Final Results of a Phase I/II Study of the Combination of the Hypomethylating Agent 5-aza-2′-Deoxycytidine (DAC) and the Histone Deacetylase Inhibitor Valproic Acid (VPA) in Patients with Leukemia.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 408-408 ◽  
Author(s):  
Guillermo Garcia-Manero ◽  
Hagop Kantarjian ◽  
Blanca Sanchez-Gonzalez ◽  
Hui Yang ◽  
Gary Rosner ◽  
...  
Keyword(s):  
Phase I ◽  
Histone Acetylation ◽  
Phase Ii ◽  
Response Rate ◽  
Stopping Rules ◽  
Clinical Activity ◽  
Dna Hypomethylation ◽  
Global Methylation ◽  
Platelet Recovery ◽  
Number Of Patients

Abstract The combination of DAC and VPA has synergistic antileukemia activity in vitro. Based on this, we developed a phase I/II study of this combination for patients with leukemia. The dose of DAC was fixed: 15 mg/m2 IV daily x 10. Three dose levels of VPA were studied: 20, 35 and 50 mg/kg orally daily x 10 concomitantly with DAC. The phase I portion of the study followed a classic 3+3 schema. The phase II targeted a response rate of 30%. Patients with relapsed/refractory chronic and acute leukemia with adequate renal, hepatic functions and performance status were eligible. Patients older than 60 years of age with untreated disease were eligible if they were not candidates for higher priority therapies. Fifty four patients have been registered and treated on this study that is now closed to new patient accrual. Median age was 60 years (range 5 to 80). All, but 2 patients with MDS, had AML. Median number of prior therapies was 2 (range 0–5). Thirty patients (56%) had abnormal cytogenetics. No non-hematological VPA dose limiting toxicities were observed during the phase I portion of the study. Therefore the phase II combination consisted of VPA at a dose of 50 mg/kg daily with DAC. Ten patients achieved a CR and 2 a CRP (same criteria as of CR but without complete platelet recovery), for an overall response rate of 22%. The study did not meet any of its planned stopping rules and the maximal number of patients (n=40) was accrued in the phase II portion of the study. Ten out 40 patients (25%) achieved a response in that phase. Two out 12 patients (16%) achieved a response at lower doses of VPA. Five out of 11(45%) previously untreated older patients achieved a CR. The median overall survival (OS) for the whole group was 5.3 months, and it has not been reached for those patients achieving a response. The median duration of response is 8.3 months. Complete cytogenetic responses were observed in 4 out 4 patients with informative karyotypes. A trend toward higher VPA levels was observed in responders (p=0.02). Twelve out 35 (34%) patients receiving VPA at a dose of 50 mg/kg had evidence of histone acetylation compared to 1 out 12 (8%) at lower doses. Histone acetylation was transient. The effects on global methylation were assessed using the LINE assay. Median LINE methylation pretreatment was 44% (range 35.7–57.6%) and it decline to 37.08% (p=0.000) by day 10 to return to baseline by day 28. Methylation of p15, p57, p73, MDR1 and THSB1 was measured pretreatment and serially during therapy. Pretreatment p15 methylation was observed in 36 out 46 patients (78%) with a median value of 18.4% (range 0–80) to decline to 11.7% (range 1.3–67.8), p=0.005, by day 10. Methylation of THSB2 was observed in 19 out 48 patients (39.5%) but it was not affected by the therapy. Methylation of p57KIP2, p73 and MDR1 were rare events in this population. p15 hypomethylation was associated with the the induction of p15 mRNA expression. In summary, the combination of DAC with VPA has significant clinical activity in patients with AML and MDS and effect potentially mediated by the induction of DNA hypomethylation and histone acetylation.

Phase I/II study of the combination of 5-azacytidine(5-AC), all-trans retinoic acid (ATRA) and valproic Acid (VPA) in patients with myelodysplastic syndrome (MDS) and leukemia

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 6563-6563
Author(s):  
A. O. Soriano ◽  
H. Yang ◽  
S. Verstovsek ◽  
W. Wierda ◽  
C. Koller ◽  
...  
Keyword(s):  
Phase I ◽  
Histone Acetylation ◽  
Performance Status ◽  
Median Number ◽  
Clinical Activity ◽  
Synergistic Activity ◽  
Dna Hypomethylation ◽  
Platelet Recovery ◽  
Hypomethylating Agent ◽  
And Performance

