scholarly journals Use of High Dose Cytarabine (HiDAC) for Post-Remission or Re-Induction Therapy Is Safe and Effective in Select Older AML Patients

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 4422-4422
Author(s):  
Jillian Lykon ◽  
Ellen Madarang ◽  
Nina Nguyen ◽  
Wenhui Li ◽  
Sunil G. Iyer ◽  
...  
Keyword(s):  
Older Adults ◽  
Febrile Neutropenia ◽  
Board Of Directors ◽  
Research Funding ◽  
Average Dose ◽  
Advisory Committees ◽  
Poor Risk ◽  
Risk Patients ◽  
Dose Reductions

Abstract Introduction A standard therapy for fit older adults (≥60 years) with acute myeloid leukemia (AML) being treated with curative intent consists of induction chemotherapy with cytarabine and an anthracycline followed by 1-4 cycles of shorter course post-remission therapy with cytarabine +/- anthracycline. Historically, HiDAC has been reserved for younger patients due to the high incidence of cytarabine-induced neurotoxicity, febrile neutropenia, and hospital re-admissions in older patients (Mayer et al. 1994). In select older adults (e.g., those with good-risk cytogenetic/molecular abnormalities, or requiring reinduction for persistent AML), the risk/benefit for HiDAC may favor its use. Real world evidence is lacking on the safety of full dose HiDAC (total 18 grams/cycle) in fit older adults in the 60-75 age range. Methods We performed a retrospective analysis of AML patients ≥60 years who received at least one cycle of HiDAC, defined as 3g/m2 every 12 hours for 6 doses, either days 1-3 or days 1, 3, 5, as post-remission therapy or primary re-induction (i.e., after failure of primary induction with 7+3 or CPX-351) between July 1, 2014 and May 28, 2021. AML risk was defined by European LeukemiaNet (ELN) guidelines. All patients had daily neurologic exams including prior to each dose of HiDAC and at the beginning of each nursing shift. The primary endpoint was tolerability, defined as average dose per cycle, rate of dose reductions, incidence of febrile neutropenia, cerebellar toxicity, and rate of hospital re-admissions. Secondary endpoints were overall survival (OS), composite complete remission (CCR) for patients treated with HiDAC re-induction, and duration of relapse-free survival (RFS) (from day 1 of treatment) in all patients. Results From July 2014 to May 2021, 34 patients ≥60-years-old were treated with HiDAC at our center. Median age at HiDAC administration was 64 (60-73) [Table 1]. Approximately half the patients were Hispanic and male and almost all (97%) had ECOG performance scores of 0-1. HiDAC was used as post-remission therapy (following 7+3-type induction in 80%) in 25 patients and as re-induction in 14. Eleven patients (32%) were ELN favorable risk, 8 (25%) were intermediate, and 15 (44%) were poor risk. For post-remission therapy, the average total dose of cytarabine per cycle was 16.6 gm/m2 (6-18 gm/m2) and the median number of cycles was 4 (1-4) [Table 2]; 6 patients (24%) required dose reductions, the most common reason being upcoming allogeneic stem cell transplant (n=4). No cerebellar toxicity was observed. Duration of neutropenia was on average 15 days (7-53) in the re-induction group and 7.5 days (1-29) in the post-remission group, with 23 post-remission patients (92%) receiving granulocyte colony stimulating factors (G-CSF). Eleven hospital readmissions occurred, most commonly (73%) for febrile neutropenia. Early mortality rates were low, with one patient on the post-remission arm and one patient on the re-induction arm dying within 30 and 60 days, respectively, both due to sepsis. Median OS was 15.8 months (95% CI 0-31.8) in patients who received post-remission HiDAC, with 44% of patients still alive with a median follow up of 17.2 months (95% CI 7.2-55.8). Favorable risk patients (n=11) receiving post-remission HiDAC had median OS of 15.8 months (95% CI 0-43.1), while intermediate/poor risk patients (n=14) had median OS of 11.3 months (95% CI 9.3-13.2) [p=0.53]. Median OS was 9.8 months (95% CI 2.5-17.1) in patients who received HiDAC re-induction, with 29% of patients still alive with a median follow up of 28.6 months (95% CI 16.6-39.9) [Table 3]. Five patients (36%) achieved CCR after HiDAC re-induction, all of whom went on to receive post-remission HiDAC. Median RFS was 8.5 months for re-induction and 8.8 months for post-remission patients [Table 3]. Conclusions HiDAC (18 grams) can be safely given to select patients over age 60. Critical to tolerability is rigorous screening of "fitness," limiting the upper age receiving HiDAC to 75, ensuring adequate renal function and euvolemia, and advances in supportive care. Encouraging survival outcomes were observed in older adults receiving post-remission or re-induction HiDAC, independent of ELN risk. Figure 1 Figure 1. Disclosures Bradley: AbbVie: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees. Sekeres: Takeda/Millenium: Membership on an entity's Board of Directors or advisory committees; BMS: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees. Watts: Rafael Pharmaceuticals: Consultancy; Genentech: Consultancy; Bristol Myers Squibb: Consultancy; Takeda: Consultancy, Research Funding; Jazz Pharmaceuticals: Consultancy; Aptevo Therapeutices: Research Funding.

ABVD Versus Escalated Beacopp in Advanced Stage Hodgkin's Lymphoma: Results from a Retrospective, Multicenter European Study

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 1565-1565 ◽  
Author(s):  
Patrizia Mondello ◽  
Irene Dogliotti ◽  
Jan-Paul Bohn ◽  
Federica Cavallo ◽  
Simone Ferrero ◽  
...  
Keyword(s):  
High Risk ◽  
Board Of Directors ◽  
Research Funding ◽  
Advanced Stage ◽  
Advisory Committees ◽  
Free Survival ◽  
High Risk Patients ◽  
Risk Patients

