FLT3-mutated AML Research Articles

Approaching a therapeutic inflection point for FLT3-mutated AML.

Combining FLT3 inhibitors with intensive chemotherapy and transplant has substantially improved AML outcomes, prompting a recent re-evaluation of FLT3-ITD's historically negative prognostic effect. Treatment approaches may soon undergo major changes as emerging data suggest maximal intensity does not benefit all patients and MRD potentially can guide several treatment choices. Finally, recent data also suggest FLT3 inhibitors could transform outcomes in patients unsuitable for intensive therapy. If confirmed, this has important implications for fit patients and could revolutionize the treatment paradigm.

Managing post-transplant relapse in FLT3-mutated AML with gilteritinib

Managing post-transplant relapse in FLT3-mutated AML with gilteritinib

142 (PB130): Preclinical characterization of HD10019, a FLT3 kinase inhibitor with optimized polypharmacology to treat FLT3-mutant AML

142 (PB130): Preclinical characterization of HD10019, a FLT3 kinase inhibitor with optimized polypharmacology to treat FLT3-mutant AML

15-year remission in refractory FLT3-mutated AML attained by sorafenib.

15-year remission in refractory FLT3-mutated AML attained by sorafenib.

Outcomes with single-agent gilteritinib for relapsed or refractory FLT3-mutant AML after contemporary induction therapy

AbstractGilteritinib is the current standard of care for relapsed or refractory fms related receptor tyrosine kinase 3 (FLT3)–mutated acute myeloid leukemia in many countries, however outcomes for patients relapsing after contemporary first-line therapies (intensive chemotherapy with midostaurin, or nonintensive chemotherapy with venetoclax) are uncertain. Moreover, reported data on toxicity and health care resource use is limited. Here, we describe a large real-world cohort of 152 patients receiving single-agent gilteritinib in 38 UK hospitals. Median age was 61 years, and 36% had received ≥2 prior lines of therapy, including a FLT3 inhibitor in 41% and venetoclax in 24%. A median of 4 cycles of gilteritinib were administered, with 56% of patients requiring hospitalization in the first cycle (median, 10 days). Over half of patients required transfusion in each of the first 4 cycles. Complete remission (CR) was achieved in 21%, and CR with incomplete recovery (CRi) in a further 9%. Remission rates were lower for patients with FLT3–tyrosine kinase domain or adverse karyotype. Day-30 and day-60 mortality were 1% and 10.6%, respectively, and median overall survival was 9.5 months. On multivariable analysis, increasing age, KMT2A rearrangement, and complex karyotype were associated with worse survival whereas RUNX1 mutations were associated with improved survival. Twenty patients received gilteritinib as first salvage having progressed after first-line therapy with venetoclax, with CR/CRi achieved in 25% and median survival 4.5 months. Real-world results with gilteritinib mirror those seen in the clinical trials, but outcomes remain suboptimal, with more effective strategies needed.

Developments of Fms-like Tyrosine Kinase 3 Inhibitors as Anticancer Agents for AML Treatment.

FMS-like tyrosine kinase 3 (FLT3) is a commonly mutated gene in acute myeloid leukemia. As a receptor tyrosine kinase (RTK), FLT3 plays a role in the proliferation and differentiation of hematopoietic stem cells. As the most frequent molecular alteration in AML, FLT3 has drawn the attention of many researchers, and a lot of small molecule inhibitors targeting FLT3 have been intensively investigated as potential drugs for AML therapy. In this paper, PubMed and SciFinder® were used as a tool; the publications about "FLT3 inhibitor" and "Acute myeloid leukemia" were surveyed from 2014 to the present with an exclusion of those published as patents. In this study, the structural characterization and biological activities of representative FLT3 inhibitors were summarized. The major challenges and future directions for further research are discussed. Recently, numerous FLT3 inhibitors have been discovered and employed in FLT3-mutated AML treatment. In order to overcome the drug resistance caused by FLT3 mutations, screening multitargets FLT3 inhibitors has become the main research direction. In addition, the emergence of irreversible FLT3 inhibitors also provides new ideas for discovering new FLT3 inhibitors.

Real-Life Management of FLT3-Mutated AML: Single-Centre Experience over 24 Years.

We analyzed 140 patients with a median age of 51 years; 21% had WBC ≥ 100 × 109/L, and 52% had an NPM1 co-mutation. Until 2018, 101 patients received chemotherapy; thereafter, 39 received 3+7+midostaurin. The overall CR rate was 64%, higher in NPM1 mutant patients (73%). Univariate analysis showed that NPM1 mutation (p = 0.032) and WBC < 100 × 109/L (p = 0.013) positively influenced the response, with a trend for FLT3i administration (p = 0.052). Multivariate analysis confirmed WBC count as an independent prognostic factor (p = 0.017). In CR1, 41/90 patients underwent allogeneic and 18 autologous transplantation. The median EFS was 1.1 vs. 1.6 years in autografted and allografted patients, respectively (p = 0.9). The one-year non-relapse mortality was 0.00% for autologous and 28% for allogeneic transplants (p = 0.007); CIR at 1 and 3 years was higher in autologous transplants (39% vs. 15% and 57% vs. 21%, p = 0.004). The median survival was not reached in the FLT3i group. Overall, 69 patients received stem cell transplantation (18 autologous, 51 allogeneic). Post-transplant FLT3i was resumed in eight patients, all alive after a median of 65 months. Allogeneic transplantation is crucial in FLT3-mutated AML, but the next challenge will be to identify which patients can benefit from transplants in CR1 and in which to intensify post-transplant therapy.

