Symposium on Advances in Therapy

Recent Advances in Management of Acute Myeloid Leukemia (AML)

Manasi Shah and Bharat Agarwal1
Bridgeport Hospital, Yale University School of Medicine, USA. 1Department of Pediatric Hematology and Oncology, B.J.Wadia Hospital for Children, Institute of Child Health & Research Centre, Mumbai, India

ABSTRACT
Acute myeloid leukemia (AML) is the most common childhood malignancy. AML has therapentically been difficult to treat. In 2001, the World Health Organization (WHO), in conjunction with the Society for Hematopathology and the European Association of Hematopathology, published a new classification for myeloid neoplasms. A number of chromosomal abnormalities are used to predict outcome and stratify therapeutic risk groups in children with AML. Recently, alterations in receptor tyrosine kinases, tyrosine phosphatases and in oncogenes such as RAS have been implicated in the pathogenesis of AML. This article aims to review the recent development in diagnosis, treatment and monitoring of AML. Better understanding of the molecular pathogenesis of AML has led to the development of target-specific therapies. Some of the new classes of drugs include monoclonal antibody directed against the CD33 antigen, farnesyltransferase inhibitors (FTI), and FMSlike tyrosine kinase 3 (FLT3) inhibitors. The role of allogenic SCT, particularly whether it should be done during first CR or reserved for second remission, remains the most controversial issue in pediatric AML. There is a need of collaboration with international pediatric cooperative oncology groups and definitive clinical trials in order to estabilish use of these newer molecules in pediatric populations. [Indian J Pediatr 2008; 75 (8) : 831-837] Email: mansi1227@gmail.com Key words : Acute myeloid leukemia (AML); Oncogenes; FLT3 inhibitors; Gemtuzumab ozogamicin

Acute leukemia is the most common childhood malignancy. It accounts for one third of the malignancies in children. Acute lymphoblastic leukemias (ALL) are more frequent in children than AML. 1 The expected current cure rates for ALL have been encouraging at 7580% 2 . In contrast to childhood ALL, AML has traditionally been difficult to treat. Over all survival in the 1960s was less than 10%. However, with recent innovations in diagnosis, treatment and follow-up, prognosis of childhood AML has improved significantly to a present probability of cure rate of approximately 60%.3 This review summarizes the classification, recent advances in the diagnosis and treatment and future possibilities of more precise stratification and targeted therapies for pediatric AML. CURRENT CLASSIFICATION FOR AML In 2001 WHO, in conjunction with the Society for Hematopathology and the European Association of

Hematopathology, published a new classification for myeloid neoplasms. In contrast to the French- AmericanBritish (FAB) classification (Table 1), the WHO classification included morphologic findings and genetic, immunophenotypic, biologic, and clinical features to define specific disease entities (Table 2).4 This classification is not yet routinely implemented in pediatric hematology/ oncology because of several differentiating factors in pediatric oncology.5
TABLE 1. FAB Classification M0- AML with minimal differentiation M1- Myeloblastic leukemia without maturation M2- Myeloblastic leukemia with maturation M3- Acute promyelocytic leukemia M4- Acute myelomonocytic leukemia M5- Acute monoblastic leukemia M6- Acute erythroblastic leukemia M7- Acute megakaryoblastic leukemia

Neither the WHO or FAB classification uses age criteria to classify AML. There are several differences in pediatric and adult AML in terms of survival, cytogenetic distributions and host factors. The WHO classification does not characterize important subgroups of pediatric AML such as infants with AML FAB M7 and a translocation (1; 22), and
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Correspondence and Reprint requests : Dr Manasi Shah, 23, MattaBasset Dr, MERIDEN, CT 06450,USA. [Received March 6, 2007; Accepted April 1, 2008]

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M. Shah and B. Agarwal

TABLE 2. WHO Classification Acute Myeloid Leukemia with Recurrent Genetic Abnormalities Acute myeloid leukemia with t (8; 21) (q22; q22), (AML1/ETO) Acute myeloid leukemia with abnormal bone marrow eosinophils and inv (16) (p13q22) or t (16; 16) (p13; q22), (CBF /MYH11) Acute promyelocytic leukemia with t (15; 17) (q22; q12), (PML/ RAR ) and variants Acute myeloid leukemia with 11q23 (MLL) abnormalities Acute Myeloid Leukemia with Multilineage Dysplasia Following MDS or MDS/MPD Without antecedent MDS or MDS/MPD, but with dysplasia in at least 50% of cells in 2 or more myeloid lineages Acute Myeloid Leukemia and Myelodysplastic Syndromes, Therapy Related Alkylating agent/radiation-related type Topoisomerase II inhibitor-related type (some may be lymphoid) Others Acute Myeloid Leukemia, Not Otherwise Categorized Acute myeloid leukemia, minimally differentiated Acute myeloid leukemia without maturation Acute myeloid leukemia with maturation Acute myelomonocytic leukemia Acute monoblastic/acute monocytic leukemia Acute erythroid leukemia (erythroid/myeloid and pure erythroleukemia) Acute megakaryoblastic leukemia Acute basophilic leukemia Acute panmyelosis with myelofibrosis Myeloid sarcoma

has been reported in many cases of AML, new molecular tools now are identifying multiple genetic mutations in such cases.6 The abnormalities t(8;21), inv(16)(p13q22) or t(16;16)(p 1 3;q22), t(15;17)(q22;q11-12), t(9;1 1)(p22;q23) are associated with a high complete remission rate 7 while del(5q), +13, +8, -7, inv 3, del(12p), t(9;22), or complex abnormalities are associated with a lower rate of complete remission (CR). 8 Translocations of the mixed linkage leukemia (MLL) gene at 11q23 are frequent in childhood AML (14%) and are associated with 65% of infant AML. They confer an intermediate risk. Recently, alterations in receptor tyrosine kinases, tyrosine phosphatases and in oncogenes such as RAS have been implicated in the pathogenesis of AML. 5 Activating mutations of FMS- like tyrosine kinase 3 (FLT3) receptor occur because of an internal tandem duplication of the juxta-membrane domain (FLT3/ITD) or point mutation of the activation loop domain (FLT3/ ALM). The presence of FLT3 mutations as well as the allelic ratio of FLT3/ITD (ITD-AR, mutantwild type ratio) may have prognostic significance. This mutation causes autonomous, cytokine-independent proliferation in vitro. In a recent study by Meshinchi et al, 630 children with de novo AML were analyzed for Flt3 mutation as well as allelic ratio of FLT3/ITD (ITD-AR, mutantwild type ratio). Progression free survival (PFS) at 4 years from entry point for patients with FLT3/ITD was inferior to that of patients with FLT3/WT (31% versus 55%, P < .001). PFS decreased with increasing FLT3/ITD-AR (P < .001), and those with ITD-AR greater than 0.4 had a significantly worse PFS than those with lower ITD-AR (16% versus 72%, P = .001) or with FLT3/WT (55%, P < .001).9 Another novel mutation of significant importance discovered is the frameshift mutation in exon 12 of the nucleophosmin gene (NPM1) results in aberrant cytoplasmic localization of the NPM protein (NPMc(+)). It occurs in 25% to 35% of adult AML, but is relatively less frequent in childhood AML. There is a favorable impact of NPMc (+) on survival in children lacking FLT3/ITD, which is similar in magnitude to the favorable impact of t (8; 21) and inv (16).10 In addition to NPM1 mutations and FLT3/ITDs, several new genetic abnormalities have been identified in normal karyotype AML, such as CCAAT/ enhancer binding protein alpha gene CEPB , the neuroblastoma RAS viral oncogene (NRAS), and brain and acute leukemia cytoplasmic (BAALC) gene. CEPB is associated with a favorable prognosis. Other abnormalities including BAALC genes are associated with poor prognosis.40, 41 DRUG THERAPY 1. Anthracyclines Daunorubicin was the first anthracycline of demonstrated
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children with myeloid leukemia of Down syndrome. The threshold for the blast percentage was reduced from 30% to 20%. Hence, pediatric cases formerly diagnosed with myelodysplasia are now classified as AML. Based on this classification, there are no definite treatment protocols for intensive chemotherapy prior to stem cell transplantation. GENETIC ABNORMALITIES IN AML A number of chromosomal abnormalities are used to predict outcome and stratify therapeutic risk groups in children with AML. Mutations in a number of genes that confer a proliferative and/or survival advantage to cells but do not affect differentiation (Class I mutations) have been identified in AML, including mutations of FLT3, ALM, oncogenic RAS and PTPN11, and the BCR/ABL and TEL/PDGFR gene fusions. Similarly, gene mutations and translocation-associated fusions that impair differentiation and apoptosis (Class II mutations) in AML include the AML/ETO and PML/RAR fusions, MLL rearrangements, and mutations in CEBPA, CBF, HOX family members, CBP/P300, and co-activators of TIF1. AML results when hematopoietic precursor cells acquire both Class I and Class II genetic abnormalities. Although only one cytogenetic or molecular abnormality
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Recent Advances in Management of Acute Myeloid Leukemia (AML)