Purpose: Hodgkin's lymphoma (HL) is a highly curable disease even in advanced-stage, with >90% of long-term survivors. Currently, the standard of care is ABVD (doxorubicin, etoposide, vinblastine and dacarbazine), as it is less toxic and as effective as other more intensive chemotherapy regimens. Alternatively, BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine and prednisone) has been proposed as front-line intensified regimen with a better initial disease control and prolonged time to relapse when compared to ABVD. However, this advantage is associated with higher rates of severe hematologic toxicity, treatment-related deaths, secondary neoplasms and infertility. To date, the debate regarding which regimen should be preferred as first line for advanced-stage HL is still ongoing. To shed some light on this open question we compared efficacy and safety of both regimens in clinical practice. Patients and Methods: From October 2009 to October 2018, patients with HL stage III-IV treated with either ABVD or BEACOPP escalated (BEACOPPesc) were retrospectively assessed in 7 European cancer centers. Results: A total of 372 consecutive patients were included in the study. One-hundred and ten patients were treated with BEACOPPesc and 262 with ABVD. The baseline characteristics of the two groups did not differ significantly, except for a higher rate of high-risk patients in the BEACOPPesc group in contrast to the ABVD one (47% vs 18%; p= 0.003). Complete response rate (CR) assessed by PET imaging at the end of the second cycle was 67% and 78% for the ABVD and BEACOPPesc group (p= 0.003), respectively. Thirteen patients of the ABVD group achieved stable disease (SD) and 6 had a progression disease (PD). On the other hand, 4 of the patients in the BEACOPPesc group progressed, another 2 interrupted therapy because life-threatening toxicity. At the end of the therapy, CR was 76% in the ABVD group and 85% in the BEACOPPesc group (p= 0.01). A total of 20% patients in the ABVD group and 14% patients in the BEACOPPesc group received consolidation radiotherapy on the mediastinal mass at the dose of 30Gy. After radiotherapy, the number of patients with CR increased to 79% and 87% in the two groups (p= 0.041), respectively. Thirty-nine patients (35%) in the BEACOPPesc group required dose reduction of chemotherapy due to toxicity compared to 12 patients (5%; p= <0.001) in the ABVD group. Overall, the rate of severe toxicities was higher in the BEACOPPesc group in comparison with the ABVD cohort. In particular, there was a significant increased frequency of acute grade 3-4 hematologic adverse events (neutropenia 61% vs 24%; anemia 29% vs 4%; thrombocytopenia 29% vs 3%), febrile neutropenia (29% vs 3%), severe infections (18% vs 3%). Myeloid growth factors were administered to 85% and 59% of patients in the BEACOPPesc group compared to the ABVD group. Blood transfusions were required in 51% and 6% of patients in the BEACOPPesc group compared to the ABVD cohort. Progression during or shortly after treatment occurred in 5 patients in the BEACOPPesc group (4%) and in 16 patients in the ABVD group (6%; p= 0.62). Among the 96 patients who achieved a CR after BEACOPPesc and radiotherapy, 8 relapsed (8%), compared to 29 of 208 patients in the ABVD group (14%; p= 0.04). At a median follow-up period of 5 years, no statistical difference in progression free survival (PFS; p=0.11) and event-free survival (EFS; p=0.22) was observed between the BEACOPPesc and ABVD cohorts. Similarly, overall survival (OS) did not differ between the two groups (p=0.14). The baseline international prognostic score (IPS <3 vs ≥ 3) significantly influenced the EFS with an advantage for the high-risk group treated with BEACOPPesc (Figure 1A; p=0.03), but not the PFS (Figure 1B; p=0.06) and OS (Figure 1C; p=0.14). During the follow-up period, in the BEACOPPesc group one patient developed myelodysplasia and one acute leukemia. Second solid tumors developed in one patient in the ABVD group (lung cancer) and one in BEACOPPesc group (breast cancer). Conclusion: We confirm that the ABVD regimen is an effective and less toxic therapeutic option for advanced-stage HL. Although BEACOPP results in better initial tumor control especially in high-risk patients, the long-term outcome remains similar between the two regimens. Disclosures Ferrero: EUSA Pharma: Membership on an entity's Board of Directors or advisory committees; Servier: Speakers Bureau; Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Gilead: Speakers Bureau. Martinelli:BMS: Consultancy; Pfizer: Consultancy; ARIAD: Consultancy; Roche: Consultancy; Novartis: Consultancy. Willenbacher:European Commission: Research Funding; Takeda: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Myelom- und Lymphomselbsthilfe Österreich: Consultancy, Honoraria; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Gilead Science: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; IQVIA: Membership on an entity's Board of Directors or advisory committees; Merck: Consultancy, Membership on an entity's Board of Directors or advisory committees; oncotyrol: Employment, Research Funding; Bristol-Myers Squibb: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Fujimoto: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Sanofi: Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Tirol Program: Research Funding; Abbvie: Consultancy, Honoraria; Sandoz: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees.

Global DNA Methylation Analysis Identifies Key Pathway Differences Between Poor (Low OCT-1 Activity) and Standard Risk CP-CML Patients At Diagnosis

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 3730-3730
Author(s):  
Dale B. Watkins ◽  
Chung Hoow Kok ◽  
Richard J. D'Andrea ◽  
Timothy P. Hughes ◽  
Deborah L. White
Keyword(s):  
Dna Methylation ◽  
Board Of Directors ◽  
Research Funding ◽  
Global Dna Methylation ◽  
Advisory Committees ◽  
Poor Risk ◽  
Normal Individuals ◽  
Risk Patients ◽  
Dna Methylation Analysis ◽  
Standard Risk

Abstract Abstract 3730 Background: DNA methylation, specifically CpG methylation, is an essential mediator of epigenetic gene expression which is of vital importance to many biological processes and human malignancies. DNA hypermethylation has been previously described in a small number of genes in chronic myeloid leukemia (CML); however, current published studies have only examined the methylation status of selected genes, often based on the results of studies in other malignancies. Therefore, the global DNA methylation profile of chronic phase-CML (CP-CML) remains poorly understood, as does the impact of the epigenome on patient response to tyrosine kinase inhibitors (TKIs) including imatinib. The organic cation transport-1 (OCT-1) protein is the major active protein involved in imatinib transport, and we have previously demonstrated that measuring its function in leukemic mononuclear cells, expressed as OCT-1 activity (OA), in patient cells prior to imatinib therapy, provides a strong prognostic indicator. Notably, very low OA (poor risk cohort) is associated with patients at significant risk for poor molecular response, mutation development and leukemic transformation on imatinib therapy. Therefore, it is of particular interest to ascertain whether epigenetic changes are distinct and potentially biologically relevant in these poor risk patients. Aim: To investigate the global DNA methylation profile in CP-CML patients with a particular focus on poor risk patients (very low OCT-1 activity), and to ascertain whether aberrant epigenetic programming may underlie their poor response. Method: Cells were isolated from the blood of 55 CP-CML patients at diagnosis and 5 normal individuals. CP-CML patients were classified according to their OA values, with 29 classified as poor (very low OA) and 26 standard risk (high OA). Whole genome DNA methylation analysis was performed using the Illumina Infinium® HumanMethylation450 BeadChip. Analysis of array data was performed with R v2.15.0, using the minfiBioconductor package. Results: The methylation profile of CP-CML was significantly different to that of normal individuals, as shown in Table 1. GeneGo enrichment analysis revealed a significant enrichment in CML for genes known to be involved in other leukemias (p=4.92e−26) particularly AML and CLL, suggesting similar pathways may be under epigenetic control in CML. A significant number of polycomb group (BMI1 and EZH2) target genes were also identified, suggesting the likely involvement of this pathway in CML. Table 1: Summary of significant CpGs and corresponding genes when comparisons of CP-CML to normal individuals, and poor to standard risk patients, are made using methylation profiles. A significant difference was also observed when the methylation profiles of poor and standard risk CP-CML patients were analysed (Table 1). GeneGo analysis again identified polycomb group (SUZ12 and EZH2) target enrichment and significant enrichment of NOTCH, Hedgehog and WNT signalling (p=7.93e−9, p=2.42e−5 and p=3.66e−5 respectively) in poor risk patients, indicating these pathways may play a significant role in the unfavourable responses observed in many of these patients. Of particular interest were the ten CpGs where a fold change >4 was observed between the methylation profiles of poor and standard risk patients. Using the Prediction Analysis of Microarrays supervised learning algorithm, a classifier for patient OA prediction based on this 10 CpG signature was evaluated. This classifier had an overall accuracy of 94% (sensitivity: 95%, specificity: 93%). Conclusion: We present a comprehensive global DNA methylation analysis of CP-CML that indicates significant and widespread changes to the CML epigenome, compared with that of normal individuals. Importantly, we have generated a classifier, which identifies the poor risk patient subgroup (very low OA) with 94% accuracy. Validation of this classifier is currently in progress. The epigenetic changes identified here may contribute to CML pathogenesis, and also to the response heterogeneity observed between CP-CML patients treated with TKI therapy. Disclosures: Hughes: Novartis Oncology: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; BMS: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Ariad: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. White:Novartis Oncology: Honoraria, Research Funding; BMS: Research Funding; CSL: Research Funding.