Abstract 7153: PHI-101 synergizes with chemotherapy and venetoclax in preclinical models of acute myeloid leukemia

Abstract FLT3 mutations are one of the most frequent genetic alterations in AML, resulting in poor prognosis. Although the development of FLT3 tyrosine kinase inhibitors (TKIs) provided new treatment options, patients with FLT3-mutant AML still suffer from high relapse rates when treated with FLT3 TKI alone. Accumulating evidence supports a combination treatment strategy to lower the recurrence rate. We have previously shown that PHI-101 demonstrated potent activity in various FLT3 mutant AML cell lines when used alone. Here we explore the use of PHI-101 in combination with other therapeutics in preclinical models of AML. We investigated the preclinical efficacy of the combination of PHI-101 with FDA-approved AML therapeutic agents in FLT3 mutant (MV4-11, Molm13, Molm14) and wild-type (THP-1) AML cell lines. Cell growth inhibition was assessed by CCK-8 and/or CellTiter-Glo assays. The Chou-Talalay method was used to calculate the combination index (CI) to test for synergy. Western blotting analysis was performed to explore the potential mechanisms underlying the combination effects. AML xenograft mouse models were used to assess the in vivo efficacy of PHI-101 combination therapy. Statistical comparisons included unpaired t-tests or one-way ANOVA. Combination treatment of PHI-101 with venetoclax or azacytidine showed strong synergistic effects on growth inhibition against both FLT3-ITD mutant (CI&amp;lt;0.3) and wild-type AML cells (CI &amp;lt;0.6). It is noteworthy that the FLT3-ITD homozygous cell line (MV4-11) showed especially strong synergism (CI &amp;lt;0.1). In the xenograft mouse model experiments, 14-day treatment with either PHI-101 alone or in combination with venetoclax or azacytidine showed significant suppression of tumor growth compared to venetoclax or azacytidine alone (in average tumor growth inhibition (TGI) 88.3% vs 8.6%)(p&amp;lt;0.05). In particular, PHI-101 3 mg/kg/day (mpk) with venetoclax 80mpk resulted in a stronger anti-tumor effect (TGI 94.2%) compared to PHI-101 (TGI 87.4%) or venetoclax alone (-9.6% of TGI) (p&amp;lt;0.05) even 21 days after stopping the treatment. In addition, PHI-101 treatment showed a survival advantage in AML animal models, and the combination with venetoclax led to significantly longer survival compared to the control groups. Our preclinical data showed that the combination of PHI-101 with venetoclax or azacytidine resulted in a highly effective anti-leukemic response against AML cells by inducing DNA damage, BCL-2 inhibition, and MCL-1 degradation. Additionally, treatment of mice with low-dose PHI-101 inhibited tumor regrowth and further potentiated venetoclax or azacytidine response in vivo. Our results suggest that the combination of PHI-101 and venetoclax or azacitidine may have the advantage of improving clinical responses in FLT3-ITD AML patients and offers a potential therapeutic option to treat patients with newly diagnosed or relapsed/refractory FLT3-mutant AML. Citation Format: Hee-sun Hwang, Gi-Jun Sung, Kyung-Ah Kim, Ky-Youb Nam, Kyu-Tae Kim, June H. Han, Jeong-Hyeok Yoon, Bao Nguyen, Li Li, Tessa Seale, Donald Small. PHI-101 synergizes with chemotherapy and venetoclax in preclinical models of acute myeloid leukemia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 7153.

Abstract 611: Discovery of LNX231, a multi-kinase inhibitor mainly target FLT3 with robust in vivo efficacy in FLT3 mutant AML models

Abstract LNX231 is a multi-kinase inhibitor mainly target FLT3, which could both directly kill cancer cells and promote tumor immunity. LNX231 potently inhibits FLT3 activity in biochemical assay, with a 50% inhibitory concentration (IC50) of 3.5 nM, significantly inhibits FLT3-D835Y and FLT3 ITD, the values of IC50 are 20 nM and 4.4 nM. LNX231 inhibits the proliferation of FLT3 mutant AML cell lines via RAS-MARK and JAK-STAT pathway. LNX231 significantly decreases the phosphorylation of STAT5 and ERK in MV-4-11 cells at the high concentration, but has no effect on the phosphorylation of FLT3 and AKT. LNX231 significantly decreases the phosphorylation of FLT3, STAT5 and ERK in MOLM-13 cells at the high concentration, but has no effect on the phosphorylation of AKT. In FLT3 mutated AML models, LNX231 induced sustained tumor shrinkage as a single agent and was well tolerated. At the same dose, LNX231 was more potent than the FDA-approved drug Gilteritinib. In the MC38 tumor-bearing model, the efficacy of LNX231 was better than Sunitinib and Lenvatinib. LNX231 has good oral bioavailability in different species, such as mouse, rat, dog and monkey. DMPK data predicted oral QD dosing in human. It also showed excellent ADMET profile as a pre-clinical candidate. Safety tolerability studies were conducted in mice and dogs. LNX231 has low cardiotoxicity (IC50 of hERG is 25.84 µM) and 5-6 times safety window. In conclusion, we discovered LNX231 as a multi-kinase inhibitor for FLT3 mutated AML. Citation Format: Lizhi Zhao, Guizhou Hao, Rong Deng, Naihua Zhang, Jingchun Yao, Anguo Zhu, Guangyan Li, Enli Wang, Zhenyu Li, Zhong Liu, Guimin Zhang. Discovery of LNX231, a multi-kinase inhibitor mainly target FLT3 with robust in vivo efficacy in FLT3 mutant AML models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 611.

Abstract 3626: Day 21 early bone marrow response does not offer high concordance with response bone marrow in the induction chemotherapy setting of FLT3 mutant acute myeloid leukemia