6563 Background: The combination of a hypomethylating agent with a histone deacetylase inhibitor (HDACI) has synergistic activity. The combination of ATRA with either a hypomethylating agent or a HDACI restores ATRA sensitivity in resistant cells. The combination of VPA and ATRA has activity in patients with MDS. Based on this, we developed a phase I/II study of the combination of 5-AC, VPA and ATRA for patients with MDS or AML. Methods: The dose of 5-AC was fixed: 75 mg/m2 sq daily × 7. ATRA dose was: 45 mg/m2 orally daily × 5 starting on day 3. Three dose levels of VPA were studied: 50, 62.5 and 75 mg/kg orally daily × 7. The phase I portion of the study followed a 3+3 design. Patients with high risk MDS (≥10% blasts) or relapsed/refractory AML and patients older than 60 years with untreated disease and adequate renal, hepatic functions and performance status were eligible. Results: Nineteen patients were registered and 16 were evaluable. Median age was 68 years (5–78). All, but one patient with MDS had AML. Median number of prior therapies was 2 (0–5). Twelve patients (75%) had abnormal cytogenetics. At a VPA dose of 50 mg/kg, 1 of 6 patients developed grade 3 confusion; at 62.5 mg/kg, 0 of 6, and at 75 mg/kg, 2 of 6. One patient had a CR, 2 a complete marrow response (marrow blasts < 5%), and 1 a CRP (same criteria as of CR but without complete platelet recovery), overall response rate was 30% of 13 patients that have completed 1 course. All 4 responses occurred during the first cycle. The CR occurred at a VPA dose of 75mg/kg. The other 3 responses occurred at 62.5 and 75 mg/kg. One out of 2 previously untreated older patients achieved a CR. To assess the hypomethylating effect of 5-AC, we used the LINE assay. Median LINE methylation pretreatment was 62.5% (57–67%), declined to 58% by day 7 and returned to baseline by day 0 of next cycle (p<0.001). Analysis of histone acetylation and gene re-expression are ongoing. Conclusions: The combination of 5-AC with VPA and ATRA is well tolerated. The dose of 62.5 mg/kg daily × 7 is currently being expanded. Significant clinical activity was observed and the effects are potentially mediated by the synergistic action of the combination including induction of DNA hypomethylation and histone acetylation. [Table: see text]

Phase II Study of the Histone Deacetylase Inhibitor Panabinostat (LBH589) in Patients with Low or Intermediate-1 Risk Myelodysplastic syndrome

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 1731-1731
Author(s):  
Sophie Dimicoli ◽  
Elias Jabbour ◽  
Gautam Borthakur ◽  
Tapan Kadia ◽  
Zeev Estrov ◽  
...  
Keyword(s):  
Adverse Events ◽  
Phase Ii ◽  
Median Duration ◽  
Lower Risk ◽  
Response Rate ◽  
Phase Ii Study ◽  
Single Agent ◽  
Clinical Activity ◽  
Number Of Patients ◽  
Deacetylase Inhibitor

Abstract Abstract 1731 Panabinostat is a very potent panhistone deacetylase inhibitor (HDACi) with activity in acute myelogenous leukemia (CCR 2006;12: 4628). We hypothesized that single agent panabinostat could be active in patients with low and intermediate-1 risk MDS. Oral route of administration and safety profile further increased interest in this approach. To test this concept we designed a phase II study of panabinostat for patients above 18 years of age with lower risk disease. Patients could have received prior therapy or be treatment naïve. Appropriate renal, hepatic and cardiac functions were required. Patients were excluded if they had previous HDACi treatment. Patients with history of cardiac pathology such as rhythm alterations were excluded from the study. Use of drugs that could induce QT prolongation and CYP3A4 inhibitors were not allowed. Panabinostat was used at dose of 20 mg orally three times a week for consecutive 3 weeks with cycles repeated every 4 weeks. The primary objective of the study was overall response rate defined by IWG. A maximum of 40 patients could be enrolled. The study was to stop early if the expected response rate was less than 15%. Stopping rules were as follows: Stop if the number of patients with hematologic improvement/the number of patients evaluated was 0/15 or 1/32. The study also contained a stopping rule for non-hematological toxicity. Thirteen patients were enrolled between August 2009 and December 2010. Median age was 70 years (range 47 to 84, 84% of patients older than 60), 70% were transfusion dependent, 70% had intermediate-1 risk MDS, most patients were diploid but one patient with del(5q), one with trisomy 8, one with complex cytogenetics and 2 with deletion of 20q were included. Median percent of marrow blasts was 1% (range 1 to 6%). At start of therapy, median hemoglobin was 9.5 (range 7.5–11.2 G/dL), median platelet count was 56 (range 6–431 k/uL) and median white blood cell count was 4.6 (range 0.8–20.3 k/uL). Approximately 40% had previous therapy for MDS including hypomethylating agents, lenalidomide and investigational agent. Median number of prior therapies for treated patients was 2 (range 1 to 4). Median duration of disease at time of enrollment was 10 months (range 1–50). Patients received a median of 4 cycles of panabinostat (range 1–9). Of 13 patients, 1(8%) achieved a hematological improvement including both an erythroid and platelet response that lasted for 3 months. No complete remissions or partial responses were documented. Six patients (46%) had stable disease for a median duration of 6 months (range 2–13.6). Median overall survival was 15 months (1–31 months). Two patients died because progression to AML. Therapy was well tolerated: no major adverse events were documented except for one patient that developed significant QTc prolongation. Adverse events included mild fatigue and gastrointestinal toxicity. As a biomarker of molecular activity, histone H3 acetylation was measured in 5 patients with variable results. Induction of acetylation was documented in 2. Despite the fact that the stopping rule for activity was not officially met, because of the very modest clinical activity observed, the study was closed to new patient entry. In conclusion, panabinostat given as a single agent orally at a dose of 20 mg thee times a week for 3 weeks followed by one week of rest has limited clinical activity in patients with lower risk MDS. Disclosures: No relevant conflicts of interest to declare.