A Phase I Study of Selinexor in Combination with Daunorubicin and Cytarabine in Patients with Newly Diagnosed Poor-Risk Acute Myeloid Leukemia

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 4040-4040 ◽  
Author(s):  
Kendra L. Sweet ◽  
Rami S. Komrokji ◽  
Eric Padron ◽  
Christopher L Cubitt ◽  
Leyla Khavarian ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Overall Survival ◽  
Febrile Neutropenia ◽  
Phase I ◽  
Board Of Directors ◽  
Induction Chemotherapy ◽  
Research Funding ◽  
Newly Diagnosed ◽  
Advisory Committees ◽  
Poor Risk

Abstract Background: Induction chemotherapy for older adults with poor-risk AML has remained largely unchanged over the past 40 years, with complete remission (CR) rates ranging from 20-50%. Five-year overall survival (OS) ranges from 2-15%, illustrating the need for novel treatment strategies. Selinexor is an oral selective inhibitor of nuclear export (SINE) that has shown promising single agent activity in AML (NCT01607892). By inhibiting the primary export protein, XPO1, selinexor localizes tumor suppressor proteins to the nucleus leading to their activation. Furthermore, selinexor inhibits DNA damage repair, rationalizing its use in combination with DNA damaging agents. Preclinical data from our institution suggest Selinexor synergizes with daunorubicin when used in CD34+ AML cells. Here we report early results from a phase I clinical trial with selinexor plus cytarabine and daunorubicin in patients (pts) with newly diagnosed, poor-risk AML. Methods: This is a single institution phase I clinical trial with a 3+3 design and an expansion phase at the maximum tolerated dose (MTD)/recommended phase 2 dose (RP2D). The primary endpoint was to determine the MTD/RP2D of selinexor. Secondary endpoints included rate of CR/CRi, overall survival (OS), relapse free survival (RFS) and toxicity assessment. Eligible pts had a diagnosis of previously untreated AML (non-M3), with poor-risk features based on karyotype, mutational profile, secondary AML (sAML) arising from an antecedent hematologic disorder (AHD) or prior chemotherapy, or age ≥60 years. Prior treatment for an AHD was allowed. Induction included daunorubicin 60 mg/m2/day on days 1-3 and cytarabine 100 mg/m2/day CIVI days 1-7 (7+3) with two dose cohorts of selinexor: 60 mg and 80 mg PO. Selinexor was given on days 1, 3, 8, 10, 15 and 17. Re-induction with 5+2 plus selinexor was allowed if indicated. Once in CR, pts received 1-2 cycles of consolidation with 5+2 plus selinexor followed by maintenance selinexor on days 1 and 8 of a 21 day cycle for up 12 months. Selinexor was given at the same dose for all phases of the study. Pts could proceed to hematopoietic stem cell transplant (HCT) at any time after achieving CR. Results: 21 pts (14 (67%) M / 7 (33%) F) were enrolled from June 2015 to June 2016. Median age was 68 years (range 37-77); 18 (86%) were age ≥60 and 9 (43%) were age ≥70. Nineteen (90%) pts were considered poor-risk (unrelated to age), and two (10%) were eligible due to age ≥60 only. Each cohort enrolled 4 pts, and 13 pts were enrolled in the expansion. One pt in each cohort was replaced before completing the 28-day DLT period; one withdrew consent and the second died on day 23 from acute renal failure related to antibiotics. At data cutoff, 18 pts were included in the safety and efficacy assessment. Three additional patients have not completed induction. The early death rate (≤60 days) was 4.8%. No DLTs occurred in the dose-escalation cohorts. The MTD of selinexor was not reached and the RP2D was 80 mg twice weekly. The most common grade 3/4 non-hematologic, treatment emergent AEs in all pts were febrile neutropenia (56%), diarrhea (22%), hyponatremia (22%) and sepsis (17%). Nine patients (50%) achieved CR/CRi. Of the 14 pts treated at the RP2D (selinexor 80 mg), 6 (43%) achieved CR/CRi. In the entire cohort, the median age of the responders was 69 (61-77) and 4 (44%) were age ≥70. Seven (78%) were considered high-risk. Four (44%) had sAML. Two (22%) required a second induction. The median time to response was 47 days (range 28-77) At a median follow up of 8.7 months in the 9 responding pts, 7 (78%) remain in remission. Overall, 4 pts (44%) underwent HCT, and 1 (11%) relapsed just prior to HCT. Conclusion: Results from this phase I trial suggest that selinexor 80mg PO twice weekly can be safely administered in combination with induction chemotherapy using cytarabine and daunorubicin to pts with poor-risk AML, including older pts. The most prominent AEs were febrile neutropenia, diarrhea and hyponatremia. Response rates are encouraging and many elderly pts proceeded to transplant, suggesting this regimen warrants further investigation in this challenging population. Disclosures Sweet: Karyopharm: Honoraria, Research Funding; Incyte Corporation: Research Funding; Novartis: Consultancy, Speakers Bureau; Ariad: Consultancy, Speakers Bureau; Pfizer: Speakers Bureau. Komrokji:Novartis: Consultancy, Speakers Bureau; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding. Sullivan:Karyopharm: Research Funding. Shah:Incyte: Research Funding; Rosetta Genomics: Research Funding; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Baxalta: Membership on an entity's Board of Directors or advisory committees; Bayer: Honoraria; Pfizer: Honoraria.

Differential Lineage Involvement Between Very Low and Higher OCT-1 Activity Chronic-Phase CML Patients

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 1675-1675
Author(s):  
Dale B. Watkins ◽  
Chung Hoow Kok ◽  
Timothy P. Hughes ◽  
Cassandra Slader ◽  
Richard D'Andrea ◽  
...  
Keyword(s):  
Board Of Directors ◽  
Research Funding ◽  
Chronic Phase ◽  
Cell Populations ◽  
Molecular Response ◽  
Advisory Committees ◽  
Poor Risk ◽  
The Poor ◽  
Risk Patients ◽  
Standard Risk

Abstract Abstract 1675 Background: While the use of tyrosine kinase inhibitors (TKI) for the treatment of chronic-phase chronic myeloid leukemia (CP-CML) has dramatically improved patient survival, clinical responses are heterogeneous. Approximately 28% of imatinib (IM), 55% of nilotinib and 46% of dasatinib treated patients achieve major molecular response (MMR) by 12 months. We have previously demonstrated that the functional activity of IM's major active transport protein, OCT-1 (OCT-1 activity, OA), performed on patient cells prior to IM commencement, provides a strong prognostic indicator of response. Importantly, very low OA (bottom 25%, poor risk cohort) is associated with CP-CML patients at significant risk for poor molecular response, mutation development and leukemic transformation. Furthermore, we have also demonstrated in the TIDEL II study that patients with very low OA frequently fail to achieve a MMR when switched to nilotinib. Identifying patients at diagnosis that are more likely to respond sub-optimally to TKI is critical to enable therapeutic intervention aimed at overcoming poor response. To date however, this assay is not widely used because of the requirement for live cells and 14-C IM. Aim: To determine the variation in CP-CML patient immunophenotype at diagnosis using the more widely transferable technique of flow cytometry and relate this to the patient OA characteristics at presentation. Method: Immunophenotyping of PB-MNCs from 27 newly diagnosed CP-CML patients [10 very low OA (poor risk), 17 higher OA (standard risk)] was undertaken using a 39-marker antibody panel. Cell surface antigen profiles were determined by multicolour flow cytometry with the Beckman Coulter FC500. Statistical analysis was performed using GraphPad Prism. Further analysis was performed using gene set enrichment analysis (GSEA) for comparison to publicly available microarray datasets. Results: Differential lineage involvement was identified between the poor risk and standard risk OA patients. A number of cell populations; CD45negGlyA+ (erythroid), CD14+ (monocytic), CD20+ (B-cell) and ITGB5+ (selective monocyte-associated expression and cell adhesion) displayed significant variation between these two patient groups. The CD45negGlyA+ population was significantly increased in poor risk patients (p=0.022), while the CD14+, CD20+ and ITGB5+ cell populations also displayed significantly increased mean fluorescence intensity (MFI) in the poor risk patients (p=0.029, p=0.029 and p=0.042 respectively), as shown in Table 1. Discussion: Our previous gene expression profiling of CP patients with poor or standard risk OA revealed significant lineage differences in these two groups based on GSEA. This preliminary data demonstrated enrichment of monocytic and erythroid cell populations in the poor risk patients, whereas the granulocytic cell population was enriched in the standard risk patients. Additionally the monocyte-associated gene ITGB5, which was initially identified from the microarray results, was also validated by the immunophenotyping. Thus, both the gene expression profiling and immunophenotyping results support differential lineage involvement in CP-CML patients. We postulate that poor risk CP-CML is characterised by an increased erythroid and monocytic component, with possibly increased cellular adhesion characteristics. These differences in cellular characteristics may allow the development of a predictive classifier that will enable quick and accurate identification of these patient groups. Importantly this analysis may provide a valuable tool for dissecting underlying disease biology which likely contributes to the response heterogeneity observed in TKI-treated CP-CML patients. Ultimately, accurate identification of poor risk patients will enable tailored therapeutic intervention, improving the poor outcomes currently observed for this patient cohort. Disclosures: Hughes: Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; BMS: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Ariad: Honoraria, Membership on an entity's Board of Directors or advisory committees. Slader:Novartis Pharmaceuticals: Employment, Equity Ownership. White:Novartis Pharmaceuticals: Research Funding; BMS: Research Funding.

scholarly journals Improving Risk Assessment of AML with a Precision Genomic Strategy to Assess Mutation Clearance

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 5277-5277
Author(s):  
Meagan Jacoby ◽  
David H Spencer ◽  
Emma Hughes ◽  
Robert S Fulton ◽  
Michelle O'Laughlin ◽  
...  
Keyword(s):  
Board Of Directors ◽  
Research Funding ◽  
Time Frame ◽  
Intermediate Risk ◽  
Advisory Committees ◽  
Free Survival ◽  
Post Induction ◽  
Flow Cytometric ◽  
Risk Patients

Abstract The persistence of leukemic mutation(s) in AML patients who have achieved a morphologic complete remission (CR) after intensive induction chemotherapy is a strong predictor of early relapse and reduced overall survival (OS) (Klco JAMA, 2015; Morita, J Clin Oncol 2018; Jongen-Lavrencic, NEJM, 2018). There is no clinical consensus as to the optimal consolidation therapy for the ~50% of patients with intermediate-risk AML. The median relapse-free survival (RFS) for patients ≤60 years with ELN intermediate-risk disease is 0.8 years to 1.2 years, with a median OS of 1.2-2.1 years (Mrozek, J Clin Oncol, 2012). We have shown that intermediate-risk patients who clear all leukemia-associated mutations (LAMs) to a variant allele fraction (VAF) of <2.5% in first morphologic CR have a median event-free survival of 25.6 months, vs 8.8 months if they do not (HR 3.32). Median overall survival is 46.8 months if all LAMs are cleared, vs 19.3 months if they are not (HR 2.88). We hypothesized that improved post-remission risk stratification using LAM clearance can further refine risk assessment and optimize alloHCT decisions by identifying patients at lower risk of relapse, who might be expected to do well with standard chemotherapy. Here, we report the development of a pipeline to prospectively determine the persistence of LAMs after remission-induction, and return results in a clinically actionable time-frame. We perform enhanced exome sequencing (EES) of paired skin or buccal swab (normal tissue) and bone marrow DNA to comprehensively identify all LAMs at diagnosis (Day 0) and to assess their clearance post-induction (~Day 30). EES data are generated using a CLIA-compliant assay in the CLIA-licensed environment (CLE) lab at the McDonnell Genome Institute, and results are returned to the treating physician. Intermediate risk patients ≤60 years with clearance of all LAMs (VAFs <2.5%) are assigned to receive consolidation with high-dose cytarabine (HiDAC) (Cohort A). Patients with persistence of any mutation at a VAF ≥ 2.5% are assigned to the investigator's choice arm, and are treated with HiDAC and/or alloHCT at the discretion of the treating physician (Cohort B). This stratification is part of an ongoing clinical protocol (NCT02756962) whose primary objective is to determine whether the RFS of patients who have cleared all LAM(s) post-induction (VAFs <2.5%) and are treated with HiDAC alone (Cohort A) is significantly higher than expected from a historical intermediate risk group. Measurable residual disease testing by "difference from normal" flow cytometry (lower level of detection of 0.02%, Hematologics, Seattle WA) post-induction will be correlated with clearance or persistence of mutations and clinical outcomes. For the 23 patients sequenced to date, the mean turnaround time to issue sequencing results to the treating physician was 24 days from the time of the remission biopsy. All 23 patients had detectable LAMs at presentation (mean 28 per patient, range, 6 to 43) that could be used to track persistent disease in the day 30 remission sample. Eleven patients (48%) cleared all LAMs and received HiDAC only (Cohort A). There was no flow cytometric evidence of residual AML in Cohort A. Twelve patients (52%) had persistent LAMs (Cohort B, investigator's choice). The number of persistent leukemia-associated variants present in Cohort B ranged between 1 and 14. Surprisingly, 9 of the 12 patients with persistent LAMs by sequencing had no flow cytometric evidence of residual leukemia. Seven of 12 patients on the investigator's choice arm have received an alloHCT, and none have relapsed to date. The median follow-up for all subjects is 378 days (range, 59-683). Neither the median RFS (Fig. 1A) nor the median OS (Fig. 1B) has been reached for either cohort. While preliminary, these results suggest that patients who clear all LAMs to a VAF of <2.5% may have durable responses with HiDAC alone. The encouraging RFS seen in the investigator's choice arm (Cohort B) may reflect the decision to recommend transplant "upfront" in CR1 for patients who have molecular persistent disease. In summary, identifying persistent LAMs after induction chemotherapy is feasible in an actionable time-frame. Early data suggest that using LAM clearance post-induction may improve current risk-stratification for intermediate-risk AML. Accrual of patients and continued follow-up are ongoing. Disclosures Jacoby: NovoNordisk: Consultancy; Celgene: Speakers Bureau. Loken:Hematologics, Inc: Employment, Equity Ownership. Schroeder:Amgen Inc.: Consultancy, Membership on an entity's Board of Directors or advisory committees. Uy:GlycoMimetics: Consultancy; Curis: Consultancy. Vij:Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Bristol-Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Jansson: Honoraria, Membership on an entity's Board of Directors or advisory committees; Jazz Pharmaceuticals: Honoraria, Membership on an entity's Board of Directors or advisory committees; Karyopharma: Honoraria, Membership on an entity's Board of Directors or advisory committees; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Kahl:Gilead: Consultancy; AstraZeneca: Consultancy; Genentech: Consultancy; CTI: Consultancy; ADC Therapeutics: Consultancy; Abbvie: Consultancy; Seattle Genetics: Consultancy; Acerta: Consultancy; Juno: Consultancy; Celgene: Consultancy.

scholarly journals Oral Azacitidine (CC-486) Plus R-CHOP in Patients with High-Risk or Previously Untreated Diffuse Large B-Cell Lymphoma, Grade 3B Follicular Lymphoma, or Transformed Lymphoma (AFT-08)