Abstract Purpose: Day 14 early bone marrow biopsies are routinely initiated to determine need for reinduction chemotherapy, but poorly predict true response and risk overtreatment. Day 21 (D21) bone marrow biopsies have been performed in the context of trials utilizing FLT3-targeted therapies in combination with induction chemotherapy (Stone et al. NEJM 2017). However, the utility of D21 bone marrow responses is not well defined. Methods: We retrospectively identified 26 newly diagnosed FLT3 mutant AML patients who underwent induction chemotherapy with midostaurin and Next Generation Sequencing (NGS) of bone marrow aspirate within a week of diagnosis. Results: 19/26 (73%) of patients had both D21 and response bone marrow biopsy. Of the remaining 7 patients, 4 patients did not have D21 bone marrow, 2 died of unrelated complications prior to response bone marrow, and 1 did not have recovery marrow available for assessment. Our cohort included 13 (50%) men with a median age of 57 years (range, 21 - 73 years). All patients had ECOG of 0 - 1. 96% of cases were de novo AML and 81% had normal cytogenetics. FLT3 ITD mutations were detected in 17 (65%) patients with a median FLT3 ITD ratio of 0.305 (range, 0.03 - 1) and median FLT3 VAF of 23.8% (range, 3.2 - 80.6%). 7 patients (26.9%) underwent additional allogeneic stem cell transplant. In the 19 patients evaluable for analysis, 13/13 (100%) patients with blast % ≤ 5 at D21 achieved a complete response (CR) based on recovery marrow. 4/6 (67%) patients with blast % &amp;gt; 5 at D21 which were considered to have residual disease based on pathology review (median blast % 11 (range, 6 - 17%) ultimately achieved a CR. The 2 patients that did not achieve a CR has a blast % of 29% and 9% on D21 marrow. Thus, the positive predictive value of D21 early bone marrow response corresponding with the response bone marrow was only 33% in our patient cohort. Of the 4 patients that did not have D21 marrow but had recovery marrows available for review, the CR rate was 100%. No other significant differences in initial disease characteristics were seen. There were no differences proportion of co-mutations in NPM1, DNMT3A, TP53, IDH2, and IDH1, and higher FLT3 ITD ratio nor FLT3 VAF corresponded with ability to clear D21 bone marrow. Additionally, there were no differences in minimal residual disease (MRD) and overall survival (OS) between the groups. Conclusions: Our study suggests early bone marrow response in the context of FLT3-mutant disease is not dependent on inherent disease characteristics and does not correspond to overall response to targeted induction chemotherapy. The utility of these marrows in is this population needs to be studied further in a larger cohort to better understand the clinical necessity to avoid unnecessary cost/procedures to patients and even more importantly unnecessary reinductions. Citation Format: Vincent Lok, Su Bin Hahn, Nikesh N. Shah, Daniel A. Kerr, Ivan M. Borrello, Eduardo M. Sotomayor, David M. Swoboda. Day 21 early bone marrow response does not offer high concordance with response bone marrow in the induction chemotherapy setting of FLT3 mutant acute myeloid leukemia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3626.

Unpredicted transformation of acute myeloid leukemia with translocation (16;16) (p13; q22): a case report and review of the literature

IntroductionThe transformation of acute myeloid leukemia with translocation (16;16) (p13; q22) from AML M2 to acute monocytic leukemia (AML M5) during therapy is a rare clinical occurrence, and this is the first time it has been reported.Clinical complainA 19-year-old male patient was admitted for severe fatigue with anemic manifestation and weight loss, for more than 1 month, with exacerbation of the condition in the last 2 days.DiagnosisA primary diagnosis was made for AML M2 with t (16;16) (p13; q22) established on bone marrow (BM) morphology. A consequential detection of FLT-3 ITD mutation was done. At day 28 follow-up after induction and maintenance therapy, the diagnosis of AML M2 was maintained with a high bone marrow (BM) blast count, prompting the initiation of a more aggressive treatment protocol. After 1 month of implementing the recent protocol, the patient remains morphologically resistant with a notable transformation of bone marrow infiltration by an abnormal monocytic population (monoblasts and promonocytes). The final diagnosis of transforming FLT3-mutated AML with t (16;16) (p13; q22) was established.InterventionAfter the initial diagnosis of AML M2 with t (16;16) (p13; q22), the patient received the 3 + 7 induction protocol. The 2nd induction protocol initiated after the second evaluation and morphological resistance was the FLAG Adrian protocol. The 3rd protocol after transformation to AML M5 was 1 cycle of the MEC protocol. Anti-FLT3 treatment was considered.OutcomesThe patient was maintained on the 3rd protocol of chemotherapy. Unfortunately, he was admitted to the ICU unit complaining of neutropenic fever and severe sepsis where he died before final re-evaluation and the anti-FLT3 treatment initiation.ConclusionAML with t (16;16) (p13; q22) characterized by favorable outcome. However, identifying additional chromosome abnormality or genetic aberration, especially FLT3 gene mutation, is recognized as an important factor influencing final disease outcome. Therefore, early detection of FLT3 mutations will allow comprehensive disease course prediction and targeted therapy that might achieve longer and more durable remissions.

Crenolanib and Intensive Chemotherapy in Adults With Newly Diagnosed FLT3-Mutated AML.

Crenolanib is a second-generation tyrosine kinase inhibitor with activity against FLT3-ITD- and TKD-mutant AML. We conducted a trial of crenolanib plus intensive chemotherapy in adults with newly diagnosed FLT3-mutant AML. Eligible patients were 18 years and older. Induction chemotherapy consisted of cytarabine (100 mg/m2) continuous infusion on days 1-7 and anthracycline (daunorubicin 60-90 mg/m2 or idarubicin 12 mg/m2, once daily) on days 1-3 followed by consolidation with high-dose cytarabine (1-3 g/m2 twice daily on days 1, 3, 5) and/or allogeneic transplant. Crenolanib (100 mg thrice a day) was given from day 9 until 72 hours before the next cycle, after consolidation, and for 12 months after consolidation or transplant. Forty-four patients (median age, 57; range, 19-75 years) were enrolled. Thirty-six had FLT3-ITD, and 11 had FLT3-TKD mutations. European LeukemiaNet 2017 disease risk was favorable in 34%, intermediate in 30%, and adverse in 36%. The overall response rate was 86% (complete remission [CR], 77%; CR with incomplete count recovery [CRi], 9%): 90% in patients 60 years and younger and 80% in older patients. Measurable residual disease-negative CR/CRi rates were 89% and 45%, respectively. With a 45-month follow-up, median overall survival has not been reached and the median event-free survival was 44.7 months. Among younger patients, the estimated 3-year survival was 71.4% with 15% cumulative incidence of relapse. Treatment-related serious adverse events included febrile neutropenia, diarrhea, and nausea. The median time to platelets ≥100,000/µL and absolute neutrophil count ≥1,000/µL during induction was 29 and 32 days, respectively. No new FLT3-mutant clones were detected at relapse in patients completing consolidation. Crenolanib plus intensive chemotherapy in adults with newly diagnosed FLT3-mutant AML results in high rate of deep responses and long-term survival with acceptable toxicity. A randomized trial of crenolanib versus midostaurin plus chemotherapy in younger patients is ongoing.

