A Final Report: Phase I/II Study of Sequential Azacitidine and Lenalidomide in Patients with Higher-Risk Myelodysplastic Syndrome (MDS) and Acute Myeloid Leukemia (AML)

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 164-164
Author(s):  
Courtney D. DiNardo ◽  
Naval Daver ◽  
Elias Jabbour ◽  
Tapan Kadia ◽  
Gautam Borthakur ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Overall Survival ◽  
High Risk ◽  
Phase I ◽  
Phase Ii ◽  
Median Overall Survival ◽  
Somatic Mutations ◽  
Front Line ◽  
50Mg Daily ◽  
Bone Marrow Blasts

Abstract Hypomethylating agents (HMAs) are currently the front-line therapeutic choice for patients with higher risk MDS, and also frequently employed in elderly AML or in AML patients not otherwise eligible for standard intensive therapy. A number of combination strategies are under development to improve the results of HMA monotherapy. Given the single-agent activity of both azacitidine (AZA) and lenalidomide (LEN) in patients with MDS and AML, a scientific rationale exists to explore this therapeutic combination strategy. Previous studies have evaluated the combination of AZA and lenalidomide in this population with encouraging results, using lenalidomide at doses ranging from 5 to 50mg daily over 5 to 28 days per cycle. The optimal dose and schedule for this combination remains unknown. We report our completed Phase I/II study of sequential AZA and lenalidomide in 88 patients with high-risk MDS and AML. Phase I eligibility included relapsed/refractory AML or MDS patients with bone marrow blasts >10%. Phase II eligibility included untreated high-risk MDS, or AML with 20-30% blasts. All subjects were registered into the RevAssist® program. Median age was 67 (range 32–88). Per WHO criteria, there were 42 MDS patients (48%), 3 (3%) with CMML-2, 20 (23%) with RAEB-T (i.e. 20-30% bone marrow blasts), and 23 patients (26%) with AML (>30% blasts). All subjects received 75mg/m²/day AZA days 1-5 of each 28-day cycle. LEN was administered orally for 5 or 10 days, starting on day 6 per cycle. 28 patients in the Phase I and 60 in the Phase II portion were treated. In the Phase I portion, 7 levels of LEN were evaluated with the following doses and schedules: 10mg x 5 days (n=5), 15mg x 5 days (n=3), 20mg x 5 days (n=3), 25mg x 5 days (n=3), 50mg x 5 days (n=4), 75mg x 5 days (n=3), and 75mg x 10 days (n=7). The initial Phase II starting dose was LEN 50mg daily x 10 days, however due to myelosuppression and infections with repeated cycles in the first 20 Phase II subjects, the Phase II dose was amended to LEN 25mg daily x 5 days, and another 40 patients were evaluated. In the entire cohort, overall response rate (ORR) was 35% (31/88) (15 CR; 16 CR with incomplete count recovery (CRi)), with median overall survival (OS) of 33 weeks (range 1-172). Phase I ORR was 14% (4/28) and Phase II ORR was 45% (27/60). Of the 40 patients receiving the optimal Phase II dose, ORR was 55% (22/40), with 75 week median OS. In responding patients (n=31), the median response duration was 29 weeks (range 2 - 127 weeks), with a median overall survival that has not been reached with a median follow-up time of 57 weeks (Figure 1). 13 of the 31 responding patients (42%) proceeded with stem cell transplant, of which 10 patients continue in a sustained remission. In a cohort of 25 molecularly annotated patients (Table 1), 5 of 9 (56%) TP53-mutant patients, all with complex cytogenetics, achieved CR/CRi. By multivariate analysis, treatment was associated with worse OS in patients with bone marrow blasts > 30% (HR 4.5, 95% CI 2.4 – 8.5, p < 0.001), complex cytogenetics (HR 3.4, 95% CI 1.8 – 6.2, p < 0.001), and lenalidomide dose (HR 2.2, 95% CI 1.1-4.4, p = 0.03). In conclusion, we identify the combination of AZA 75mg/m²/day on days 1-5 with 25mg LEN on days 6-10 over a 28-day cycle as an effective front-line regimen for high-risk MDS and AML with up to 30% blasts. Responses are rapid with a median of 2 cycles for response, durable, and treatment with this dosing schedule is well tolerated. Figure 1: Overall survival of responders (n=31) Figure 1:. Overall survival of responders (n=31) Figure 2: Somatic mutations, cytogenetics and response in the annotated subset of 25 patients Figure 2:. Somatic mutations, cytogenetics and response in the annotated subset of 25 patients Disclosures Garcia-Manero: Celgene: Research Funding.