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 2964-2964 ◽  
Author(s):  
Peter Martin ◽  
Nancy L. Bartlett ◽  
Julio C. Chavez ◽  
John L. Reagan ◽  
Sonali M. Smith ◽  
...  
Keyword(s):  
High Risk ◽  
Febrile Neutropenia ◽  
Board Of Directors ◽  
Dose Escalation ◽  
Research Funding ◽  
B Cell Lymphoma ◽  
Advisory Committees ◽  
Equity Ownership ◽  
Grade 3

Abstract Background: For patients with diffuse large B-cell lymphoma (DLBCL), resistance to standard R-CHOP immunochemotherapy remains an urgent and unmet clinical challenge. Aberrant DNA methylation likely contributes to chemoresistance and may represent a therapeutic target.In a phase I study of R-CHOP plus subcutaneous azacitidine, a DNA methyltransferase inhibitor, complete responses (CRs) were achieved in 10/11 high-risk DLBCL patients (Clozel et al. Cancer Discovery 2013), providing the rationale for this study of oral azacytidine (CC-486) plus R-CHOP. Previously reported data from the dose escalation phase of this study demonstrated promising response rates in patients with high-risk DLBCL (Martin et al. Blood 2017). Here, we present results from both the dose escalation and expansion phases after substantially longer follow-up. Methods: CC-486-DLBCL-001 (NCT02343536) is a phase I, open-label, multicenter study of CC-486 plus standard R-CHOP in patients with previously untreated DLBCL, grade 3B follicular lymphoma (FL), or transformed FL. Eligible patients were aged ≥18-80 years with no active viral hepatitis, had an International Prognostic Index (IPI) score ≥2 or DLBCL double-positive for BCL2 and c-MYC, an Eastern Cooperative Oncology Group performance status ≤2, and Ann Arbor stage II-IV disease. Patients in the dose escalation phase were enrolled sequentially into 4 dose cohorts of CC-486 (100, 150, 200, and 300 mg) using the time-to-event continual reassessment method. Additional patients were enrolled in the expansion phase to evaluate preliminary efficacy. Patients received up to six 21-day cycles. CC-486 was administered for 7 days before initiation of R-CHOP and on days 8-21 of cycles 1-5. Granulocyte-colony stimulating factor was mandated by protocol and anti-emetics were standard treatment. The primary objectives were to determine safety (per NCI CTCAE v4.03) and the recommended phase 2 dose (RP2D) of CC-486 in combination with standard R-CHOP. Secondary endpoints included pharmacokinetics and preliminary efficacy per the International Working Group criteria (Cheson et al.J Clin Oncol 2014). Results: Fifty-nine patients were enrolled as of May 31, 2018, including 40 treated at the RP2D of CC-486 300 mg. The median age in the overall population was 66 years (range, 25-80), 76% were aged >60 years, 59% were male, and 59% had an IPI score ≥3. Fifty-four patients (92%) completed all 6 planned cycles of study treatment. Thirteen patients (22%) had CC-486 dose reductions because of adverse events (AEs). Two patients discontinued CC-486 due to AEs: febrile neutropenia (n=1; 150 mg) and sepsis (n=1; 300 mg). The most common AEs were gastrointestinal, which were mainly grade 1/2; hematologic AEs were the most common grade 3/4 toxicity (Table 1). Grade 3/4 AEs related to CC-486 occurred in 36 (61%) patients, most commonly neutropenia (41%) and febrile neutropenia (20%). Febrile neutropenia was more common among older patients (9/15 patients with this AE were aged >70 years) and those with IPI scores ≥3 versus ≤2 (31% vs 17%) but was not correlated with CC-486 dose. One patient died during the study (acute respiratory failure possibly related to study treatment). All patients were evaluable for response. The overall response rate was 95%, with 52 patients (88%) achieving a CR; response rates were generally similar in patients with IPI scores ≥3 and ≤2 and in patients treated at the RP2D (Table 2). Median progression-free survival (PFS) was not reached (median follow-up of 12 months); estimated 1-year PFS rates were similar in the overall population (86%) and in patients with IPI scores ≥3 (84%) and ≤2 (89%). Conclusions: Epigenetic priming with CC-486 before R-CHOP demonstrated promising clinical activity in patients with high-risk, previously untreated DLBCL, transformed FL, or grade 3B FL. AEs were generally consistent with the known safety profile of azacitidine and toxicities associated with R-CHOP. These results support further investigation of oral azacitidine (CC-486) in combination with R-CHOP, including patients with high-risk disease. Disclosures Martin: Gilead: Consultancy; Janssen: Consultancy; Kite: Consultancy; AstraZeneca: Consultancy; Seattle Genetics: Consultancy; Bayer: Consultancy. Bartlett:Astra Zeneca: Research Funding; Forty Seven: Research Funding; Celgene: Research Funding; Genentech: Research Funding; Bristol-Meyers Squibb: Research Funding; Novartis: Research Funding; ImaginAB: Research Funding; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Gilead: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; KITE: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Affimed: Research Funding; Pharmacyclics: Research Funding; Millennium: Research Funding; Seattle Genetics: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Merck & Co: Research Funding; Pharmacyclics: Research Funding; Acerta: Membership on an entity's Board of Directors or advisory committees; Janssen: Research Funding; Novartis: Research Funding; Immune Design: Research Funding. Chavez:Merck: Research Funding; Kite: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Genentech: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Janssen: Speakers Bureau; Humanigen: Consultancy. Reagan:Alexion: Honoraria; Takeda Oncology: Research Funding; Pfizer: Research Funding. Smith:Portola: Honoraria; BMS: Consultancy. LaCasce:Seattle Genetics: Consultancy, Honoraria; Humanigen: Consultancy, Honoraria; Bristol-Myers Squibb: Other: Data safety and monitoring board; Research to Practice: Speakers Bureau. Jones:Celgene: Employment, Equity Ownership. Drew:Celgene Corp.: Employment. Wu:Celgene: Employment, Equity Ownership. Cerchietti:Celgene: Research Funding; Weill Cornell Medicine: Employment. Leonard:ADC Therapeutics: Consultancy; Karyopharm: Consultancy; MEI Pharma: Consultancy; Bayer: Consultancy; Pfizer: Consultancy; Genentech/Roche: Consultancy; BMS: Consultancy; Juno: Consultancy; Celgene: Consultancy; Biotest: Consultancy; Novartis: Consultancy; AstraZeneca: Consultancy; Gilead: Consultancy; Sutro: Consultancy; United Therapeutics: Consultancy.

Extended Follow-up of the Multi-Center Multi-National Prospective Cohort Study That Derived the “Men Continue and HERDOO2” Clinical Decision Rule Which Identifies Low Risk Patients Who May Be Able to Discontinue Oral Anticoagulants (Oac) 5-7 Months After Treatment for Unprovoked Venous Thromboembolism (VTE).