Azacitidine, Venetoclax, and Gilteritinib in Newly Diagnosed and Relapsed or Refractory FLT3-Mutated AML.

Azacitidine plus venetoclax is a standard of care for patients with newly diagnosed AML who are unfit for intensive chemotherapy. However, FLT3 mutations are a common mechanism of resistance to this regimen. The addition of gilteritinib, an oral FLT3 inhibitor, to azacitidine and venetoclax may improve outcomes in patients with FLT3-mutated AML. This phase I/II study evaluated azacitidine, venetoclax, and gilteritinib in two cohorts: patients with (1) newly diagnosed FLT3-mutated AML who were unfit for intensive chemotherapy or (2) relapsed/refractory FLT3-mutated AML (ClinicalTrials.gov identifier: NCT04140487). The primary end points were the maximum tolerated dose of gilteritinib (phase I) and the combined complete remission (CR)/CR with incomplete hematologic recovery (CRi) rate (phase II). Fifty-two patients were enrolled (frontline [n = 30]; relapsed/refractory [n = 22]). The recommended phase II dose was gilteritinib 80 mg once daily in combination with azacitidine and venetoclax. In the frontline cohort, the median age was 71 years and 73% of patients had an FLT3-internal tandem duplication (ITD) mutation. The CR/CRi rate was 96% (CR, 90%; CRi, 6%). Sixty-five percent of evaluable patients achieved FLT3-ITD measurable residual disease <5 × 10-5 within four cycles. With a median follow-up of 19.3 months, the median relapse-free survival (RFS) and overall survival (OS) have not been reached and the 18-month RFS and OS rates are 71% and 72%, respectively. In the relapsed/refractory cohort, the CR/CRi rate was 27%; nine additional patients (41%) achieved a morphologic leukemia-free state. The most common grade 3 or higher nonhematologic adverse events were infection (62%) and febrile neutropenia (38%), which were more frequent in the relapsed/refractory cohort. The combination of azacitidine, venetoclax, and gilteritinib resulted in high rates of CR/CRi, deep FLT3 molecular responses, and encouraging survival in newly diagnosed FLT3-mutated AML. Myelosuppression was manageable with mitigative dosing strategies.

Excellent Outcome Following Maintenance Therapy with Gilteritinib after Allogeneic Hematopoietic Stem Cell Transplantation for FLT3-Mutated Acute Myeloid Leukemia Even in Non-Remission Status

[Background] FMS-like tyrosine kinase 3 (FLT3) mutation has been shown to be a poor prognostic factor for recurrence and overall survival in AML. In recent years, various FLT3 inhibitors have been successively developed and reported to improve the prognosis of FLT3-mutated AML. However, relapse after allogeneic stem cell transplantation(allo-HSCT) remains high, and strategies to improve prognosis are desired. Clinical trials have been conducted using FLT3 inhibitors as maintenance therapy allo-HSCT to reduce the relapse rate and some efficacy has been reported, but real-world data on maintenance therapy with gilteritinib for FLT3-mutated AML after allo-HSCT are limited, especially after cord blood transplantation (CBT). [Objective and method] To assess the efficacy, safety, clinical features and outcome of gilteritinib maintenance after allo-HSCT for FLT3-mutated AML, we retrospectively analyzed patients underwent allo-HSCT, most of which are CBT for FLT3-mutated AML from April 2019 to October 2022. [Result] During the study period, 46 patients received allo-HSCT for FLT3-mutated AML in our institute. The median follow-up day of survivors was 649 (115-1149). The median age of the patients was 55 years (range, 20-75). Twenty-seven patients had de novo AML, 16 had AML with myelodysplasia related changes, and 3 had therapy related AML. One had favorable karyotype, 37 had intermediate, and 6 had adverse. Thirty-six patients received myeloablative pretransplant conditionings (MAC), and 10 received reduced intensity conditionings (RIC). All but 9 were in in non-remission at HSCT. The majority, 40, had used unrelated cord blood, 3 did unrelated bone marrow, 2 did unrelated peripheral blood, and 1 did related peripheral blood as grafts. Twenty-eight patients received gilteritinib maintenance therapy after HSCT, whereas 18 did not. Between the 2 groups, the patient characteristics, AML status, and HSCT procedures were well balanced. At 2 years after HSCT, overall survival (OS), disease free survival (DFS), relapse rate (RR), and non-relapse mortality (NRM) of whole studied population were 65.0%, 56.3%, 27.0%, and 21.1%, respectively. Patients with gilteritinib maintenance showed significantly superior OS and DFS to those without gilteritinib maintenance (2-year OS; 84.2% vs 35.7%, P = 0.0030, 2-year DFS; 71.4% vs 30.4%, P = 0.0036)(Figure 1A, 1B). RR and NRM tended to be lower in patients with gilteritinib maintenance than those without (2-year RR; 41.4% vs 18.1%, P = 0.1350, 2-year NRM; 34.4% vs 11.9%, P = 0.0548). Even if in non-remission status at HSCT, 23 patients with gilteritinib maintenance showed excellent outcome with 2-year OS 81.6%, DFS 70.9%, RR 21.2%, and NRM13.9%. A subanalysis of the four groups by with or without gilteritinib maintenance and by pretreatment conditioning intensity showed that patients who received MAC and gilteritinib maintenance had the most superior 2-year OS 94.1%. [Conclusion] Our data indicated that following maintenance therapy with gilteritinib after allo-HSCT could overcome the poor prognosis of FLT3-mutated AML even for those in non-remission status, despite the profound chemo-resistant character of FLT3-mutated AML.