A Phase I/II Trial of Combination of Midostaurin (PKC412) and 5-Azacytidine (5-AZA) for the Treatment of Patients with Refractory or Relapsed (R/R) Acute Myeloid Leukemia (AML) and Myelodysplastic Syndrome (MDS)

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 3587-3587 ◽  
Author(s):  
Aziz Nazha ◽  
Hagop M. Kantarjian ◽  
Gautam Borthakur ◽  
Guillermo Garcia-Manero ◽  
Tapan M. Kadia ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Acute Myeloid Leukemia ◽  
Phase I ◽  
Phase Ii ◽  
Myeloid Leukemia ◽  
Research Funding ◽  
Response Rate ◽  
Allelic Ratio ◽  
Bone Marrow Blasts ◽  
Acute Myeloid

Abstract Abstract 3587 Background: Midostaurin (PKC412) is a potent orally bioavailable FLT3 inhibitor with activity in acute myeloid leukemia (AML). 5-azacytidine (5-AZA) is a hypomethylating agent that plays an important role in the treatment of AML and MDS. We hypothesized that adding midostaurin to 5-AZA may improve the response rate with limited toxicity profile. Materials and Methods: Patients ≥18 years with MDS, chronic myelomonocytic leukemia (CMML) or AML, who failed prior therapies with performance status ≤ 2, adequate liver (bilirubin ≤ 2 × ULN, ALT ≤ 2.5× ULN) and renal (creatinine ≤2× ULN) functions were eligible. Patients were included in phase I regardless of FLT3 mutation status; only FLT3 mutated patients were included in phase II. Patients received 5-AZA 75 mg/m2 subcutaneously or intravenously for 7 days of each cycle (Days 1–7) and midostaurin at 25 mg (cohort 1) and 50 mg (cohort 2; target dose) orally twice daily for 14 days (Days 8–21) per cycle. Patients were planned to receive up to 12 cycles if benefit from treatment. Supportive care was standard. The study was approved by institutional IRB and conducted in accordance of the declaration of Helsinki. Results: 20 patients have been enrolled: 13 included in phase I (6 in cohort 1 and 7 in cohort 2) and 6 patients in phase II. One patient in cohort 1 was inevaluable for DLT (withdrawal before completing cycle #1). One patient in cohort 2 received midostaurin dose as per cohort 1 dose by patient error. Patients' characteristics and responses are summarized in table 1. Overall response rate (ORR) in phase I was 3/13 (21%) (2 CRi and 1 patient decreased BM blasts from 27% to 7% after 2 cycles and went to transplant). ORR in phase II was 2/6 (33%) (1 patient with AML achieved CRi, 1 patient with CMML {received prior sorafenib} achieved CR). In addition, 1 AML patient had bone marrow blasts improved form 77% to 10% after 1 cycle, completed 3 cycles of therapy and then refused further treatment, and 1 AML patient had bone marrow blasts improve from 34% to 7 % and was continued on treatment). A total of nine patients with FLT3-ITD mutations enrolled in the trial: four patients in phase I with a median allelic ratio of 0.44 (range, 0.219–0.726); 1/4 (25%) achieved CRi, 2 of the non-responders had received prior FLT3 inhibitors (1 had developed FLT3-D835). Five patients in phase II had FLT3-ITD (median allelic ratio 0.06, range 0.014–0.279; one with concomitant D835 mutation) and one patient had FLT3-D835 mutation only (allelic ratio 0.238). 4/6 patients in phase II had failed prior FLT 3 inhibitors. In total, the ORR among patients with FLT3-ITD mutations was 3/9 (33%). All toxicities were grade 1 and 2 with no difference between the 2 dose schedules of midostaurin. No DLT or deaths were identified. Conclusion: The combination of midostaurin/5-AZA is safe and well tolerated at the intended doses (midostaurin 50 mg PO twice daily). Good ORR in high risk patients with relapsed or primary refractory FLT3-ITD positive AML was observed. Schedule is being amended to allow uninterrupted midostaurin administration. Phase II study continues to enroll patients with FLT3 mutations and updated results will be presented at the meeting. Disclosures: Off Label Use: 5-azacytidine in AML. Cortes:Novartis: Consultancy, Research Funding; Celgene: Research Funding; Ambit: Research Funding.

scholarly journals Final Results from a Phase 2 Study of Pracinostat in Combination with Azacitidine in Elderly Patients with Acute Myeloid Leukemia (AML)

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 453-453 ◽  
Author(s):  
Guillermo Garcia-Manero ◽  
Ehab Atallah ◽  
Samer K Khaled ◽  
Martha Arellano ◽  
Mrinal M Patnaik ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Overall Survival ◽  
High Risk ◽  
Primary Endpoint ◽  
Research Funding ◽  
Median Overall Survival ◽  
Myelogenous Leukemia ◽  
Motor Neuropathy ◽  
Oncology Research ◽  
Study Therapy