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 451-451 ◽  
Author(s):  
Marc Rodger ◽  
Michael J. Kovacs ◽  
Susan Kahn ◽  
Phil Wells ◽  
David Anderson ◽  
...  
Keyword(s):  
High Risk ◽  
Board Of Directors ◽  
Research Funding ◽  
Low Risk ◽  
Advisory Committees ◽  
High Risk Women ◽  
Risk Patients ◽  
Recurrent Vte ◽  
Annual Risk

Abstract Abstract 451 Introduction: To continue or discontinue OAC after 6 months of therapy for VTE is one of the most important unanswered questions in VTE management. In 2007, we developed a clinical decision rule to identify low risk patients with unprovoked VTE who could safely discontinue OAC after 5-7 months of therapy. This clinical decision rule was developed from a large prospective cohort study of patients with unprovoked VTE who discontinued anticoagulants after 5-7 months of OAC and were subsequently followed for a mean of 18 months for recurrent VTE. The “MEN continue and HERDOO2” rule states that men and high risk women should continue anticoagulants indefinitely after unprovoked VTE. High risk women are women with ≥2 of the following 1)Hyperpigmentation, Edema or Redness (HER) on exam in either leg, 2)Vidas D-Dimer >250, 3)Obesity- BMI >30 or 4)Older age over 65. Given that the OAC treatment decision is a long-term treatment decision that needs to be counter-balanced with long-term bleeding risk from OAC (1-3% annual risk of major hemorrhage) it is important to determine long-term risks of recurrent VTE in unprovoked VTE patients, high risk patients and low risk patients. Objective: We sought to confirm that the risk of recurrent VTE in high risk patients remains elevated and conversely that the risk remains low in low risk women over longer term follow-up. Methods: Multi-centre prospective cohort study of first unprovoked VTE patients who had potential predictors collected while on OAC (including D-Dimer) enrolled from 2001 to March 2006. Patients were excluded if they had: 1) recurrent unprovoked VTE, 2) known high risk thrombophilia or 3) no consent. Symptomatic suspected VTE during subsequent follow-up (up to july 2009) off of OAC was investigated with reference to baseline imaging and then independently adjudicated. Results: 646 participants were enrolled in 11 centers. At enrolment, mean age of 53 (range 17-95) and 49% were female. During a mean 3.1 years (range 0.01-6.5) of follow-up, 131/512 suspected VTE were adjudicated as recurrent VTE resulting in an annual risk of recurrent VTE of 6.7% (95% CI 5.5-7.6%) in patients with unprovoked VTE. Men had a 9.9% (95% CI 8.3-11.8%) annual risk of recurrent VTE. High risk women with 2 or more HERDOO points had an annual risk of recurrent VTE of 8.3% (95%CI 5.7-11.3%). Low risk women (1 or 0 HERDOO points) had 1.3% (95% CI 0.5-2.8%) annual risk of recurrent VTE compared to 9.5% (8.1-11.0%) annual risk of recurrent VTE in high risk patients (men and high risk women). Conclusions: Men and high risk women with unprovoked VTE should be considered for long-term OAC therapy given a high risk of recurrent VTE over 3 year follow-up . Women with a low HER DOO 2 score may be able to safely discontinue anticoagulants. Disclosures: Rodger: Bayer: Research Funding; Leo Pharma: Research Funding; Pfizer: Research Funding; Boehringer Ingelheim: Membership on an entity's Board of Directors or advisory committees; Biomerieux: Research Funding; GTC Therapeutics: Research Funding. Crowther:BI: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Bayer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Honoraria, Research Funding; Leo Pharma: Consultancy, Honoraria, Research Funding; Sanofi-Aventis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Artisan Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees.

scholarly journals KD025 for Patients with Chronic Graft-Versus-Host Disease (cGVHD) - Long-Term Follow-up of a Phase 2a Study (KD025-208)

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 872-872 ◽  
Author(s):  
Madan Jagasia ◽  
Amandeep Salhotra ◽  
Carlos R. Bachier ◽  
Behyar Zoghi, MD, PhD, FACP ◽  
Aleksandr Lazaryan ◽  
...  
Keyword(s):  
Board Of Directors ◽  
Median Duration ◽  
Systemic Therapy ◽  
Research Funding ◽  
Advisory Committees ◽  
Meaningful Improvement ◽  
Grade 3 ◽  
Dose Reductions ◽  
Fund Research

Introduction: cGVHD exhibits both autoimmune and fibrotic features across multiple organ systems. KD025 is an orally available Rho-associated coiled-coil kinase 2 (ROCK2) selective inhibitor that (1) decreases human T cell IL-21 and IL-17 secretion via STAT3, IRF4 and RORγt regulation; (2) increases percentages and function of Foxp3+ T regulatory cells via a STAT5-dependent mechanism; and (3) reverses established cGVHD in 2 distinct preclinical models. KD025 modulates the immune system by shifting the Th17/Treg balance towards homeostasis. Methods: KD025-208 enrolled 3 sequential cohorts (C) (C1: 200 mg QD, C2: 200 mg BID and C3: 400 mg QD) of patients (pts) with cGVHD after 1-3 prior lines of systemic therapy. Treatment is in 28-Day continuous cycles until disease progression or unacceptable toxicity. The primary endpoint is the overall response rate (ORR) as per 2014 NIH response criteria in the mITT population. Additional endpoints include duration of response (DOR), corticosteroid (CS) dose reductions, failure free survival (FFS) and Lee Symptom Scale (LSS) score. Results: 17, 16 and 21 pts were enrolled in C1, C2, and C3 between Sep-2016 and Mar-2018. Data as of 8-Mar-2019 are included, reflecting a median duration of follow up of 112, 97 and 64 weeks (wks), respectively. At enrollment, median age was 52 yrs, median time from cGVHD diagnosis to treatment was 20 mos, and patients had received a median of 2 prior lines of therapy. 71% of patients were refractory to the last line of therapy prior to enrollment. 50% of pts had cGVHD in ≥4 organs. The median duration of treatment was 37, 33 and 39 wks, respectively. As of 30-Jun-2019, 24% of pts had received &gt;18 months of KD025 therapy. 14 pts remain on KD025 treatment. Reasons for discontinuation included cGVHD progression (18), pt voluntary withdrawal (7), relapse of underlying disease (5), investigator decision (5), AE (3) and death (2). ORR (95% CI) was 65% (38%, 85%) in C1, 69% (41%, 89%) in C2, and 62% (38%, 82%) in C3, i.e. 65% (51%, 77%) across all 3 cohorts. Responses were achieved across key subgroups with ORRs of 62% (24/39) in pts with ≥2 prior lines of systemic therapy, 70% (19/27) in pts with ≥4 organs involved and 60% (25/42) in pts with severe cGVHD. CRs were observed in all affected organs except lung; PRs were observed in lung. Responses were rapid, and often achieved within 8 wks, although 4/35 responses occurred after 24 wks. Of note, organs with fibrotic manifestations such as lungs, joints and eyes responded after 24 weeks in some pts. Responses were durable, with a Kaplan-Meier (K-M) median DOR of 34 weeks across all cohorts. 57% of responders sustained a response for ≥20 wks. The K-M median DOR was 34 wks in pts with ≥2 prior lines of systemic therapy. FFS at 6, 12, 18 and 24 mos was 76%, 47%, 40% and 33%, respectively. Baseline median CS dose was 0.21 mg/kg/day of prednisone equivalent. During treatment with KD025, the median CS dose was reduced by 50%. 67% of pts reduced CS dose and 20% discontinued CS completely. The median CS dose reduction was 66% in responders and 25% in non-responders. 52% of pts reported a clinically meaningful improvement (≥7-point reduction) in LSS score during treatment with KD025 with a median time to improvement of 9 wks and a duration for responders of 21 wks. 63% of responders and 32% of non-responders reported a meaningful improvement in LSS score. KD025 was well tolerated with a median Relative Dose Intensity of 98%. Dose reductions/interruptions occurred in 21/54 pts; median duration of interruption was 8.5 days (range 3-20). AEs were consistent with those expected in cGVHD pts receiving CS. Common AEs were URI (35%), diarrhea (31%), nausea (31%), fatigue (30%), dyspnea (28%), increased LFTs (24%), and peripheral edema (22%). 63% had a Grade ≥3 AE; the most common was dyspnea (13%). &lt;10% of pts experienced Grade 3 anemia, neutropenia or thrombocytopenia. SAEs were reported in 43%; none were considered related to KD025. Three pts discontinued KD025 due to possibly related AEs (C1: diarrhea, headache; C3: fatigue). No apparent increased risk of infection was observed. Three pts died on study (C3: relapse of leukemia; lung infection; cardiac arrest); none were considered related to KD025. Conclusions: Durable and clinically meaningful responses have been observed across all 3 cohorts. KD025 was well tolerated, allowing pts to remain on treatment and realize potential benefits of sustained therapy. Disclosures Jagasia: Kadmon: Consultancy; Incyte: Consultancy; Janssen: Research Funding. Salhotra:Celgene: Other: Research Support; Kadmon Corporation: Other: Non paid consultant. Bachier:Viracyte: Consultancy; Sanofi: Speakers Bureau; Kadmon Corporation, LLC: Consultancy. Lazaryan:Kadmon: Consultancy. Weisdorf:Pharmacyclics: Consultancy; Fate Therapeutics: Consultancy; Incyte: Research Funding. Green:Kadmon Corporation, LLC: Employment. Schueller:Kadmon Corporation LLC: Employment. Huang:Kadmon Corporation, LLC: Employment. Yang:Kadmon Corporation: Employment. Eiznhamer:Kadmon Corporation: Employment. Aggarwal:Kadmon Corporation, LLC: Employment, Equity Ownership. Blazar:Fate Therapeutics, Inc.: Research Funding; Magenta Therapeutics and BlueRock Therapeuetics: Membership on an entity's Board of Directors or advisory committees; Kamon Pharmaceuticals, Inc: Membership on an entity's Board of Directors or advisory committees; Five Prime Therapeutics Inc: Co-Founder, Membership on an entity's Board of Directors or advisory committees; Regeneron Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; RXi Pharmaceuticals: Research Funding; Alpine Immune Sciences, Inc.: Research Funding; Abbvie Inc: Research Funding; Leukemia and Lymphoma Society: Research Funding; Childrens' Cancer Research Fund: Research Funding; KidsFirst Fund: Research Funding; Tmunity: Other: Co-Founder; BlueRock Therapeutics: Membership on an entity's Board of Directors or advisory committees. Lee:Incyte: Research Funding; Syndax: Research Funding; Amgen: Research Funding; Novartis: Research Funding; Takeda: Research Funding; Kadmon: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; AstraZeneca: Research Funding.

scholarly journals First Line Chemo-Free Therapy with the BRAF Inhibitor Vemurafenib Combined with Obinutuzumab Is Effective in Patients with Hcl

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 3998-3998
Author(s):  
Jae H. Park ◽  
Madhulika Shukla ◽  
Jose M Salcedo ◽  
Shreya Vemuri ◽  
Julie C Kinoshita ◽  
...  
Keyword(s):  
Board Of Directors ◽  
Hairy Cell Leukemia ◽  
Research Funding ◽  
Braf Inhibitor ◽  
Digital Pcr ◽  
Hairy Cell ◽  
Cell Leukemia ◽  
Advisory Committees ◽  
Dose Reductions

Background: We have previously reported initial high response rates of the BRAF inhibitor, vemurafenib, in patients (pts) with relapsed or refractory hairy cell leukemia (HCL) (Tiacci and Park et al. NEJM 2015). However, complete response (CR) rates were low at 35-40% with detectable minimal residual disease (MRD) in most patients, and a longer follow up revealed a relapse rate of 50% (Park JH et al. Blood 2018, 132;392). Based on the recent data suggesting improved CR rate in combination with rituximab in relapsed HCL (Tiacci et al. Blood 2016, 128:1214), we initiated a phase II clinical trial to investigate the efficacy of vemurafenib and obinutuzumab in patients with newly diagnosed HCL (NCT03410875). Methods: Adult pts with previously untreated HCL who met the treatment initiation criteria (i.e. ANC <1.0k/ul, Hgb <10.0g/dL or PLT <100k/ul) are eligible for the study. Patients received vemurafenib 960mg bid from months 1-4 and obinutuzumab from months 2-4, for a total treatment duration of 4 months. Obinutuzumab was administered at 1000mg IV on days 1, 8, and 15 of month 2, and day 1 of month 3 and 4. Vemurafenib dose reductions were allowed for drug-related adverse events (AEs). Response was assessed at the end of month 4 with bone marrow (BM) biopsy and CT scans. The primary objective was to determine the efficacy of vemurafenib and obinutuzumab combination as assessed by CR rates, and the secondary objectives include assessment of safety, duration of response, MRD negativity, and BRAF allele burden by digital PCR. The study adopted a Simon's minimax 2-stage design and required ≥7 CR in the first 9 pts in the first stage to continue accrual for a total of 28 pts. We report the result of the first 9 pts in the first stage of the study. Results: A total of 11 pts have been enrolled to the study to date. The median age of the patients is 49 years old (range, 35-79). The median pretreatment ANC, Hgb and PLT is 0.7k/ul (range, 0.0-2.6), 11.5g/dL (range, 7.0-15.0), and 83k/ul (range, 21-153), respectively. Nine of 11 pts had a baseline splenomegaly. Nine pts completed all treatments to date, and 2 pts remain on active therapy. Among the 9 pts who completed the treatment, all pts achieved a response with normalization of cytopenia, including 7 pts with MRD negative CR and 2 pts with PR at the end of month four. Two pts with PR at month 4 converted to MRD+ and MRD negative CR by month 7 and 10, respectively, with no further treatment, with the best overall CR rate of 100% (9/9 pts) (Figure). All MRD negative CR had undetectable BRAFV600E by highly sensitive digital PCR. After 1 month of vemurafenib and before the first dose of obinutuzumab, 7 of 9 pts had ANC recovery to >1.0K/ul and 8 of 9 pts had Hgb >10 g/dL and PLT 100k/uL. With a median follow-up of 9.7 months (range, 4.6-15.4), all pts remain in remission with no relapse. The most common vemurafenib-related AEs were rash (73%; Gr2-9%, Gr3-64%), arthralgia (64%; Gr1-27%, Gr2-27%, Gr3-18%), alopecia (45%, all Gr1), dry skin (27%, all Gr1), and fatigue (27%, Gr1). Two pts experienced obinutuzumab infusion reaction but were able to complete all intended doses of obinutuzumab. No case of cutaneous squamous cell carcinomas has been observed. No pt discontinued the therapy due to toxicity but 8 pts had vemurafenib dose reductions due to rash (n=5) and arthralgia (n=2). Conclusion: Vemurafenib and obinutuzumab combination therapy induced a high CR rate of 100% and high rates of MRD negativity (89%) in patients with HCL in the frontline setting and appears to be a promising chemo-free targeted therapeutic approach for HCL. A majority of the pts achieved a normalization of cytopenia within 4 weeks of starting therapy. A longer follow-up is needed to assess durability of remission and degree of immunosuppression compared to cladribine-treated cohorts. Figure Disclosures Park: Kite Pharma: Consultancy; Incyte: Consultancy; GSK: Consultancy; Autolus: Consultancy; AstraZeneca: Consultancy; Allogene: Consultancy; Amgen: Consultancy; Novartis: Consultancy; Takeda: Consultancy. Winer:Jazz Pharmaceuticals, Pfizer: Consultancy. Tallman:Cellerant: Research Funding; Abbvie: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Abbvie: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; KAHR: Consultancy, Membership on an entity's Board of Directors or advisory committees; BioLineRx: Consultancy, Membership on an entity's Board of Directors or advisory committees; Nohla: Consultancy, Membership on an entity's Board of Directors or advisory committees; Rigel: Consultancy, Membership on an entity's Board of Directors or advisory committees; Oncolyze: Consultancy, Membership on an entity's Board of Directors or advisory committees; Orsenix: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; ADC Therapeutics: Research Funding; Biosight: Research Funding; Daiichi-Sankyo: Consultancy, Membership on an entity's Board of Directors or advisory committees; Jazz Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees; UpToDate: Patents & Royalties; Tetraphase: Consultancy, Membership on an entity's Board of Directors or advisory committees; Delta Fly Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees; Cellerant: Research Funding. OffLabel Disclosure: Vemurafenib and obinutuzumab for treatment of hairy cell leukemia

scholarly journals Midostaurin in Adults with Newly Diagnosed FLT3-Mutation-Positive Acute Myeloid Leukemia Eligible for Standard Chemotherapy: Update from the Radius-X Midostaurin Expanded Access Program

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 4038-4038 ◽  
Author(s):  
Alexander E. Perl ◽  
Kendra L. Sweet ◽  
Gail J. Roboz ◽  
Stephen A. Strickland ◽  
Mark R. Litzow ◽  
...  
Keyword(s):  
Febrile Neutropenia ◽  
Board Of Directors ◽  
Myeloid Leukemia ◽  
Research Funding ◽  
Safety Data ◽  
Newly Diagnosed ◽  
Consolidation Chemotherapy ◽  
Advisory Committees ◽  
Acute Myeloid

Abstract Introduction: Midostaurin was the first multikinase inhibitor approved in combination with daunorubicin and cytarabine induction and high-dose cytarabine (HiDAC) consolidation chemotherapy for the treatment of adults with newly diagnosed FLT3-mutation-positive (mut+) acute myeloid leukemia (AML). Approval was largely based on the results from the phase 3 RATIFY trial; patients who received midostaurin had significantly improved overall and event-free survival than those who received placebo (Stone et al, N Engl J Med, 2017). RADIUS-X (NCT02624570) is an expanded treatment protocol (ETP) designed to provide access to midostaurin during the US Food and Drug Administration's review process and to extend the understanding of the safety and tolerability of midostaurin in patients with newly diagnosed FLT3-mut+ AML. The safety profile of midostaurin in preliminary data from RADIUS-X was consistent with that in the RATIFY study (Roboz et al, Blood, 2017 [abstract 1338]). Here we report updated safety data for midostaurin during induction and consolidation and safety data during the maintenance phase. Methods: In this open-label, single-arm ETP, patients (aged ≥18 years) received 1-2 cycles of induction therapy (cytarabine plus daunorubicin [60-90 mg/m2/day] or idarubicin [12 mg/m2/day]) and up to 4 cycles of HiDAC consolidation chemotherapy plus midostaurin (50 mg twice daily [bid] on days 8-21 of each 28-day cycle), followed by up to 12 months of single-agent midostaurin (50 mg bid on days 1-28). Patients could enroll at any point before completion of a second cycle of consolidation. Patients achieving complete remission (CR) or CR with incomplete hematologic recovery (CRi) after induction proceeded to consolidation; patients who maintained a response were eligible to proceed to maintenance. The primary endpoints were safety and tolerability of midostaurin. Results: Of 111 patients screened, 103 were enrolled in the study: 47 during induction (46%) and 56 during consolidation (54%) (Figure). The median age was 58 y (range, 19-79 y); all patients were FLT3-mut+ (Table). Of 47 patients enrolled during induction, 15 received daunorubicin and 32 received idarubicin as the anthracycline. Of 35 patients who completed consolidation and entered maintenance, 9 had completed the protocol treatment and 3 remained on therapy at the data cutoff date (March 30, 2018). The CR/CRi rate for the induction phase was 74% (57% CR, 17% CRi). The relapse rate was 14% overall. The most common reason for study discontinuation was proceeding to transplant (overall, 52%; induction, 11%; consolidation, 42%; maintenance, 34%). The median duration of midostaurin exposure was 35 days (range, 3-426 days). Dose adjustment or interruption due to adverse events (AEs) occurred in 26 patients, most commonly due to febrile neutropenia (n=9) and gastrointestinal disorders (n=6). No new safety events were observed with longer follow-up. Most patients (99%) experienced ≥1 any-grade AE, mostly during induction and/or consolidation. Due to the timing of patient enrollment (up to the second cycle of consolidation), hematologic AEs were lower than reported in comparable studies. The most common AEs occurring in ≥20% of patients were febrile neutropenia (53%), nausea (42%), diarrhea (37%), anemia (36%), platelet count decreased (31%), fatigue (23%), headache (22%), and vomiting (22%). Serious AEs occurred in 50% of patients overall, most commonly febrile neutropenia (37%). AEs during induction were generally similar, regardless of anthracycline received. Overall, 9 patients discontinued due to AEs: 5 during induction (febrile neutropenia, blood bilirubin increased, electrocardiogram QT prolonged, renal impairment, and respiratory distress), 1 during consolidation (sepsis), and 1 during maintenance (leukocytosis). During maintenance, 16 of 35 patients (46%) reported any-grade AEs with midostaurin monotherapy; the most common any-grade and grade 3/4 AEs occurring in >1 patient were platelet count decrease (11% and 3%), nausea (9% and 0%), and oropharyngeal pain (6% and 0%).The rate of death during the study was low, with 1 death reported (disease progression). Conclusions: Midostaurin continued to demonstrate a manageable safety profile with longer follow-up and was associated with high transplant and low relapse rates. Maintenance therapy with midostaurin was well tolerated; no new safety signals were observed. Disclosures Perl: Daiichi Sankyo: Consultancy; Arog: Consultancy; AbbVie: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees; Actinium Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Astellas: Consultancy; NewLink Genetics: Membership on an entity's Board of Directors or advisory committees. Sweet:Agios: Consultancy; Novartis: Consultancy, Honoraria, Speakers Bureau; Pfizer: Consultancy, Honoraria; Incyte: Research Funding; Bristol Myers Squibb: Honoraria; Jazz Pharmaceuticals: Honoraria, Speakers Bureau; Celgene: Speakers Bureau. Roboz:Novartis: Consultancy; Daiichi Sankyo: Consultancy; Pfizer: Consultancy; Eisai: Consultancy; Janssen Pharmaceuticals: Consultancy; Argenx: Consultancy; Orsenix: Consultancy; Aphivena Therapeutics: Consultancy; Daiichi Sankyo: Consultancy; Roche/Genentech: Consultancy; Orsenix: Consultancy; Celgene Corporation: Consultancy; Celltrion: Consultancy; Jazz Pharmaceuticals: Consultancy; Celltrion: Consultancy; Cellectis: Research Funding; Jazz Pharmaceuticals: Consultancy; Sandoz: Consultancy; Otsuka: Consultancy; Otsuka: Consultancy; Roche/Genentech: Consultancy; Pfizer: Consultancy; AbbVie: Consultancy; Janssen Pharmaceuticals: Consultancy; Bayer: Consultancy; Astex Pharmaceuticals: Consultancy; Eisai: Consultancy; Aphivena Therapeutics: Consultancy; Argenx: Consultancy; Celgene Corporation: Consultancy; AbbVie: Consultancy; Bayer: Consultancy; Novartis: Consultancy; Astex Pharmaceuticals: Consultancy; Cellectis: Research Funding; Sandoz: Consultancy. Strickland:Astellas Pharma: Consultancy; Boehringer Ingelheim: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees; Baxalta: Consultancy, Membership on an entity's Board of Directors or advisory committees; CTI Biopharma: Consultancy, Membership on an entity's Board of Directors or advisory committees; Sunesis Pharmaceuticals: Consultancy, Research Funding; Tolero Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees. Bonifacio:Novartis: Employment. Haines:Novartis: Employment. Barbera:Novartis: Employment. Purkayastha:Novartis Pharmaceuticals Corporation: Employment.

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