Hafnium oxide nanoparticles activated by SABR in combination with PD-1 inhibitors for the treatment of patients with advanced HNSCC or NSCLC: A phase I/II trial.

2019 ◽  
Vol 37 (8_suppl) ◽  
pp. TPS23-TPS23 ◽  
Author(s):  
Tanguy Y. Seiwert ◽  
Corey Christian Foster ◽  
Christophe Le Tourneau ◽  
Valentin Calugaru ◽  
Sylvie Bonvalot
Keyword(s):  
Clinical Trial ◽  
Phase I ◽  
Phase Ii ◽  
Hafnium Oxide ◽  
Response Rate ◽  
Locally Advanced ◽  
Recommended Dose ◽  
Oxide Nanoparticles ◽  
Intrinsic Resistance ◽  
Number Of Patients

TPS23 Background: Despite proven efficacy, a limited number of patients (pts) with recurrent/metastatic head and neck squamous cell carcinoma (HNSCC) or metastatic non-small cell lung cancer (NSCLC) benefit from anti-PD-1 treatment. Indeed, most pts do not respond to initial therapy due to intrinsic resistance to checkpoint inhibition. There is thus an important unmet medical need for a curative treatment in these pts and converting the local immune microenvironment to a “hot” phenotype may help to overcome therapeutic resistance. Hafnium oxide nanoparticles (NBTXR3) activated by radiotherapy (RT) increase radiation dose deposit within cancer cells compared to RT alone. Recently, a phase II/III randomized trial of NBTXR3 in locally advanced soft tissue sarcoma (STS) met primary and main secondary endpoints with significant superiority compared to RT alone. Furthermore NBTXR3+RT demonstrated an immunogenic cell death-mediated abscopal effect in a pre-clinical setting, and immune cell infiltration was observed in some tumors from STS pts treated with NBTXR3+RT but not in tumors from pts treated with RT alone. NBTXR3 is currently being evaluated in 7 clinical trials, including a phase I/II study in elderly frail patients with locally advanced HNSCC. To date, no early dose limiting toxicities (DLTs) have been observed. Methods: Overall, these results have led us to evaluate NBTXR3 activated by stereotactic ablative radiotherapy (SABR) in combination with an approved anti-PD-1 antibody in an open label phase I/II, non-randomized clinical trial in pts with more advanced diseases: locoregionally recurrent or metastatic HNSCC, metastatic NSCLC, and liver metastasis pts. The phase I primary objectives are to determine NBTXR3 maximum tolerated dose(s), incidence of early DLTs and recommended dose(s). The phase II primary objectives are Complete Response Rate of target lesions and Objective Response Rate for the locoregional recurrent and the metastatic group respectively by RECIST 1.1, and safety/tolerability of treatment at the recommended dose(s). [NCT02379845] [NCT01946867]. Clinical trial information: NCT03589339.

Significant Clinical Activity of the Combination of 5-Azacytidine, Valproic Acid and All-Trans Retinoic (ATRA) Acid in Leukemia: Results of a Phase I/II Study.

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 160-160 ◽  
Author(s):  
Andres O. Soriano ◽  
Hui Yang ◽  
Weigang Tong ◽  
Stefan Faderl ◽  
William Wierda ◽  
...  
Keyword(s):  
Valproic Acid ◽  
Phase I ◽  
Phase Ii ◽  
Median Number ◽  
Fixed Dose ◽  
Clinical Activity ◽  
Hypomethylating Agents ◽  
Platelet Recovery ◽  
Significant Difference ◽  
Significant Clinical Activity