Mediator Kinase/CDK8 Inhibition As a Strategy to Improve FLT3 Inhibitor Activity in Acute Myeloid Leukemia

Acquired resistance to targeted FLT3 tyrosine kinase inhibitors (TKIs) remains a major barrier to durable clinical responses for patients with FLT3-mutant AML. Multiple resistance mechanisms to next generation FLT3 TKIs converge upon RAS/MAPK pathway activation, including protective cytokine stimuli of the bone marrow microenvironment or through secondary oncogenic RAS mutations. RAS mutations also decrease efficacy of the BCL2 inhibitor venetoclax now widely used in AML, suggesting an anti-apoptotic influence of MAPK signaling. These findings highlight a significant unmet need for novel therapeutic combinations to address MAPK-mediated resistance in AML. We report results from a genome-wide CRISPR interference (CRISPRi) apoptosis screen using FLT3-ITD mutant MOLM-14 cells treated with the FLT3 TKI gilteritinib while cultured in HS5 conditioned media (CM) to mimic cell-extrinsic MAPK-driven TKI resistance. We identified RNA pol II and Mediator kinase/CDK8 ascritical nodes for AML cell survival in the setting of FLT3 inhibition. We further demonstrated that CDK8 inhibition with the small-molecule SEL120 re-sensitized multiple FLT3-mutant AML cell lines and primary samples to gilteritinib. We also performed a second CRISPRi apoptosis screen to identify hits that sensitize to gilteritinib in a model of cell-intrinsic MAPK-mediated resistance using MOLM-14 cells that harbor secondary NRAS-G12C mutation.We used Enrichr to perform an integrated analysis and validated the Core Mediator Complex and CDK8 knockdown genes as cellular components significantly enriched among sensitizing hits in both screens. The Mediator subunit MED12 was identified as a top gene level hit that strongly sensitized cells to gilteritinib in both screens, further emphasizing that Mediator kinase and its transcriptional regulation may be a central pathway engaged in MAPK-dependent survival in FLT3-mutant AML. To better understand potential mechanisms of increased combinatorial CDK8i/FLT3i activity, we performed RNA-seq in MOLM-14 cells treated with gilteritinib, SEL120, or the combination in HS5 CM. Using GSEA we found that gilteritinib stimulated adaptive interferon/inflammatory gene signatures at 16h drug treatment, but this response was restrained by addition of SEL120. Additionally, we identified a striking upregulation of the lineage-controlling transcription factor IRF8 and its gene expression signature with concomitant silencing of SPI1 transcriptional output in cells treated with gilteritinib/SEL120. CDK8i treatment alone in AML has previously been shown to increase expression of super-enhancer (SE) associated genes, including IRF8. Interestingly, SPI1was also a significant gene-level hit in both CRISPRi screens. Using CRISPRi we repressed IRF8 expression in MOLM-14, MOLM-14 NRAS-G12C, and MV411 (another FLT3-mutant line) cells and found this significantly blunted the combinatorial pro-apoptotic effect of SEL120, implying that induction of IRF8 expression plays a significant role in driving response to combined gilteritinib/SEL120. We finally assessed in vivo activity of gilteritinib combined with SEL120. We first performed pilot toxicity studies in NSG mice and determined that gilteritinib 30 mg/kg, SEL120 30 mg/kg, or the combination dosed 5 days/week by oral gavage (OG) were regimens well tolerated by mice. We then engrafted luciferase-tagged MOLM-14 and MOLM-14 NRAS-G12C cells into NSG mice and treated for 4-weeks with gilteritinib, SEL120, or the combination. We found gilteritinib/SEL120 extended survival in both MOLM-14 and MOLM-14 NRAS-G12C models. Similar efficacy studies are ongoing in FLT3-mutant patient-derived xenograft (PDX) models with NSGS mice and will be reported. Our results indicate that FLT3-mutant AML cells employ an adaptive inflammatory response to evade FLT3i-induced apoptosis, and CDK8i represses this adaptation while concomitantly increasing the ratio of IRF8 to SPI1-driven gene expression programs. We speculate this latter effect may in part alter an AML cell's differentiation state to sensitize cells to apoptosis, though further study to explore this hypothesis is needed. Our in vitro and in vivo efficacy data further validated combined FLT3i/CDK8i as a promising investigational strategy to pre-empt or overcome MAPK-mediated FLT3 TKI resistance.

Gilteritinib and Venetoclax for Relapsed/Refractory FLT3-Mutated Acute Myeloid Leukemia - a Real-World Multicenter Retrospective Study

Introduction: Relapsed/Refractory (R/R) FLT3-mutated AML is a challenging clinical scenario with a dismal outcome. Gilteritinib, a selective and potent oral FLT3 tyrosine kinase inhibitor (TKI), is approved for treatment of FLT3 mutated R/R AML, and was shown to improve response rates and overall survival (OS) as compared to standard chemotherapy (Perl et al, NEJM 2019). However, remission rates and long-term survival with gilteritinib monotherapy are still unsatisfactory, highlighting the need for new therapies to improve patient outcomes. Recently, the combination of gilteritinib and venetoclax (Gilt-Ven) was shown to achieve a response rate of 75% in R/R FLT3 AML patients (Daver et al, JCO 2022). Data regarding Gilt-Ven based combinations in patients outside of clinical trials is lacking. We therefore aimed to investigate the characteristics and outcomes of real-world patients with R/R FLT-3 mutated AML treated with Gilt-Ven based combinations. Methods: A multicenter retrospective cohort study in seven academic centers in Israel. Demographic, clinical and treatment related data were collected. The decision to treat a patient with Gilt-Ven (with or without azacitidine) as well as dosing were at discretion of the treating physician. Results: Eighteen patients were treated with Gilt-Ven based therapies for FLT-3 mutated R/R AML between January 2018 and June 2023. Median follow-up time was 5 months (range 0-24). Median age at treatment initiation was 48 years (range 24-79). Twelve patients (66.7%) had relapsed disease, while 6 (33.3%) had refractory disease. Thirteen patients (72.2%) had a normal karyotype; two had complex karyotype and one had monosomal karyotype. Sixty-one percent had prior therapy with a FLT3 inhibitor, and 33% had prior venetoclax exposure. Eighty-eight percent received a prior intensive induction regimen and 61% had prior Allogeneic Hematopoietic Stem Cell Transplantation (AlloHSCT) (Figure 1A). Most patients received Gilt-Ven doublet, while 27% received Gilt-Ven in combination with other agents (three patients with azacitidine, one with low-dose cytarabine and one with FLAG-IDA). The median dose for gilteritinib was 120 (range, 80-120) mg and all patients received 400 mg venetoclax (or equivalent dose adjustment to azoles). Overall Response Rate (CR+CRi+MLFS) was 83%; Complete remission rate was 50% (Figure 1B). The median number of cycles was 1.5 (range 1-34) for the whole cohort. Five patients (27%) proceeded to alloHSCT. Of these, four patients required one course of Gilt-Ven, and one patient received 6 courses and proceeded to AlloHSCT after a subsequent relapse and another line of therapy. Median OS was not reached for all patients (range 6-NR), but was only 6 months (range 0-10) for patients who did not proceed to AlloHSCT. Hematologic adverse events were most common with 89% of patients experiencing grade 3/4 neutropenia; however, infections were relatively uncommon with only 17% of patients experiencing grade 3/4 Infection. Transaminitis grade 1/2 was observed in 38.9% of patients while no patient developed grade 3/4. No cases of differentiation syndrome were recorded. Conclusion: In a real-world setting, Gilt-Ven based therapy is effective for heavily pre-treated patients with FLT-3 mutated R/R AML, especially as a bridge to AlloHSCT.

