Introduction
The treatment landscape for acute myeloid leukemia (AML) has shifted dramatically from a morphology-based approach to one governed by molecular genetics. CPX-351, a liposomal formulation of cytarabine and daunorubicin in a fixed 5:1 molar ratio, was initially approved based on its superior overall survival (OS) compared to the standard 7+3 regimen in older patients with previously untreated, high-risk AML. However, the original trial (NCT01696084) utilized clinical and morphological definitions that have since been superseded by the World Health Organization (WHO) 5th Edition and International Consensus Classification (ICC). A critical question remained: Does the survival benefit of CPX-351 apply broadly to high-risk patients, or is it restricted to specific molecularly defined subgroups?
Background and Clinical Context
Historically, patients with secondary AML (sAML) or AML with myelodysplasia-related changes (AML-MRC) have faced dismal outcomes with conventional intensive chemotherapy. CPX-351 offered a significant breakthrough, demonstrating a median OS of 9.56 months versus 5.95 months for 7+3 in the pivotal trial. Despite this success, the heterogeneity of AML means that many patients, particularly those with TP53 mutations or complex karyotypes, still experience poor responses. As our understanding of AML genomics has advanced, it has become clear that the clinical label of ‘secondary AML’ often masks a diverse range of molecular drivers. This re-analysis by Shimony et al. sought to align the original trial data with modern genomic classifications to better guide clinical decision-making.
Study Design and Molecular Stratification
Investigators performed DNA sequencing on samples from 184 patients enrolled in the original phase 3 randomized trial. Patients were retrospectively categorized into four hierarchical molecular subgroups:
1. TP53-AML
Defined by the presence of TP53 mutations. This group was further subclassified as single-hit (TP53single) or multi-hit (TP53multi), the latter involving more than one allele alteration via mutation, deletion, or copy-neutral loss of heterozygosity.
2. DDX41-AML
Defined by mutations in the DDX41 gene, a group often associated with better prognoses.
3. AML-MR (Myelodysplasia-Related)
Defined according to the WHO 5th edition, which focuses on specific mutations (e.g., ASXL1, BCOR, EZH2, SF3B1, SRSF2, STAG2, U2AF1, or ZRSR2) rather than purely morphological or clinical history.
4. Other-AML
Patients who did not fit into the above categories.
Key Findings: Selective Benefit in AML-MR
The study revealed that the overall survival benefit observed in the original trial was not uniform across all molecular categories. The most striking finding was that the benefit of CPX-351 over 7+3 was primarily driven by the AML-MR subgroup.
Survival Disparities by Subgroup
The two-year OS varied significantly across the molecular groups: TP53-AML (7%), AML-MR (19%), other-AML (37%), and DDX41-AML (70%). In the AML-MR cohort, CPX-351 demonstrated a statistically significant improvement in median OS compared to 7+3 (9.7 months vs. 6.8 months; p=0.037). In contrast, no significant survival advantage was found for CPX-351 in the TP53-AML or ‘Other-AML’ groups.
The TP53 Allelic State
The analysis also provided deeper insights into TP53-mutated AML. The study confirmed that the allelic state—whether the mutation was single or multi-hit—was the primary prognostic factor. Patients with TP53multi mutations had a significantly worse median OS (3.8 months) compared to those with TP53single mutations (7.0 months; p=0.004). Notably, CPX-351 did not improve outcomes for either TP53-mutated group compared to 7+3, suggesting that this ultra-high-risk population requires novel therapeutic strategies beyond liposomal anthracycline/cytarabine combinations.
Transplantation: A Path to Long-term Survival
One of the most compelling aspects of the CPX-351 data has been its role as a bridge to hematopoietic cell transplantation (HCT). This re-analysis confirmed that CPX-351 significantly improved 2-year post-transplant survival (76% vs 27%; p < 0.01). However, this effect was again primarily concentrated in the AML-MR subgroup. Multivariable analysis identified both the use of CPX-351 and the ability to proceed to HCT as independent positive prognostic factors for survival in AML-MR patients.
Expert Commentary and Clinical Implications
The results of this study underscore the importance of rapid molecular profiling in the management of AML. While CPX-351 remains a standard of care for high-risk AML, clinicians should recognize that its clinical ‘magic’ is most potent in the presence of myelodysplasia-related mutations.
Mechanistic Insights
The superior efficacy of CPX-351 in AML-MR may be attributed to the liposomal delivery system’s ability to maintain the 5:1 molar ratio within the bone marrow, potentially overcoming the relative chemoresistance characteristic of secondary-type leukemic blasts. However, the lack of benefit in TP53-AML highlights the biological distinctness of this subgroup, where p53 dysfunction likely bypasses the cytotoxic mechanisms of standard nucleoside analogs and anthracyclines regardless of their delivery format.
Limitations and Future Directions
While the study provides high-quality evidence from a randomized trial, the sample size for certain subgroups (like DDX41-AML) was small. Additionally, the emergence of venetoclax-based regimens as a standard for older or unfit patients raises questions about the relative performance of CPX-351 versus non-intensive triplets or doublets in molecularly defined subsets.
Conclusion
The re-analysis of the pivotal CPX-351 trial demonstrates that the survival advantage of this liposomal formulation is selectively confined to patients with AML-MR as defined by the WHO 5th edition. For patients with TP53 mutations, CPX-351 offers no clear benefit over standard induction, emphasizing the urgent need for clinical trials investigating targeted agents or immunotherapies in this population. For patients with AML-MR, CPX-351 remains a superior induction strategy, particularly when used as a bridge to allogeneic transplantation.
Funding and ClinicalTrials.gov
The original phase 3 trial was funded by Jazz Pharmaceuticals. This molecular re-analysis was supported by institutional research funds and grants to the investigators. ClinicalTrials.gov Identifier: NCT01696084.
References
1. Shimony S, Murdock HM, Keating JH, et al. CPX-351 Selectively Benefits Patients with AML and Myelodysplasia-Related Mutations in the Pivotal Randomized Trial. Blood Adv. 2026. doi: 10.1182/bloodadvances.2025019378.
2. Lancet JE, Uy GL, Cortes JE, et al. CPX-351 (cytarabine and daunorubicin liposome for injection) versus 7+3 regimen in older patients with newly diagnosed high-risk acute myeloid leukemia: a randomized, multicenter, open-label, phase 3 trial. J Clin Oncol. 2018;36(26):2684-2692.
3. Khoury JD, Solary E, Abla O, et al. The 5th edition of the World Health Organization Classification of Haematolymphoid Tumours: Myeloid and Histiocytic/Dendritic Neoplasms. Leukemia. 2022;36(7):1703-1719.