Abstract 5-azacitidine (5-AC), and its analogue 5-aza-2′-deoxycitidine (5-DAC), are DNA hypomethylating agents. Valproic acid (VPA) is a histone deacetylase inhibitor (HDACI). Hypomethylating agents and HDACI restore ATRA sensitivity in resistant cells. The combination of a hypomethylating agent with an HDACI is antileukemic in vitro. Based on this, and on a prior study of 5-DAC and VPA (Garcia-Manero, Blood, in press), we developed a phase I/II study of the combination of 5-AC, VPA and ATRA. Patients (pts) with high risk MDS (≥10% blasts); relapsed/refractory AML; and pts > 60 years with untreated disease and adequate renal, hepatic functions and performance status were eligible. A fixed-dose of 5-AC was used: 75 mg/m2 sq daily x 7. ATRA dose was: 45 mg/m2 PO daily x 5 starting on day 3 of 5-AC. The phase I followed a classic 3+3 design. The initial dose of VPA was 50 mg/kg PO daily x 7 concomitantly with 5-AC. Cycles were at least 21 days long. The phase II targets a response rate of ≥30% with stopping rules. Cohorts of 10 pts (max 40) are studied. Thirty one pts are evaluable. Median age is 60 years (5–78). All, but 2 pts with MDS, had AML. Median number of prior therapies was 2 (0–5). Twenty six pts (83%) had abnormal cytogenetics. During the phase I, at a VPA dose of 50 mg/kg, 1/6 pts developed grade 3 non-hematological toxicity; at 62.5 mg/kg, 2/7, and at 75 mg/kg, 3/6. The dose limiting toxicity (DLT) was neurotoxicity, confusion and somnolence. The MTD was 50 mg/kg daily x 7. Twelve pts are enrolled in the phase II. Of the 31 evaluable pts, 9 achieved CR (ANC 10 9/L, platelets 100 x 10 9/L, and marrow blasts ≤5%) and 3 a CRp (same criteria as of CR but without complete platelet recovery), overall response (OR)39%. The median number of courses to response was 1 (1–3). Nine responses occurred in 16 untreated pts, OR 56% (Table). Eighteen patients were treated at the MTD with 9 responses (50%). Cytogenetic responses were observed in all responding pts. To assess the hypomethylating effect of 5-AC, the LINE test was used. Median LINE methylation pretreatment was 62.5% (57–67%), declined to 58% by day 7 and returned to baseline by day 0 of next cycle (p<0.001). No significant difference was observed between responders and non responders. Eighteen pts had evidence of histone 3 and 4 acetylation (66%). VPA bound level on day 2 was 146 mcg/ml (95% CI 122–170) in responders and 103 mcg/ml (95% CI 88–118) in non-responders, p< 0.005. Analysis of gene re-expression and cell differentiation are ongoing. In conclusion, the combination of 5-AC, VPA and ATRA is safe. The MTD of VPA is 50mg/kg daily x 7. The DLT is neurotoxicity. The combination has significant clinical activity. An OR of 56% was observed in patients > 60 years with previously untreated AML/MDS. Histone acetylation and transient global hypomethylation are observed. Higher levels of VPA are found in responders. Based on prior CALGB experience (Silverman, ASH 2005), this combination appears to be more active than single agent 5-AC in AML. The study continues to accrue. Responses VPA (mg/kg) Number of Patients CR CRp OR% Courses to response Duration of response (months) 50 18 7 2 50 1(1–3) 2.6(0.5–3.2) 62.5 7 1 0 14 2 3.73+ 75 6 1 1 33 1 8.1(7–9.2+) Total 31 9 3 38 1(1–3) 2.9(0.5–9.2+) Untreated AML/MDS>60 years 16 7 2 56 1(1–3) 2.9 (0.5–9.2+)

Phase I/II Study of MGCD0103, an Oral Isotype-Selective Histone Deacetylase (HDAC) Inhibitor, in Combination with 5-Azacitidine in Higher-Risk Myelodysplastic Syndrome (MDS) and Acute Myelogenous Leukemia (AML).

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 444-444 ◽  
Author(s):  
Guillermo Garcia-Manero ◽  
Allen S. Yang ◽  
Virginia Klimek ◽  
Jorge Cortes ◽  
Farhad Ravandi ◽  
...  
Keyword(s):  
Phase I ◽  
Phase Ii ◽  
Hdac Inhibitor ◽  
Response Rate ◽  
Single Agent ◽  
Substantial Reduction ◽  
Myelogenous Leukemia ◽  
Clinical Activity ◽  
Flat Dose ◽  
Dose Levels

Abstract Epigenetic alterations are common in leukemia. MGCD0103 in an oral isotype-selective HDAC inhibitor that synergizes in vitro with the DNA methyltransferase inhibitor 5-azacitidine (Vidaza, Pharmion). Both agents have single-agent clinical activity in MDS and AML (Garcia-Manero, ASCO, 2006 & Silverman, JCO, 2002). We have developed a Phase I/II study of 5-azacitidine in combination with MGCD0103 in patients with AML and MDS. Patients with MDS (≥10% marrow blasts), relapsed/refractory AML, or untreated elderly patients with AML were eligible. Adequate performance status, renal and hepatic functions were required. 5-azacitidine was administered at its approved dose/schedule: 75 mg/m2 SC daily for the first 7 days of a 28 day cycle. MGCD0103 was administered as a flat dose orally three-times a week starting on the 5th day of 5-azacitidine administration. The phase I portion of the study design followed a classic “3+3” model and only MGCD0103 was dose escalated. The phase II portion targeted a 30% response rate. Final data from the Phase I and II portions of the study will be presented at the Meeting. Five dose levels of MGCD0103 have been evaluated: 35, 60, 90, 110 and 135 mg. At current data cut-off, 37 patients registered in the study were fully evaluable: median age was 67 (range 27–85); 31 patients had AML and 6 MDS. A total of 97 cycles were administered to date, mean = 2.6 (range 1–12). Dose limiting toxicities included nausea, vomiting, anorexia, diarrhea and dehydration which appear similar to dose limiting toxicities for MGCD0103 alone. The MTD of MGCD0103 was initially determined to be 110 mg, however, upon cohort expansion, this dose level was associated with excess toxicity and the starting dose was decreased to 90 mg. Eleven (30%) patients have achieved response: 4 CR, 5 CR-i, and 2 PR. Of these 11 patients, 6 continue on study with mean duration on study of 7 cycles. Of the 5 patients discontinued, 3 discontinued due to SAEs, 1 due to progressive disease and 1 to undergo transplantation. Of the 27 patients at the phase II dose levels of 90 and 110mg, 10 achieved a response (37%; same rate at both doses). Preliminary response data are available at the time of abstract preparation for 13 additional patients, revealing 4 with CR (one of which had 1% residual peripheral blast) and 3 with CR-I for a response rate of 53% in this subset. MGCD0103 pharmacokinetics were not affected by 5-azacitidine. Likewise, co-administration of MGCD0103 had no impact on the pharmacokinetics of 5-azacitidine. A majority of patients exhibited a substantial reduction in PBMC HDAC activity during treatment with the combination. Analysis of DNA methylation is ongoing. In conclusion, the combination of 5-azacitidine with MGCD0103 is safe in patients with advanced AML/MDS and has clinical activity potentially superior to that expected with 5-azacitidine alone in this patient population. These results form the bases of a planned randomized study of 5-azacitidine with or without MGCD0103 in AML and MDS.