Evaluation of Synergistic Anti-Leukemic Efficacy of PHI-101 in Preclinical Model of FLT3-ITD Acute Myeloid Leukemia

Background: AML is a heterogeneous disease with an overall cure rate of 40-50%. Some types of AML have even poorer prognosis with FLT3 mutant AML patients having only a 20-25% cure rate with chemotherapy alone. In order to improve the outcome for this high-risk AML, a number of tyrosine kinase inhibitors (TKI) have been developed and to date. Given the difficulty of identifying appropriate targets and treatment options for AML, combining drug options for AML treatment may produce clinical benefits. PHI-101 is a selective next-generation type I FLT3 inhibitor that shows potent anti-leukemic activity against AML samples harboring FLT3-ITD and/or TKD mutations. In a clinical trial, PHI-101 demonstrates significant clinical responses and tolerability in refractory or relapsed AML patients as monotherapy. To investigate the optimal way to combine PHI-101 with other therapies, a number of other drugs utilized in treating AML were tested both, in vitro and in vivo to determine synergistic or additive effects that might improve efficacy for relapsed/refractory/elderly FLT3 mutant AML patients. Study Design and Methods: Combination effects of simultaneous versus sequential treatment of PHI-101 with other agents, including daunorubicin, cytarabine, venetoclax (Ven), and azacytidine (Aza) were tested using human leukemia cell lines harboring FLT3-ITD mutations (MV4-11, Molm13, Molm14) or FLT3-wild type as controls. The cell growth inhibition was assessed by CCK-8, MTT and/or CellTiter-Glo assays as well as annexin V-binding by flow cytometry and the Chou-Talalay method was used to calculate the combination index (CI. using Compusyn software. The potential mechanisms of effect on combination therapy were explored by Western blotting of a variety of signal transduction pathways including FLT3 phosphorylation and downstream pathways BCL-2 family expression, and DNA damage. The MV4-11 xenograft mouse model was used to assess in vivo efficacy of PHI-101 combination therapy. Results: Among the substances tested for combination therapy with PHI-101 in FLT3-ITD cell lines MV4-11 and Molm14 cell lines, Aza and Ven treatment both showed synergy with both simultaneous and sequential treatment. Ven was highly synergistic when used simultaneously with PHI-101 in MV4-11 cells. Cell growth inhibition effect (GI 50) of PHI-101, Aza, and Ven used alone was measured first to calculate the CI in combination with increasing concentrations of each drug together of treatment for 72hrs. The GI 50 of PHI-101 in FLT3-mutant cell lines (MV4-11, Molm13, Molm14) were 7.0, 3.8, and 3.4 nM, respectively. The GI 50 of the gilteritinib was 5.7, 10.2, and 10.8 nM, respectively. On the other hand, the GI 50 of Aza were 198.9, 140.4, and 85.4 nM, that of Ven were 38.2, 8.4, and 56.5 nM. PHI-101 was the most efficient antitumor agent compared to other drugs tested in this study. The CI of Aza and PHI-101 was 0.01216 (EC 50), 0.05981 (EC 75), 0.29468 (EC 90) in MV4-11 cells. The observed synergistic effects were confirmed in the other FLT3-ITD cell lines as well. PHI-101 and venetoclax combined therapy in MV4-11 showed synergism (CI&amp;lt;0.1), and the CI was 0.00002 (EC 50), 0.00104 (EC 75), 0.01243 (EC 90). By Western blotting, the combination of Aza or Ven with PHI-101 resulted in a significant induction of p-H2AX and PARP cleavage in the FLT3-ITD cell lines (MV4-11), but not in FLT3-WT cell lines (THP-1). To further validate the synergistic anti-leukemic activity of PHI-101 with these agents, MV4-11-derived mouse xenograft models were generated and treated at various doses. In the MV4-11-xenograft model, PHI-101 alone or combined with Ven or Aza significantly decreased tumor volume. In line with the cell viability data, Ven and Aza combined with PHI-101 induced significant cell-killing in vivo. Conclusion: Treatment of AML cells with the combination of Ven or Aza with PHI-101 in vitro induced rapid induction of apoptosis and inhibition of cell growth that showed significant synergy. In vivo data showed improved efficacy for the combination treatment with these agents. In vitro and in vivo data from the preclinical AML models provides a rationale to evaluate the activity of PHI-101 in combination for patients who are ineligible for more intensive chemotherapeutic induction therapy. Improved anti-leukemic efficacy by combined therapy with PHI-101 represent a promising therapeutic strategy for newly diagnosed or R/R FLT3-mutant AML patients

