and leukemia. Blood 2002;100:1532–42.
- Choudhary C, Olsen JV, Brandts C, Cox J, Reddy PN, Böhmer FD, et al. . Mislocalized activation of oncogenic RTKs switches downstream signaling outcomes. Mol Cell 2009;36:326–39.
- Choudhary C, Schwäble J, Brandts C, Tickenbrock L, Sargin B, Kindler T, et al. . AML-associated Flt3 kinase domain mutations show signal transduction differences compared with Flt3 ITD mutations. Blood 2005;106:265–73.
- Mizuki M, Fenski R, Halfter H, Matsumura I, Schmidt R, Müller C, et al. . Flt3 mutations from patients with acute myeloid leukemia induce transformation of 32D cells mediated by the Ras and STAT5 pathways. Blood 2000;96:3907–14.
- Takahashi S. Downstream molecular pathways of FLT3 in the pathogenesis of acute myeloid leukemia: biology and therapeutic implications. J Hematol Oncol 2011;4:13.
- DiNardo CD, Tiong IS, Quaglieri A, MacRaild S, Loghavi S, Brown FC, et al. . Molecular patterns of response and treatment failure after frontline venetoclax combinations in older patients with AML. Blood 2020;135:791–803.
- Jin S, Cojocari D, Purkal JJ, Popovic R, Talaty NN, Xiao Y, et al. . 5-Azacitidine induces NOXA to prime AML cells for venetoclax-mediated apoptosis. Clin Cancer Res 2020;26:3371.
- Singh Mali R, Zhang Q, DeFilippis RA, Cavazos A, Kuruvilla VM, Raman J, et al. . Venetoclax combines synergistically with FLT3 inhibition to effectively target leukemic cells in FLT3-ITD+ acute myeloid leukemia models. Haematologica 2021;106:1034–46.
- Raghuveer Singh M, Qi Z, RosaAnna D, Antonio C, Vinitha Mary K, Jayant R, et al. . Venetoclax combines synergistically with FLT3 inhibition to effectively target leukemic cells in FLT3-ITD+ acute myeloid leukemia models. Haematologica 2020;106:1034–46.
- DiNardo CD, BA J, Pullarkat V, Thirman MJ, Garcia JS, Wei AH, et al. . Azacitidine and venetoclax in previously untreated acute myeloid leukemia. N Engl J Med 2020;383:617–29.
- Konopleva M, Thirman M, Pratz KW, Letai AG, Recher C, Pullarkat VA, et al. . Results of venetoclax and azacitidine combination in chemotherapy ineligible untreated patients with acute myeloid leukemia with FLT3 mutations. Blood 2020;136:8–10.
- DiNardo CD, Pratz K, Pullarkat V, Jonas BA, Arellano M, Becker PS, et al. . Venetoclax combined with decitabine or azacitidine in treatment-naive, elderly patients with acute myeloid leukemia. Blood 2019;133:7–17.
- Cheson BD, Bennett JM, Kopecky KJ, Buchner T, Willman CL, Estey EH, et al. . Revised recommendations of the International Working Group for Diagnosis, Standardization of Response Criteria, Treatment Outcomes, and Reporting Standards for Therapeutic Trials in Acute Myeloid Leukemia. J Clin Oncol 2003;21:4642–9.
- Pratz KW, Jonas BA, Pullarkat V, Recher C, Schuh AC, Thirman MJ, et al. . Measurable residual disease response and prognosis in treatment-naïve acute myeloid leukemia with venetoclax and azacitidine. J Clin Oncol 2021.
- U.S. Department of Health and Human Services. 2018 August 14. National Cancer Institute. Common Terminology Criteria for Adverse Events (CTCAE) v4.03. Available from: .
- Chyla B, Daver N, Doyle K, McKeegan E, Huang X, Ruvolo V, et al. . Genetic biomarkers of sensitivity and resistance to venetoclax monotherapy in patients with relapsed acute myeloid leukemia. Am J Hematol 2018;93:E202–5.
- Mali RS, Lasater EA, Doyle K, Malla R, Boghaert E, Souers A, et al. . FLT3-ITD activation mediates resistance to the BCL-2 selective antagonist, venetoclax, in FLT3-ITD mutant AML models. Blood 2017;130:1348.
- Bose P, Grant S. Mcl-1 as a therapeutic target in acute myelogenous leukemia (AML). Leukemia Research Reports 2013;2:12–4.
- Ma J, Zhao S, Qiao X, Knight T, Edwards H, Polin L, et al. . Inhibition of Bcl-2 synergistically enhances the antileukemic activity of midostaurin and gilteritinib in preclinical models of FLT3-mutated acute myeloid leukemia. Clin Cancer Res 2019;25:6815–26.
Source: PubMed