Phase I/II Trial to Evaluate the Efficacy and Safety of Nanoparticle Albumin-Bound Paclitaxel in Combination With Gemcitabine in Patients With Pancreatic Cancer and an ECOG Performance Status of 2

2019 ◽  
Vol 37 (3) ◽  
pp. 230-238 ◽  
Author(s):  
Teresa Macarulla ◽  
Roberto Pazo-Cid ◽  
Carmen Guillén-Ponce ◽  
Rafael López ◽  
Ruth Vera ◽  
...  
Keyword(s):  
Phase I ◽  
Pancreatic Ductal Adenocarcinoma ◽  
Phase Ii ◽  
Karnofsky Performance Status ◽  
Performance Status ◽  
Ductal Adenocarcinoma ◽  
Tolerability Profile ◽  
Ecog Performance Status ◽  
Actuarial Survival ◽  
Number Of Patients

Purpose Gemcitabine plus nanoparticle albumin-bound (NAB) paclitaxel (GA) significantly improved survival compared with gemcitabine alone in patients with metastatic pancreatic ductal adenocarcinoma (PDAC) and a Karnofsky performance status (PS) of 70% or greater. Because of the low number of patients with reduced PS, the efficacy of this regimen in fragile patients remains unclear. This study aimed to evaluate the efficacy and tolerability of different GA dosing regimens in patients with a poor PS. Patients and Methods In the phase I part of this study, patients were randomly assigned to one of the following four parallel GA treatment arms (six patients per arm): a biweekly schedule of NAB-paclitaxel (150 mg/m2 [arm A] or 125 mg/m2 [arm C]) plus gemcitabine 1,000 mg/m2 or a standard schedule of 3 weeks on and 1 week off of NAB-paclitaxel (100 mg/m2 [arm B] or 125 mg/m2 [arm D]) plus gemcitabine 1,000 mg/m2. The two regimens with the better tolerability profile on the basis of predefined criteria were evaluated in the phase II part of the study, the primary end point of which was 6-month actuarial survival. Results Arms B and D were selected for the phase II part of the study. A total of 221 patients (111 patients in arm B and 110 patients in arm D) were enrolled. Baseline characteristics including median age (71 and 68 years in arms B and D, respectively), sex (51% and 55% men in arms B and D, respectively), and metastatic disease (88% and 84% in arms B and D, respectively) were comparable between arms. The most frequent grade 3 or 4 toxicities in arms B and D were anemia (12% and 7%, respectively), neutropenia (32% and 30%, respectively), thrombocytopenia (7% and 11%, respectively), asthenia (14% and 16%, respectively), and neurotoxicity (11% and 16%, respectively). In arms B and D, there were no significant differences in response rate (24% and 28%, respectively), median progression-free survival (5.7 and 6.7 months, respectively), and 6-month overall survival (63% and 69%, respectively). Conclusion NAB-paclitaxel administered at either 100 and 125 mg/m2 in combination with gemcitabine on days 1, 8, and 15 every 28 days is well tolerated and results in acceptable safety and efficacy in patients with metastatic pancreatic ductal adenocarcinoma and a poor PS.

Phase II Study of Combination of the HyperCVAD Regimen with Dasatinib in Patients with Philadelphia Chromosome (Ph) or BCR-ABL Positive Acute Lymphoblastic Leukemia (ALL) and Lymphoid Blast Phase Chronic Myeloid Leukemia (CML-LB).

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 2814-2814 ◽  
Author(s):  
Farhad Ravandi ◽  
Deborah Thomas ◽  
Hagop Kantarjian ◽  
Stefan Faderl ◽  
Charles Koller ◽  
...  
Keyword(s):  
Phase Ii ◽  
Residual Disease ◽  
Lymphoblastic Leukemia ◽  
Philadelphia Chromosome ◽  
Clinical Activity ◽  
High Dose ◽  
Cell Transplant ◽  
Newly Diagnosed ◽  
Blast Phase ◽  
Platelet Recovery