T Cell/Natural Killer (NK) Cell Transcriptional Profiles Are Associated with Response to Gilteritinib in FLT3-Mutated Acute Myeloid Leukemia

S.R. &amp; A.C. equally contributed Background: Despite significative improvements in the management of FLT3-mutated AML and its prognosis since FLT3 inhibitors ( FLT3i) adoption, a significant proportion of patients results refractory or ultimately relapses after this targeted treatment. Gilteritinib is an oral and selective FLT3i with single-agent activity as salvage therapy in Relapsed/Refractory patients (R/R). The investigation of resistance mechanism to Gilteritinib is crucial to guide next therapeutic choices and improve drug effectiveness. Thus far, correlative studies have elucidated mainly intrinsic and mutational resistance mechanisms. However, less is known regarding potential extrinsic mechanisms and about the role of the immune system in influencing this FLT3i activity. Herein, we aimed at investigating intrinsic as well as novel extrinsic (immunological) mechanisms of resistance to Gilteritinib in routine clinical practice. Methods: A cohort of FLT3-mut AML patients treated with Gilteritinib at Hematology Institute of Bologna was selected. DNA/RNA were extracted from bone marrow (BM) samples pre-therapy and at first response assessment and screened by a custom NGS panel covering the full-coding sequence of 28 genes and a NanoString gene-expression analysis using the PanCancer IO 360 Panel. Data were collected in accordance with GCP and Helsinki declaration. NanoString data were acquired and analyzed using the nCounter FLEX Analysis System and the nSolver advanced analysis module (version 2.0.115). DESeq2 multi-factor design was employed to account for potential confounders. A public sc-RNA-seq dataset of newly diagnosed AMLs (Dufva et al. Cancer Cell 2020) was used to map DEGs between Responders and Non-Responders to Gilteritinib onto reference AML BM samples. Single-cell gene expression scores were computed using the UCell package in R. Results: Overall, 20 FLT3-mutated R/R AML patients receiving Gilteritinib as single-agent therapy were enrolled in this study. The median age at Gilteritinib therapy was 62 (range 33 - 77) years and 13/20 (65%) patients were male. Seventeen out of 20 (85 %) patients harbored a FLT3-ITD mutation, 2/20 (10 %) a TKD mutation and 1 (5 %) patient both mutations. Eleven out of 20 (55 %) patients had a concomitant NPM1 mutation. Patients were dichotomized into Responders (R) (n=9) and Non-Responders (NR) (n = 11) according to BM response. Intrinsic mechanisms of resistance were evaluated by NGS analyses on 13 patients (R=7 and NR=6). Firstly, FLT3 full-coding sequencing did not detect any clearly pathogenetic Non-Canonical (NC) mutation: M737I, M837I, P890L and P534L were four detected NC variants with a possible role in FLT3i sensitivity, however their low VAF (1-2 %) suggests a “passenger” role in this cohort. Secondly, evaluating variations in VAF of non- FLT3 variants detected pre- and post-therapy we observed a new variant onset in 4/6 (66.7 %) Gilteritinib NR patients, affecting genes involved in RAS pathway in all cases (1 NRAS, 2 KRAS and 1 PTPN11). Significant differences in immune transcriptional profiles were observed when comparing R and NR patients (R = 9 and NR = 11), including higher expression of genes reflecting T/NK function ( CD8A, GZMK, KLRK1, GNLY) and, more specifically, T-cell activity ( PRF1, EOMES, ZAP70, TNFSF8) in responders. Conversely, oncogenes involved in MAPK/Akt ( PROM1, ANGPT1, ANGPT2) or cell-cycle regulators ( CDKN2A, CCNA1) were overexpressed in NR patients (Fig. 1a). We next selected the top 30 DEGs between R and NR and we averaged gene expression across all BM samples. Gene set enrichment analysis (GSEA) revealed that approximately 25% of the significantly enriched pathways when using the top 30 DEGs as input were related to T-cell function / TCR signaling. By projecting the top 30 DEGs genes onto a sc-RNA-seq map of the AML tumor microenvironment, we found that they were largely expressed by CD8 + T EM, CD8 + T CM and NK cells (Fig. 1b). Summary/Conclusion: This study confirmed evolutionary trajectories often involving RAS pathway mutations as an intrinsic mechanism of resistance to Gilteritinib therapy. Of note, differences in immune transcriptomic profiles, involving mainly CD8+ T-Cells and NK-Cells, were associated with response, pointing to a previously unappreciated role of the immune system in mediating response to Gilteritinib.

Covalent-103: A Phase 1, Open-Label, Dose-Escalation, and Dose-Expansion Study of Bmf-500, an Oral Covalent FLT3 Inhibitor, in Adults with Acute Leukemia (AL)