value against AML. It has equivalent efficacy and less toxicity than doxorubicin. Daunorubicin used as a continuous infusion used in BFM11 and MRC-1012 studies has shown superior results as compared to a bolus schedule in POG 882113 study. It is thought to be due to the pharmacokinectic properties of duanorubicin which suggest that it needs a minimum infusion time of 90 minutes for optimal binding of daunorubicin to the DNA.2 Anthraclycines are known to cause acute and long term cardiotoxicity. Liposomal anthracyclines cause less cardiotoxicity than conventional anthracyclines. This may be because of preferential release of daunorubicin in tumor cells.14 Hempel et al studied pharmacokinetics of liposomal daunorubicin (daunoxome) in children (n=19). In comparison with free daunorubicin, daunoxome shows a low volume of distribution, a lower clearance and a lower interindividual variability in these parameters. This might be advantageous in reducing the variability in exposure to the drug. 15 In one study, liposomal daunorubicin was combined with cytarabine in 69 children with relapsed/ refractory AML. 46 children (67 %) achieved a second remission, defined as clearance of blasts in bone marrow and at least a partial hematological reconstitution. The pharmacokinetic investigation showed a high overall AUC of 234.6 mg/l h at a dose of 60 mg/m2, and a volume of distribution of 1.98 l/m2, which is much lower in comparison to conventional daunorubicin. No clinical relevant cardiotoxicity was seen, but definitive results in long-term cardiotoxicity are awaited.16 The BFM group is currently randomizing between liposomal daunorubicin and idarubicin in induction for pediatric de novo AML.5 Certain anthracyclines are favored for their perceived greater antileukemic effect and/or their lower cardiotoxicity, but no anthracycline agent has been demonstrated to be superior. The MRC found daunorubicin and mitoxantrone to be equally efficacious but mitoxantrone to be more myelosuppressive. 17 Idarubicin is used commonly because in vitro and preclinical studies suggest that it offers a greater clinical benefit because of its faster cellular uptake, increased retention, and lower susceptibility to multidrug resistant glycoprotein. 18, 19 In addition, its main metabolite, idarubicinol, has a prolonged plasma half-life (54 hours) and has antileukemic activity in the cerebrospinal fluid.20 However, in clinical trials (BFM AML 93 and the Australian and New Zealand Childrens Cancer Study Group), idarubicin and daunorubicin are equally efficacious, but idarubicin showed more gastrointestinal, pulmonary, and renal toxicity.21, 22 2. High dose Cytarabine The most common remission induction regimen used for patients with AML is cytarabine given by continuous intravenous (IV) infusion (100 mg/m2 per day) for seven
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days plus daunorubicin (45 to 60 mg/m2 by IV push) daily for the first three days (the so-called 7 + 3 regimen). Depending upon age and patient selection, 60 to 80% of patients achieve a CR with this regimen.23 Alternatively, high dose cytarabine (HDAC) regimens typically use 1000 to 3000 mg/m2 given IV over one to three hours every 12 hours for 8 to 12 doses. The use of high-dose cytarabine in post-remission therapy seems to be important in improving survival. A total of 216 eligible children with newly diagnosed AML were treated in the two consecutive multi-center trials of Tokyo Childrens Cancer Study Group (TCCSG), M91-13 and M96-14, from August 1991 to September 1998. In M91- 13 trial, patients received eight courses of intensive post-remission chemotherapy, including six HD-Ara-C containing courses, after remission-induction therapy. In M96-14 trial, the last two HD-Ara-C courses were omitted from the chemotherapy arm. The remission-induction rate was 88.8% and probability of 5-year overall survival (OS) and eventfree survival (EFS) were 62% and 56% respectively. Treatment-related mortality (TRM) was 7.8%. Among patients without down syndrome (DS) or acute promyelocytic leukemia (APL), the presence of t (8; 21) or inv (16) was a significant good prognostic factor both in the univariate and multivariate analyses.24 3. Chlorodeoxyadenosine (Cladribine) It is a purine nucleoside analogue. It is a prodrug which enters the cells through a transport system and is activated via phosphorylation by deoxycytidine kinase to a 5'-triphosphate derivative. This active form incorporates into DNA resulting in inhibition of DNA synthesis and early chain termination. The induction of strand breaks results in a drop in the cofactor nicotinamide adenine dinucleotide and disruption of cell metabolism. Adenosine triphosphate ATP is depleted to deprive cells of an important source of energy. Cladribine kills both resting as well as dividing cells.25 Cellular drug resistance is one of the reasons of therapy failure in AML. Resistance to cytarabine is an important cause of treatment failure in AML.26 Clinical studies have shown efficacy of cladribine (2-CDA) in untreated and relapsed pediatric AML. Of 72 patients with primary AML treated with 2-CDA, 24% achieved CR after one course of 2- CDA and 40% after two courses of 2-CDA. Patients with FAB M5 AML had a higher rate of CR after treatment with 2-CDA (45% after one course and 70.6% after two courses) than did others (P = .002). In contrast, no patient with FAB M7 AML entered CR after treatment with 2-CDA.27 Santana et al, studied the use of continuous cladribine infusion for 5 days at 8.9 mg/m 2 /d in 17 patients with relapsed AML. 47% patients with AML had complete hematologic remissions and 12% had partial remissions, for a total response rate of 59%. However, certain studies have not shown the efficacy of cladribine and cytarabine in relapsed AML.28, 29
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M. Shah and B. Agarwal 4. Gemtuzumab ozogamicin (GO) Gemtuzumab ozogamicin consists of a semisynthetic derivative of calicheamicin, a cytotoxic antibiotic linked to a recombinant monoclonal antibody directed against the CD33 antigen present on leukemic myeloblasts in most patients with AML. Gemtuzumab ozogamicin is indicated for the treatment of patients with CD33 positive AML in first relapse who are 60 years of age or older and who are not considered candidates for cytotoxic chemotherapy. The approved dose was 9 mg/m (2) i.v. over 4 h and repeated in 14 days. The major toxicity in phase I trials is myelosuppression, especially neutropenia and thrombocytopenia, resulting from the expression of CD33 on myeloid progenitor cells. Hepatotoxicity has also been noticed.30 In pediatric AML, a phase I study was performed which showed the maximal tolerated dose was 2 infusions at 6 mg/m 2 with a 14-day interval with Sinusoidal obstruction syndrome (SOS) as dose limiting toxicity at 9 mg/m2. All patients (n=29) had anticipated myelosuppression. Other toxicities included grade 3/4 hyperbilirubinemia (7%) and elevated hepatic transaminase levels (21%); the incidence of grade 3/4 mucositis (3%) or sepsis (24%) was relatively low. Thirteen patients underwent hematopoietic stem-cell transplantation less than 3.5 months after the last dose of gemtuzumab ozogamicin; 40% developed veno-occlusive disease VOD. 28% patients achieved overall remission. Remissions were comparable in patients with refractory (30%) and relapsed (26%) disease 31. Brethon et al showed molecular response in 2 children with relapsed AML when treated with GO and cytarabine. Severe but
TABLE 3. FLT3 Inhibitors in Clinical Studies Drug CEP-701 34,35 Chemical Class Indolocarbazole Action on other RTKs TrkA Stage of Clinical Development Phase II Dosage 60-80 mg orally two times a day 75mg orally three times a day Toxicities Schedule Fatigue (grade - 18%), CHF, dyspnea (grade[g] - 6%), anorexia (g 41%), emesis (g -29% Pulmonary toxicity (g 5-15%), hypoxia (g 3- 10%), hyperbilirubi nemia (g 3- 5%) Headaches (grade 14%), infusion-related reactions (g 11%), dyspnea g 14%), fatigue (g 7%), thrombotic episodes (g 7%), bone pain (g 5%), and gastrointestinal disturbance (g 4%) Fatigue, HTN (g4 7%), LE edema (g2 20%), dysgeusia (g2-20%), mouth ulcerations, gingivitis, hematuria, increased creatinine (g220%)

manageable myelosuppression was the only toxicity.32 In one study, GO was used on a compassionate basis in 12 children with multiple relapsed or refractory AML. 5 of 12 children responded to treatment with blast reduction to below 5%, but no child achieved CR after GO. Time until reoccurrence of blasts in almost all children with GO response was 3-8 months.33 GO seems to be an acceptable option in resistant cases. Several studies are underway to see if it also improves over all survival.5 5. FLT3 inhibitors The identification of FLT3 mutations as a potential cause of AML has led to its consideration as a potential target for therapy. The success of imatinib mesylate, a small molecule inhibitor of the constitutively activated ABL tyrosine kinase that acts by competing with ATP for binding to its active site, has encouraged the development of FLT3 inhibitors. Table 3 summarizes the FLT3 inhibitors in clinical studies.34 CEP-701 is an indolocarbazole derivative which selectively inhibits FLT3. Based on these preclinical data, CEP-701 is currently being tested in phase II trials in adults with relapsed or refractory AML and FLT3 activating mutations. Fourteen heavily pretreated AML patients were treated with CEP-701, at an initial dose of 60 mg orally twice daily. CEP-701-related toxicities were minimal. Five patients had clinical evidence of biologic activity and measurable clinical response, including significant reductions in bone marrow and peripheral blood blasts from 25% to less than 5% at day 28 of therapy. Clinical responses have correlated with