Abstract Combination of cytotoxic chemotherapy with imatinib has improved the outcome for patients with Ph+ ALL and resulted in eradication of minimal residual disease and durable remissions without allogeneic stem cell transplant in some patients (Thomas D, Blood, 2004; Yanada M, JCO, 2006; Wassmann B, Blood, 2006; de Labarthe A, Blood, 2007). The dual Src and Abl inhibitor dasatinib has a significantly higher in vitro kinase inhibition against BCR-ABL and has demonstrated potent clinical activity in patients with imatinib-resistant lymphoid blast phase CML (CML-LB) and Ph+ ALL with over 50% complete cytogenetic responses (CG CR) in phase I and II trials but with median progression free survival of only 3 to 4 months. We are conducting a phase II trial in which patients with newly diagnosed or relapsed Ph+ ALL or CML-LB receive dasatinib 50 mg po bid for the first 14 days of each of 8 cycles of alternating hyperCVAD and high dose cytarabine and methotrexate. Patients in complete remission (CR) continue to receive maintenance dasatinib 50 mg po bid daily and vincristine and prednisone monthly for 2 years followed by dasatinib indefinitely. To date 15 newly diagnosed patients with Ph+ ALL (cohort I) and 4 patients with relapsed Ph+ ALL or CML-LB (cohort II) have received a median of 4 cycles (range 1 – 8); 4 patients are receiving maintenance in CR. Median age for cohort I is 55 years (range 23 – 79) and for cohort II, 43 years (range 26 – 69); 13 and 3 patients were older than 50 years, respectively. Median WBC at diagnosis for cohort I was 4.3 × 109/L (range, 0.8 – 203.4 x 109/L). Three patients had CNS involvement. Fourteen and 3 patients in the 2 cohorts are evaluable for response to induction; 2 are too early. Thirteen patients (93%) in cohort I and all evaluable patients in cohort II have achieved CR after the first cycle; 1 patient in cohort I died on day 20 from infections before response assessment; her bone marrow exam on day 14 showed no detectable disease. Ten of 11 (91%) patients in cohort I have achieved CG CR after 1 cycle; 3 are too early. Three of 4 patients in cohort II have achieved CG CR after 1 cycle; 1 had a new CG abnormality and 1 is too early. Six patients have achieved complete molecular remission after the first cycle with the lowest BCR-ABL/ABL in the other patients ranging from 0.01 to 1.91. Median time to neutrophil and platelet recovery for cohort I is 18 and 25 days and for cohort II 18.5 and 30.5 days. Grade 3 and 4 toxicity has included 7 episodes of GI bleeding as well as infections, diarrhea, hypophosphatemia, hypocalcemia, elevated transaminases, and acute renal failure unrelated to treatment. With a median follow up of 4 months (range, 0 – 10), 15 patients are alive and in CR; 1 died at induction, 1 died in CR from an unrelated cardiac event, and 2 are too early. No patient has relapsed and no patient has received an allogeneic transplant. We conclude that the combination of the hyperCVAD regimen with dasatinib is feasible and can achieve early molecular remissions in patients with Ph+ ALL and CML-LB.

NCRI CLL201 Trial: A Randomized Phase II Trial of Fludarabine, Cyclophosphamide and Mitoxantrone (FCM) with or without Rituximab in Previously Treated CLL.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 752-752 ◽  
Author(s):  
Peter Hillmen ◽  
Christopher Pocock ◽  
Dena Cohen ◽  
Kim Cocks ◽  
Hazem A. Sayala ◽  
...  
Keyword(s):  
Phase Ii ◽  
Response Rate ◽  
Phase Ii Trial ◽  
Residual Disease ◽  
Early Death ◽  
Lymphocytic Leukemia ◽  
Phase Iii ◽  
Color Flow ◽  
Randomized Phase Ii ◽  
Number Of Patients