Background: FLT3 mutations occur in 25-35% of patients with AML and are associated with poor prognosis. FLT3 mutations are most frequently the result of an internal tandem duplication (ITD) of amino acids in the juxtamembrane region of FLT3 or point mutations in the tyrosine kinase domain (TKD). FLT3-ITD mutations are associated with increased incidence of relapse, shorter duration of remission, and decreased disease-free and overall survival. BMF-500 is a novel orally bioavailable, highly potent and selective covalent inhibitor of FLT3 including wildtype (WT), ITD, TKD, as well as a variety of additional resistance-conferring mutations such as the gatekeeper F691. BMF-500 has demonstrated high affinity for FLT3, lack of cKIT inhibition, and sustained cell-killing capacity despite drug washout (Law et al., ASH 2022 Abstract 2756). BMF-500 has shown sustained tumor regression and improved survival in both subcutaneous and disseminated xenograft models of mutant FLT3-driven AML. Study Design: COVALENT-103 (NCT05918692) is an open-label, non-randomized, multicenter, first-in-human Phase I study evaluating the safety, tolerability, and clinical activity of escalating doses of twice daily oral BMF-500 in patients with relapsed or refractory (R/R) AL, including AML, ALL, or MPAL, with or without FLT3 mutations. The trial has 2 arms that will undergo dose escalation in parallel: Arm A (without) and Arm B (with) concomitant use of a moderate or strong CYP3A4 inhibitor. Utilizing an accelerated titration design (ATD), doses of BMF-500 will be escalated in single-subject cohorts until 1 subject experiences either a Grade 2 or higher related-adverse event or dose-limiting toxicity (DLT). At that point, the cohort will switch to a classical “3 +3” design. Patients with WT FLT3 AL may be enrolled, up to a limit of 33% per arm. Treatment will continue in 28-day cycles until progression or intolerability. Expansion cohorts will enroll additional patients to obtain further safety and efficacy data. Patients must be refractory, relapsed or must have progressed on or following discontinuation of the most recent anti-cancer therapy or be ineligible for any approved standard of care therapies, including HSCT. Participants with FLT3-mutant AML must have received treatment with a FLT3 inhibitor approved for treatment of relapsed or refractory FLT3-mutant AML. Key inclusion criteria include ECOG PS ≤ 2, adequate organ function, and documented FLT3 mutation status. Key exclusion criteria include known CNS disease involvement, clinically significant cardiovascular disease, and WBC count &amp;gt;50,000/µL (uncontrollable with cytoreductive therapy). Objectives: The primary objective of the study is to evaluate safety and tolerability and to determine the optimal biological dose (OBD)/ recommended Phase 2 dose (RP2D) of BMF-500 oral monotherapy based on evaluation of available PK/ PD, safety and efficacy data. Secondary objectives include characterization of the pharmacodynamics and pharmacokinetics of BMF-500, and assessment of its antitumor activity per modified Cheson (2003) criteria or the NCCN Clinical Practice Guidelines (ALL Version 1.2022) as determined by the investigator. Endpoints include best overall response rate (ORR), complete remission (CRc), duration of response (DOR), relapse-free survival (RFS) and overall survival (OS). The study was initiated in July 2023 and will enroll ~110 participants at approximately 30 sites.

Threshold Attenuation of Perk Signaling Is Sufficient to Overcome RAS-Mediated FLT3 Inhibitor Resistance

Introduction Acute myeloid leukemia (AML) with activation of FMS-related receptor tyrosine kinase 3 ( FLT3) confers a poor prognosis, principally due to disease relapse. The FLT3 inhibitor (FLT3i) gilteritinib is standard of care in relapsed/refractory FLT3-mutant AML, however its efficacy is limited by drug resistance, primarily due to RAS mutations. This suggests that RAS signaling is the critical mediator of downstream FLT3 signaling, but there is no standardized treatment for patients who relapse on FLT3i due to RAS pathway activation. Efforts to overcome resistance have been limited both by understanding of the optimal RAS effectors to target as well as the potential toxicity of simultaneously targeting FLT3 and RAS. Here, we demonstrate that while RAS-driven resistance to gilteritinib is mediated through MAPK, not PI3K, attenuation of pERK signaling is sufficient to overcome this resistance both in vitro and in vivo. Methods/ Results FLT3-ITD+ cells (Molm14) with transduced NRAS mutations are resensitized to gilteritinib by MEK inhibitor treatment, proving that MAPK signaling is necessary for RAS-driven resistance. Further, expression of a constitutively active MEK construct (MEKDD) in Molm14 confers resistance to gilteritinib, showing MAPK signaling is sufficient for RAS-driven resistance. Conversely, we show that activated PI3K signaling is neither necessary nor sufficient to drive resistance, as AKT inhibition cannot resensitize NRAS-mutants to gilteritinib, and an activated AKT mutant does not confer gilteritinib resistance. We used a doxycycline-inducible system to increase expression of MEKDD, to titrate levels of ERK signaling activation in Molm14 cells. Surprisingly, we found that the relationship between ERK phosphorylation (pERK) and FLT3i resistance was non-linear and appeared to increase at a threshold of pERK (62%). In keeping with this, suppression of pERK levels in Molm14 cells with concurrent RAS mutations to levels below 70% of baseline using the MEK inhibitor (MEKi) trametinib, was sufficient to resensitize to gilteritinib in proliferation assays. A similar phenomenon was seen in apoptosis assays. Molm14 NRAS Q61K mutant cells treated with 500nM gilteritinib plus increasing doses of trametinib showed apoptosis plateaued at the relatively low dose of 5nM trametinib. Western Blot analysis showed residual pERK activation at this dose. Thus, attenuation of MAPK signaling below a threshold, rather than its ablation, can overcome FLT3i resistance. In a patient-derived xenograft (PDX) model of AML with concurrent FLT3-ITD and NRAS Q61K, the combination of low dose MEK inhibition (PD-901 1.5mg/kg) combined with gilteritinib was equivalent to standard dose MEK inhibition (PD-901 5mg/kg) combined with gilteritinib in suppressing outgrowth of human CD45+ cells in spleen, bone marrow, and blood of NSGS mice in comparison to vehicle-treated control. Standard dose MEK inhibition in combination with gilteritinib was also noted to be intolerable in the majority of mice with only 2 of 6 mice surviving 28 days. Given the similar activity of low and high dose MAPK inhibition in combination with gilteritinib, we hypothesized that suppression of ERK activation below a critical level is sufficient to activate a shared transcriptional program to trigger cell cycle arrest and apoptosis. To test this hypothesis, we performed RNAseq analysis of Molm14 NRAS Q61K cells treated with gilteritinib, standard dosing of trametinib, low dose trametinib, or the combination. There is a gene expression signature of MAPK expression unique to the combination of gilteritinib and trametinib that is dose independent of trametinib, which includes MAPK regulators including ETV4 and ETV5. Conclusions MAPK is the critical effector pathway of RAS-driven gilteritinib resistance, but partial attenuation of pERK signaling is sufficient to inhibit proliferation and induce apoptosis, restoring sensitivity to FLT3i. Applied clinically, this suggests feasibility of low dose MAPK inhibition in combination with gilteritinib to treat resistant FLT3-activated AML. This strategy that would improve tolerability, a major concern in clinical use of MAPK pathway inhibitors.