PKC412 34,36

Staurosporine

SU5416 34,37

Indolinone

PKC VEGFR PDGFR KIT KIT VEGFR

Phase II

Phase II

145 mg/m2 iv twice weekly

SU5614 34,42 SU11248 34,43

Indolinone Indolinone

KIT VEGFR KIT VEGFR PDGFR

Phase I Phase I

50-75 mg orally once a day

RTK - receptor tyrosine kinases, PKC - protein kinase C; PDGFR- platelet-derived growth factor receptor; VEGFR- vascular endothelial growth factor receptor.

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demonstration of inhibition of FLT3 in the patients leukemic blasts.35 PKC412 (N-benzoylstaurosporine), was studied in 20 patients, each with mutant FLT3 relapsed/refractory AML or high-grade myelodysplastic syndrome not believed to be candidates for chemotherapy at a dose of 75 mg 3 times daily by mouth. The drug was generally well tolerated, although 2 patients developed fatal pulmonary events of unclear etiology. The peripheral blast count decreased by 50% in 14 patients (70%). Seven patients (35%) experienced a greater than 2-log reduction in peripheral blast count for at least 4 weeks (median response duration, 13 weeks; range, 9-47 weeks). PKC412 reduced bone marrow blast counts by 50% in 6 patients (2 of these to < 5%).36 SU5416 is a small molecule RTK inhibitor (RTKI) of VEGFR-2, c-kit, and both wild-type and mutant FLT3. A multicenter phase 2 study of SU5416 was conducted in patients with refractory AML or MDS. Of the total 55 patients, 33 had AML. They received IV 145 mg/m 2 SU5416 twice weekly intravenously. It showed modest response with only 5% partial responses and 2% patients who achieved hematologic improvement. Grade III or IV drug-related toxicities included headaches (14%), infusion-related reactions (11%), dyspnea (14%), fatigue (7%), thrombotic episodes (7%), bone pain (5%), and gastrointestinal disturbance (4%). Overall median survival was 12 weeks in AML patients (range, 4-41 weeks).37 6. Farnesyltransferase inhibitors (FTI) FTI is a class of agents that interfere with the farsenylation of several proteins such as RAS and rhoB. Farnesyltransferase inhibitor tipifarnib was used in 158 adults with previously untreated, poor-risk AML. Complete remission (CR) was achieved in 22 patients (14%); partial remission or hematologic improvement occurred in 15 patients, for an overall response rate of 23%. The median duration of CR was 7.3 months and the median survival of complete responders was 18 months. Inhibition of farnesylation of the surrogate protein HDJ-2 occurred in the large majority of marrow samples tested. Baseline levels of phosphorylated mitogen-activated protein kinase and AKT did not correlate with clinical response.38 There is no data on the safety/ efficacy of FTI in pediatric population. 2. STEM CELL TRANSPLANT (SCT) SCT is a successful curative treatment for AML; it produces a strong graft-versus-leukemia effect and can cure even relapsed AML. Its potential benefit, however, must be weighed against the risk of transplantationrelated mortality and the late sequelae of transplantation. SCT has become a less attractive option as the outcomes of increasingly intensive chemotherapy and post relapse
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salvage therapy have improved. The role of allogeneic SCT, particularly whether it should be done during first CR or reserved for second remission, remains the most controversial issue in pediatric AML. Competing factors, particularly risk group, may tip the balance in favor of SCT or intensive chemotherapy. Most groups agree that children who have APL, AML and Down syndrome or AML and t(8;21) or inv(16) are not candidates for SCT in first CR, but opinions differ about patients in the standard-risk and high-risk categories.6 A meta-analysis of studies enrolling patients younger than 21 years of age between 1985 and 2000 that recommended SCT if a histocompatible family donor were available found that SCT from a matched sibling donor reduced the risk of relapse significantly and improved DFS and OS. 39 However, it should be recognized that the actual reduction of relapse risk is highly dependent on the efficacy and intensity of the control chemotherapy arm.5 3. MINIMAL RESIDUAL DISEASE (MRD) MONITORING Response to therapy can be measured by morphologic or cytogenetic examination of bone marrow, but these methods cannot detect levels of residual leukemia below 1% (1 leukemic cell in 100 mononuclear bone marrow cells). In contrast, MRD assays provide objective and sensitive measurement of low levels of leukemic cells in childhood and adult AML. Methods of assessing MRD include DNA-based polymerase chain reaction (PCR) analysis of clonal antigen-receptor gene rearrangements (applicable to less than 10% of AML cases), RNA-based PCR analysis of leukemia specific gene fusions (applicable to less than 50% of AML cases), and flow cytometric detection of aberrant immunophenotype (applicable to more than 90% of AML cases). Recent studies in adults have confirmed that the level of residual leukemia cells detected immunophenotypically after induction or consolidation therapy is associated strongly with the risk of relapse.6 4. CONCLUSIONS
There has been a remarkable progress in understanding the pathogenesis, diagnosis, treatment and follow-up of AML in children. The probability of survival in newly diagnosed pediatric AML is now almost 60%. However, conventional chemotherapy is unsatisfactory and specifically targeted therapies are needed. The discovery of specific cytogenetic alterations and development of targeted therapies like GO, FLT3 inhibitors are examples of such a targeted approach. However, the present study need collaboration with international pediatric cooperative oncology groups and definitive clinical trials in order to establish their use in pediatric populations.