Abstract Standard front-line therapy for chronic lymphocytic leukemia (CLL) is fludarabine plus cyclophosphamide. Adding mitoxantrone (FCM) or rituximab (FCR) appears to improve responses although no large randomized trials have been reported. We report a randomized Phase II trial of FCM and FCM-R in relapsed CLL. FCM was oral fludarabine (24mg/m2 for 5 days) and cyclophosphamide (150mg/m2 for 5 days) plus i.v. mitoxantrone (6mg/m2) on Day 1 of each cycle. FCM-R was identical with rituximab on Day 1 of each cycle (375mg/m2 cycle 1; 500mg/m2 cycles 2 to 6). Prophylaxis with aciclovir and co-trimoxazole was given. The primary end-point was response by NCI Criteria 2 months after therapy. Complete remission with incomplete marrow recovery (CR(i)) was defined according to the 2007 CLL Guidelines - clinical CR with a morphologically normal marrow but persistent cytopenias (i.e. platelets <100x109/l and/or neutrophils <1.5x109/l). In addition, minimal residual disease in the marrow was studied 2 months after therapy by four-color flow cytometry with MRD negativity defined as <0.01% CLL cells. 52 patients were entered into the trial with 26 in each arm. The median age was 65 (32–79) with 79% men. 42% had a β2m >4. The median number of prior therapies was 2 (1–6), 31 had prior fludarabine and 6 (12%) were refractory to or relapsed <6 months after fludarabine. 26/44 (59%) had unmutated VH genes (15/22 FCM-R; 11/22 FCM). 11 patients had deletion of 11q (FCM-R 5, FCM 6) and 1 patient had >20% 17p deleted cells (FCM-R). 36/52 (69%) received 4 or more cycles of therapy with no difference between FCM and FCM-R (18/26). Responses are shown in the Table. 35 SAE’s were reported in 23 patients. There was no difference in the number of patients with SAE’s between the arms (FCM 11, FCM-R 12). 6/7 patients (86%) who had 4 or more prior therapies reported an SAE, compared to 17/45 patients (38%) who had less than 4. 16 SAE’s were suspected to be related to FCM-R and 10 related to FCM. In summary, FCM-R is an effective therapy for relapsed CLL with over two-thirds of patients responding. The study design does not allow a statistical comparison between FCM and FCM-R but the results suggest that adding rituximab to FCM results in a higher complete response rate (CR + CR i = 43% for FCM-R and 13% for FCM) with more patients achieving MRD negativity (5 after FCM-R; 2 after FCM). The results of this randomised Phase II trial justify the study of FC with mitoxantrone and/or rituximab in larger randomized Phase III trials. Responses in 46 evaluable patients (remaining 6 not yet evaluable) All patients FCM FCM-R Number of patients 46 23 23 Overall response rate 29 (63%) 13 (57%) 16 (70%) CR 5 (11%) 1 (4%) 4 (17%) CR(i) 8 (17%) 2 (9%) 6 (26%) PR 16 (35%) 10 (43%) 6 (26%) SD/PD 12 (26%) 7 (30%) 5 (22%) Early Death (before assessment) 4 (9%) 2 (9%) 2 (9%) Withdrew consent (before assessment) 1 (2%) 1 (4%) 0 (0%) MRD negative 7 (15%) 2 (9%) 5 (22%)

Combination of Sorafenib, Idarubicin, and Cytarabine Has a High Response Rate in Patients with Newly Diagnosed Acute Myeloid Leukemia (AML) Younger Than 65 Years

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 768-768 ◽  
Author(s):  
Farhad Ravandi ◽  
Jorge Cortes ◽  
Stefan Faderl ◽  
Guillermo Garcia-Manero ◽  
Susan O’Brien ◽  
...  
Keyword(s):  
Flow Cytometry ◽  
Phase I ◽  
Cell Lines ◽  
Phase Ii ◽  
Kinase Inhibitor ◽  
Single Agent ◽  
High Response Rate ◽  
Clinical Activity ◽  
Mutation Burden

Abstract Background: Sorafenib is an orally active multi-kinase inhibitor with potent activity against the Raf/ERK/MEK pathway, VEGFR, PDGFR-β, and c-KIT. In vitro, it has growth-inhibitory effects in several AML cell lines with or without constitutive activation of ERK signaling. Sorafenib selectively induces cell growth arrest and apoptosis in FLT3-mutant human AML cell lines at nM concentrations. In a phase I study of single agent sorafenib in patients (pts) with AML escalating doses were well tolerated with no myelosuppression and with significant clinical activity predominantly (but not exclusively) in FLT3 mutated pts. Methods: This study was conducted to determine the tolerability and efficacy of combination of sorafenib with cytarabine 1.5 g/m2 iv over 24 hours daily × 4 (× 3 for pts over 60) and idarubicin 12 mg/m2 iv daily × 3. In the phase I portion of study, pts with relapsed AML were treated with escalating doses of sorafenib po (400 mg qod, 400 mg daily and 400 mg bid) for 7 days during induction, and 400 mg bid was established as a safe dose for phase II evaluation. Pts achieving CR receive up to 5 courses of consolidation with idarubicin 8 mg/m2 iv daily × 2 and cytarabine 0.75 g/m2 iv daily × 3 in addition to continuous sorafenib 400 mg po bid for up to 28 days per cycle. Maintenance with sorafenib 400 mg bid would continue for up to a year after consolidation. Results: Ten pts (median age 34 years, range 21–58) with relapsed AML (median prior therapy 2, range 1–6) were treated on the phase I portion. Seven had FLT3-ITD mutation (5 with high mutation burden, 2 with low), and 3 were negative. Four achieved CR, and 6 failed. In the phase II portion, 30 pts (including 8 with FLT3-ITD and 2 with FLT3-TKD) have been treated. Median age is 53 years (range 18 – 65) Cytogenetics were diploid in 13, +8 in 3, −5/−7 in 3, t(9;11) in 1, miscellaneous in 6, and unavailable in 4. The median presentation WBC was 4.6 × 109/L (range 1.5 –122.7 × 109/L). FLT3 mutation burden was low in blasts from 4 pts, and high in 6). Five pts were FLT3-ITD+/NPM1-. Among 25 evaluable pts, 22 (88%) have achieved CR (n=19), or CRi (n=3); 1 achieved PR, 1 died at induction from pneumonia, 1 was resistant; 5 pts are too early. The regimen is well tolerated and grade 3 adverse events thought to be possibly related to the study combination have included elevation of transaminases (3), hyperbilirubinemia (4), small bowel obstruction (1), diarrhea (2), rash (2), pericarditis (1), elevated creatinine (1), and atrial fibrillation (1). Median follow-up is 8 weeks (range, 1 – 28) with the probability of survival at 6 months of 87%; 2 pts have relapsed with CR durations of 2 and 3 months. Samples from 8 pts were studied prior to and 24–48 hours post sorafenib administration, and prior to chemotherapy. In six pts (75%), sorafenib alone induced apoptosis in peripheral blood blasts and in CD33/CD34 positive leukemia progenitor cells as determined by flow cytometry. Expression of phospho-ERK (pERK) was detectable by flow cytometry in 5 out of 7 samples tested at baseline; 24-hour exposure to sorafenib resulted in >50% downregulation of pERK in 3 of the 5 samples. Plasma inhibitory assay was performed using day 7 samples from 10 pts; mutant FLT3 was suppressed by all samples with 5-fold more potent suppression against mutant versus wildtype FLT3. Conclusions: Combination of sorafenib with idarubicin and cytarabine is safe and has a high CR rate in frontline therapy of younger pts with AML. Correlative studies confirm potent activity of sorafenib against ERK and FLT3 signaling.

