Abstract C156: Dasatinib targets an upregulated SRC family kinase gene in extramedullary leukemia, improving prognosis in these patients
Authors: Cunningham Isabel , Yang Jianqi , Newton Herbert B , Fisher Rory A 
Published: December 2023

Abstract
Purpose: To review outcomes of pts with extramedullary leukemic tumors (EMLT) treated with the second-generation tryrosine kinase inhibitor (TKI) dasatinib. Procedures: Reported cases of extramedullary leukemic tumors in patients treated with TKIs were reviewed and survivals elicited from authors. RNA seq and RT-PCR for lymphocyte-specific kinase (LCK) mRNA were performed on cases of EMLT in breast. Summary: Leukemic cells growing as tumors in any organ lead to treatment failure and death, even if marrow is in remission. Median survival of patients with EMLT is 5 months, unchanged for the last 50 years. Like solid cancers, EMLT are invasive and metastatic, showing desmoplastic fibrosis and invasion of adipose tissue. Traditional anti-leukemia chemo has not reliably cured EMLT in any site, but excision of primary tumors followed by adjuvant chemo has achieved remissions of &gt; 20 yrs. This suggests the benefit of removing tumor microenvironment (TME) containing cytokines and immune cells influencing tumor growth and resistance. TME is a logical target to ablate EMLT; TME is not affected by agents that kill replicating leukemia cells. RNAseq of very long-stored samples of EMLT in breast found upregulation of LCK compared to normal breast, confirmed by LCK RT-PCR analysis in 3 of 5 ALL tumors (2 Ph+ALL, 1 B-ALL) and 1 of 8 AML tumors. LCK is a target of DAS, a second-generation TKI that, like first-generation imatinab (IM), effectively controls BCR-ABL+ (Ph+) chronic myeloid leukemia (CML) marrow. However, IM cannot prevent or treat EM relapse, documented in 90 reported cases, mostly in CNS sites, with or without blastic marrow. CNS leukemia can lead to blindness, deafness, and paralysis. Responses to routine CNS therapy with RT and intrathecal or high-dose chemo +/- transplant, occur but lengthy DFS is rare. Since 2004, DAS +/- routine therapy has cleared CNS sites (meninges, brain, optic nerve) for up to 7+ yrs in Ph+ and T lymphoid leukemias. LCK is expressed diffusely in the CNS within neurons and ependymal cells. Tumors in non-CNS sites have also been cleared by DAS +/- routine therapy in pts with CML, Ph+ALL, T-ALL, and Ph+ B lymphoblastic lymphoma. Sites include skin, pancreas, stomach, testis, and epidural space, with DFS up to 9+ yrs. Among 137 of 153 DAS-treated pts with EMLT with followup after response, 23 have had progression in EM sites, while 47 were disease-free for 1 to 10 yrs (29 pts &gt; 2 yrs). Conclusions: DAS appears to be an effective agent for treatment of EMLT. LCK is a potential DAS target in both Ph+ and non-Ph+ hematologic malignancies (HM), as EM tumors occur in leukemias, lymphomas, and myeloma. DAS combined with other therapies may benefit some HM patients and improve survival. Prospective clinical studies are needed to define which patients might benefit from DAS and the role of LCK. Routine scanning by PET/CT should be conducted in HM to find clinically unrecognized EMLT and to document response.
Citation Format: Isabel Cunningham, Jianqi Yang, Herbert B Newton, Rory A Fisher. Dasatinib targets an upregulated SRC family kinase gene in extramedullary leukemia, improving prognosis in these patients [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2023 Oct 11-15; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2023;22(12 Suppl):Abstract nr C156.