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Recent Advances in Management of Acute Myeloid Leukemia (AML)

leukemia. Blood 2004; 103 : 3669-3676. 36. Stone RM, DeAngelo DJ, Klimek V, Galinsky I, Estey E, Nimer SD et al. Patients with acute myeloid leukemia and an activating mutation in FLT3 respond to a small-molecule FLT3 tyrosine kinase inhibitor, PKC412. Blood 2005; 105 : 54-60. 37. Giles FJ, Stopeck AT, Silverman LR, Lancet JE, Cooper MA, Hannah AL et al. SU5416, a small molecule tyrosine kinase receptor inhibitor, has biologic activity in patients with refractory acute myeloid leukemia or myelodysplastic syndromes. Blood 2003; 102 : 795-801. 38. Lancet JE, Gojo I, Gotlib J, Feldman EJ, Greer J, Liesveld JL et al. A phase 2 study of the farnesyltransferase inhibitor tipifarnib in poor-risk and elderly patients with previously untreated acute myelogenous leukemia. Blood 2007; 109 : 13871394. 39. Bleakley M, Lau L, Shaw PJ, Kaufman A. Bone marrow transplantation for pediatric AML in first remission: a systematic review and meta-analysis. Bone Marrow Transplant 2002; 29 : 843-852. 40. Schlenk RF, Dohner K, Krauter J, Frohling S, Corbacioglu A, Bullinger L et al. Mutations and Treatment Outcome in Cytogenetically Normal Acute Myeloid Leukemia. NEJM 2008; 358 : 1909-1918. 41. Marcucci G, Radmacher M, Maharry K, Mrozek K, Ruppert A, Paschka P et al. MicroRNA Expression in Cytogenetically Normal Acute Myeloid Leukemia. NEJM 2008; 358: 1919-1928. 42. Spiekermann K, Dirschinger RJ, Schwab R, Bagrintseva K, Faber F, Buske C et al. The protein tyrosine kinase inhibitor SU5614 inhibits FLT3 and induces growth arrest and apoptosis in AML-derived cell lines expressing a constitutively activated FLT3. Blood 2003; 101 : 1494-1504. 43. Fiedler W, Serve H, Dhner H, Schwittay M, Ottmann OG, OFarrell AM et al. A phase 1 study of SU11248 in the treatment of patients with refractory or resistant acute myeloid leukemia (AML) or not amenable to conventional therapy for the disease. Blood 2005; 105 : 986-993.

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