Innovative Phase I/II Statistical Design in Combination Chemotherapy That Combines Toxicity and Efficacy Parameters to Increase Study Efficiency: Bendamustine and Idarubicin in De Novo Adult AML

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 1552-1552
Author(s):  
Jack M. Lionberger ◽  
Kathleen Shannon Dorcy ◽  
Carol Dean ◽  
Nathan Holm ◽  
Bart Lee Scott ◽  
...  
Keyword(s):  
Phase I ◽  
Phase Ii ◽  
De Novo ◽  
Statistical Design ◽  
Maximum Tolerated Dose ◽  
Dose Finding ◽  
Therapeutic Decisions ◽  
Number Of Patients ◽  
Relevant Dose ◽  
Acceptable Probability

Abstract Abstract 1552 Background: Novel drugs or drug combinations are conventionally tested first in Phase I studies (in which therapeutic decisions are based solely on toxicity) with Phase II (efficacy) evaluations following as a separate trial. This process not only slows new drug development, it is challenging for patients during the informed consent process, because they usually enter trials not merely in hope of “no toxicity” but in hope of response. Response rates in Phase I at doses less than the maximum tolerated dose (MTD) may be irrelevant to efficacy, but this common assumption remains unproven. An equally plausible alternative is efficacy failure at these lower doses augurs failure at the MTD in Phase II. This hypothesis prompted development of a Phase I-II Bayesian design that uses both efficacy and toxicity to find a clinically relevant dose (Biometrics 2004;60: 684–93). In the current study, we apply the innovative Bayesian approach to the design of a Phase I-II trial using bendamustine + idarubicin in older patients (>50 yo) with newly-diagnosed AML or high risk MDS (>10% marrow blasts). We then compare and contrast our trial operation with that of the standard 3+3 Phase I design. Methods: The design specifies anticipated probabilities (“priors”) of response (CR or no CR) and toxicity (grade 3–4 or not) at each of 4 doses of bendamustine (45,60,75,90 mg/m2 daily × 5 together with idarubicin 12 mg/m2 daily on day 1 and 2). Patients are entered in groups of 3 beginning at the 45 mg/m2 dose. As response/toxicity data became available for each cohort, Bayes theorem is used to update the priors and derive current probabilities (“posteriors”) of response/toxicity at each dose. The priors are set to be relatively non-informative allowing the posteriors to be primarily influenced by the data from the trial. The posteriors are referred to a minimum acceptable probability of response (here 40%) and a maximum acceptable probability of toxicity (30%). If the posteriors indicate that it is highly unlikely (< 2% chance) that any dose is associated with both of these probabilities the trial stops. Otherwise the next cohort of patients is treated at a dose so associated. This process is repeated iteratively to a maximum sample size of 48 patients. The parameters noted above were chosen to give desirable probabilities of selecting for future study doses meeting the minimum acceptable response and maximum acceptable toxicity rates. Results: Table 1 compares the operation of this trial with a standard 3+3 Phase I trial. Given that 2/3 patients had toxicity at the 75 dose, a Phase I 3+3 design would have declared 60 the MTD. Subsequently, an “expansion cohort” as a Phase II trial would be treated at this dose without any possibility of revisiting the 75 dose. This conclusion flies in the face of basic notions of statistical reliability and ignores the possibility that patients experiencing toxicity may have been particularly old, had significant comorbidities, or have a variable functional reserve for undefined reasons. In contrast, the Phase I-II design allows the trial to continue, and potentially revisit higher doses of therapy depending on the collective outcome of a greater number of patients. Based on our actual data, this trial continued to treat patients at the 60 mg/m2 dose level, and in the next three patients there was no toxicity. In this case response data becomes the determining factor, which improves the efficiency of the trial. If 0/3 patients had a response, the trial would return to 75 mg/m2, however, because 2/3 patients had a response, the trial continues to accrue at 60mg/m2, with the statistical force of twice the number of patients. Conclusion: Accounting for response during dose finding seems to permit more sophisticated/flexible decisions about dosing in addition to improving efficiency. Disclosures: Shannon Dorcy: Cephalon: Consultancy, Honoraria, Speakers Bureau.

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