Abstract Background: Combination studies with histone deacetylase (HDAC) inhibitors plus hypomethylating agents (HMA) have suggested beneficial clinical activity in higher risk MDS and AML, though exceptions have also been reported. Pracinostat is a potent oral HDAC inhibitor selective for class I, II and IV isoforms. A pilot phase Ib study of pracinostat in combination with azacitidine (AZA) in higher risk MDS demonstrated a complete response (CR)/CR with incomplete blood count recovery (CRi) rate of 89% (Proc ASH:3821, 2012). Preliminary data on 33 patients from a multi-center, open-label, single-arm Phase II study of Pracinostat in combination with AZA in elderly AML also reported a high CR/CRi rate (ASH 2014). Herein we report the latest survival and response results for this study. Methods: Eligibility includes previously untreated AML (≥20% bone marrow blasts), age ≥65 years, unsuitable for intensive therapy due to co-morbidities and/or AML related features, and intermediate or high-risk cytogenetics. Study therapy includes pracinostat, 60 mg p.o. 3 alternate days/week for 3 weeks plus AZA, 75 mg/m2) days 1-7 or days 1-5 and 8-9 either s.c. or i.v. with cycles repeated every 28 days until progressive disease, lack of response or intolerance. The primary endpoint is CR+CRi+ morphologic leukemia free state (MLFS) per IWG criteria. Response assessments occur at the end of cycle 1 or 2 then every other cycle or when clinically indicated. A Simon 2-stage statistical design is utilized with the following assumptions: null=0.10, alternate=0.25, a=0.10, power=0.90. Stage 1 n=27 and total stage 2 n=40. Secondary endpoints include overall response rate (ORR; CR+CRi+MLFS+partial response [PR]+PRi), duration of response and overall survival. Results: Between Dec 2013 and Dec 2014, 50 patients from 15 study sites were enrolled. At this time, 50 are evaluable for efficacy. Baseline disease characteristics for all patients include: median age 75 (range 66-84); 32 de novo AML, 13 evolved from AHD, 5 were treatment-related; 28 intermediate-risk and 20 high-risk cytogenetics and 2 unknown; baseline bone marrow blast counts ranged from 20% to 89% with a median of 40%. Thirty-one patients (62%) continue to be followed for survival (range: 8.5 to 18.5 months). Median overall survival has not been reached in the overall study population and neither in patients with high-risk cytogenics or those with AML secondary to MDS or prior anti-cancer therapy. The 1-year overall survival estimate is 60%. The primary endpoint of CR +CRi +MLFS has been observed in 27/50 evaluable patients (54%) to date, including 21/50 (42%) CR. The 60-day all-cause mortality rate is 10% (5/50). Treatment emergent adverse events (TEAEs) Grade ≥3 seen in >5% of patients: febrile neutropenia 30%; thrombocytopenia 22%; neutropenia 10%; cellulitis 10%; anemia 8%; fatigue 8%; sepsis 6%, and pancytopenia 6%. TEAE's leading to study therapy discontinuation: peripheral motor neuropathy (1), parainfluenza (1), atrial fibrillation/prolonged QTc (1), subdural hematoma after a fall (1), and sepsis (3). Conclusions: Pracinostat plus AZA produces a high rate of durable responses in this AML population. Median overall survival has not been reached; 1-year overall survival is estimated at 60%. Final response data and overall survival estimates will be presented at the meeting. Disclosures Off Label Use: Azacitidine is not approved for use in acute myelogenous leukemia.. Khaled:Sequenom: Research Funding. Arellano:Cephalon Oncology: Research Funding. Butler:MEI Pharma, Inc.: Employment. Ashby:MEI Pharma, Inc.: Employment. Medeiros:Celgene: Honoraria, Research Funding; Agios Pharmaceuticals: Honoraria.

scholarly journals Identification of Predictive Factors for Overall Survival at Baseline and during Azacitidine Treatment in High-Risk Myelodysplastic Syndromes Treated in the Clinical Practice

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 5518-5518
Author(s):  
Emilia Scalzulli ◽  
Matteo Molica ◽  
Alunni Fegatelli Danilo ◽  
Lorenzo Rizzo ◽  
Roberto Latagliata ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Overall Survival ◽  
Clinical Practice ◽  
High Risk ◽  
Myelodysplastic Syndromes ◽  
Prognostic Score ◽  
Advisory Board ◽  
Transfusion Dependency ◽  
Very High ◽  
Bone Marrow Blasts

Abstract Background. 5-Azacitidine (5-AZA) had changed the therapeutic approach to intermediate-2/high IPSS risk myelodysplastic syndromes (MDS) improving the outcome of patients, even in the absence of a complete response. However, real-life experiences have reported contradicting results compared to the AZA001 randomized study. Aim of our analysis was to identify the clinico-biological features at baseline and during treatment associated with the overall survival (OS) and progression-free survival (PFS) at two years in a consecutive cohort of patients treated with hypometylating agent in the clinical practice. Moreover, we propose a new prognostic score for the identification of OS after the first four cycles of therapy. Patients and Method. We retrospectively analyzed a series of 110 MDS patients treated at a single institution with 5-AZA between September 2003 and January 2017. Patients were diagnosed according to the WHO 2016 criteria. 5-AZA was administered at a dose of 75 mg/m2 according to the 5+2+2 schedule every 28 days. