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The AML microenvironment catalyzes a stepwise evolution to gilteritinib resistance
Sunil K Joshi1, Tamilla Nechiporuk2, Daniel Bottomly3
1Knight Cancer Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA; Department of Physiology & Pharmacology, School of Medicine, Oregon Health & Science University, Portland, OR, USA; Division of Hematology & Medical Oncology, Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
Gilteritinib resistance in FLT3-mutated acute myeloid leukemia (AML) evolves in stages. Early resistance involves the bone marrow microenvironment, while late resistance stems from intrinsic cell changes and NRAS mutations. Targeting Aurora kinase B (AURKB) with gilteritinib may overcome resistance.
Area of Science:
- Hematology
- Oncology
- Molecular Biology
Background:
- Acute myeloid leukemia (AML) with FLT3 mutations poses treatment challenges.
- Gilteritinib is a targeted therapy for FLT3-mutated AML.
- Mechanisms of gilteritinib resistance are not fully understood.
Purpose of the Study:
- To elucidate the stepwise evolution of gilteritinib resistance in FLT3-mutated AML.
- To identify key molecular and cellular mechanisms driving early and late resistance.
- To explore therapeutic strategies to overcome gilteritinib resistance.
Main Methods:
- Integration of whole-exome sequencing, CRISPR-Cas9 gene editing, metabolomics, and proteomics.
- Pharmacologic approaches to assess drug sensitivity and resistance.
- Modeling of resistance evolution using cell cultures and primary patient samples.
Main Results:
- Early gilteritinib resistance is mediated by the bone marrow microenvironment, leading to metabolic reprogramming and Aurora kinase B (AURKB) dependency.
- Late resistance is characterized by the expansion of pre-existing NRAS mutant subclones and ongoing metabolic adaptation.
- Pharmacological inhibition of AURKB resensitizes resistant AML cells to gilteritinib.
Conclusions:
- Gilteritinib resistance in FLT3-mutated AML develops through distinct early and late phases.
- Targeting AURKB in combination with gilteritinib shows promise for overcoming early resistance.
- This combinatorial strategy may prevent the emergence of more aggressive, resistant AML clones.
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