Issa GC, Aldoss I, DiPersio J, et al. The menin inhibitor revumenib in KMT2A-rearranged or NPM1-mutant leukaemia. Nature. 2023;615(7954):920-924.

Acute leukemias with KMT2A rearrangements are associated with leukocytosis at initial clinical presentation, resistance to standard chemotherapies, and higher relapse rates.1-5  To date, more than 130 5’ fusion partners for KMT2A have been identified in acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML).4,6  While KMT2A rearrangements in adults are generally associated with poor prognosis, the success of treatment in children depends on leukemia subtype, age at diagnosis, and specific KMT2A fusion partner.7,8  Detailed genetic and biologic characterization studies over the past two decades have highlighted the potential for precision medicine-based therapies that target the unique Achilles’ heels of KMT2A-rearranged acute leukemias.3,8,9 

KMT2A-rearranged leukemias overexpress HOX family genes and their co-factor MEIS1, which leads to an arrest in lymphoid or myeloid cell differentiation and ensuing leukemogenesis.10  Disruption of KMT2A binding to its essential co-factor menin downregulates aberrant HOX and MEIS1 expression and leads to release of the differentiation halt.11  Recently developed menin inhibitors that target the critical KMT2A-menin interaction have demonstrated remarkable anti-leukemia activity in preclinical studies of KMT2A-rearranged ALL and AML. Importantly, menin inhibitors also appear to have potent activity in other leukemias with high HOX gene and MEIS1 expression, including NUP98-rearranged AML and NPM1-mutant AML, and possibly in other AML subtypes harboring partial tandem duplication of KMT2A or mutations in SET2D, RUNX1, or DNMT3A.12 

Dr. Ghayas Issa and colleagues recently reported initial findings of the multi-site AUGMENT-101, a first-in-human phase 1 trial (NCT04065399) that explored the safety and dosing of the menin inhibitor revumenib (SNDX-5613), primarily in adults with relapsed/refractory KMT2A-rearranged or NPM1-mutant acute leukemias.13  Revumenib was administered orally every 12 hours as monotherapy for 28 days per cycle in two parallel dose-finding cohorts depending on concomitant use of azole antifungal prophylaxis, given the CYP3A4 metabolism of revumenib and the potential for drug interactions.

Sixty-eight patients (including eight children) were enrolled from November 2019 to March 2022 (37 in Arm A without CYP3A4 inhibitors, 37 in Arm B with CYP3A4 inhibitors). The median number of previous lines of therapy was four (range, 1-12), and nearly half of participants (31 of 68, 46%) had received prior allogeneic hematopoietic stem cell transplants. In this trial, revumenib therapy appeared to be well-tolerated overall in both cohorts of patients. Treatment-emergent adverse events included QT interval prolongation >500 ms (one adult participant with dose-limiting toxicity), nausea, febrile neutropenia, and thrombocytopenia. Consistent with the biologic mechanism of menin inhibition, eight patients (14%) experienced grade 1 or 2 differentiation syndrome, which was successfully treated with steroids or hydroxyurea. The reported overall response rate (ORR) was 55%, including a complete remission (CR)/CR with partial hematologic recovery (CRh) rate of 24%. However, somatic mutations in MEN1 (encoding the menin protein) occurred in 12 of 31 patients (38.7%) treated with revumenib, most often within two cycles, highlighting a need for additional therapeutic approaches to decrease the potential for development of rapid resistance to menin inhibition.14  Following these initial results with revumenib monotherapy, the successor AUGMENT-102 phase 1 trial (NCT05326516) is now investigating the ability of revumenib in combination with multi-agent chemotherapy in adult and pediatric patients with relapsed/refractory KMT2A-rearranged, NPM1-mutant, or NUP98-rearranged acute ALL or AML to enhance anti-leukemia activity and/or reduce differentiation syndrome complications.

Other early-phase clinical trials of menin inhibitors have recently reported exciting preliminary outcomes in adults with relapsed/refractory acute leukemias, including the KOMET-001 phase 1/2 trial of ziftomenib (KO-539; NCT04067336),15  and several other menin inhibitors are under preclinical development. The Leukemia & Lymphoma Society (LLS) PedAL/EuPAL Initiative will also explore pediatric-specific, menin inhibitor-based strategies in children with relapsed/refractory AML or ALL harboring KMT2A, NPM1, or NUP98 genetic alterations in soon-to-open phase 1 trials. These studies aim to determine safe and potentially effective pediatric dosing strategies for revumenib or ziftomenib in combination with appropriate multi-agent chemotherapy. It is hoped that results from trials in patients with relapsed leukemias will expedite swift exploration of menin inhibitor strategies in the frontline setting, particularly in infants with KMT2A-rearranged ALL who have a significant unmet clinical need.

Menin inhibition is an exciting precision medicine strategy for patients with high-risk genetic subtypes of ALL or AML. Current and planned clinical trials aim to elucidate the most effective treatments for increasing rates of leukemia remission and minimizing the development of therapeutic resistance.

Drs. Cuglievan and Tasian serve as advisors for the Leukemia & Lymphoma Society PedAL/EuPAL consortium, which is pursuing pediatric-specific early-phase clinical investigation of menin inhibitors in children with relapsed/refractory acute leukemias.

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