Emergence of polyclonal FLT3 tyrosine kinase domain mutations during sequential therapy with sorafenib and sunitinib in FLT3-ITD-positive acute myeloid leukemia.
Emergence of polyclonal FLT3 tyrosine kinase domain mutations during sequential therapy with sorafenib and sunitinib in FLT3-ITD-positive acute myeloid leukemia.
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DOI：
10.1158/1078-0432.ccr-13-1323
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发表时间：
2013-10-15
期刊：
影响因子：
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通讯作者：
Inaba H
中科院分区：
文献类型：
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作者：
Baker SD;Zimmerman EI;Wang YD;Orwick S;Zatechka DS;Buaboonnam J;Neale GA;Olsen SR;Enemark EJ;Shurtleff S;Rubnitz JE;Mullighan CG;Inaba H
评价索拉非尼和舒尼替尼序贯治疗FLT 3-ITD阳性AML的临床活性，并监测治疗期间继发性FLT 3酪氨酸激酶结构域（TKD）突变的出现。6例复发性/难治性AML患儿接受索拉非尼联合氯法拉滨和阿糖胞苷治疗，如果不是移植候选者，则接受索拉非尼单药治疗。索拉非尼复发后开始舒尼替尼治疗。获得骨髓样本，通过深度扩增子测序评估FLT 3 TKD突变。通过FLT 3外显子14至20的克隆和测序评估ITD等位基因的继发突变的阶段。在Ba/F3细胞中对鉴定的突变进行建模，并评估激酶抑制剂对FLT 3信号传导和细胞活力的影响。4例患者达到完全缓解，但3例接受索拉非尼维持治疗后14-37周复发。舒尼替尼减少了2例患者的循环原始细胞和1例患者的骨髓原始细胞。2例患者对索拉非尼联合治疗或舒尼替尼无应答。在ITD阳性和阴性等位基因的索拉非尼耐药样本中观察到残基D835和F691处的FLT 3突变。深度测序揭示了索拉非尼治疗期间的低水平突变及其演变。舒尼替尼抑制D835 H和F691 L突变的白血病克隆，但不抑制D835 Y。表达索拉非尼耐药FLT 3突变的细胞在体外对舒尼替尼敏感。舒尼替尼在索拉非尼耐药和继发性FLT 3 TKD突变患者中具有活性。在治疗期间使用敏感的方法监测FLT 3突变可能允许使用目前可用的激酶抑制剂进行个体化治疗。
To evaluate the clinical activity of sequential therapy with sorafenib and sunitinib in FLT3-ITD-positive AML and monitor the emergence of secondary FLT3 tyrosine kinase domain (TKD) mutations during treatment. Six children with relapsed/refractory AML were treated with sorafenib in combination with clofarabine and cytarabine, followed by single-agent sorafenib if not a candidate for transplantation. Sunitinib was initiated after sorafenib relapse. Bone marrow samples were obtained for assessment of FLT3 TKD mutations by deep amplicon sequencing. The phase of secondary mutations with ITD alleles was assessed by cloning and sequencing of FLT3 exons 14 through 20. Identified mutations were modeled in Ba/F3 cells and the effect of kinase inhibitors on FLT3 signaling and cell viability was assessed. Four patients achieved complete remission, but 3 receiving maintenance therapy with sorafenib relapsed after 14–37 weeks. Sunitinib reduced circulating blasts in 2 patients and marrow blasts in 1. Two patients did not respond to sorafenib combination therapy or sunitinib. FLT3 mutations at residues D835 and F691 were observed in sorafenib resistance samples on both ITD-positive and –negative alleles. Deep sequencing revealed low-level mutations and their evolution during sorafenib treatment. Sunitinib suppressed leukemic clones with D835H and F691L mutations, but not D835Y. Cells expressing sorafenib-resistant FLT3 mutations were sensitive to sunitinib in vitro. Sunitinib has activity in patients that are resistant to sorafenib and harbor secondary FLT3 TKD mutations. The use of sensitive methods to monitor FLT3 mutations during therapy may allow individualized treatment with the currently available kinase inhibitors.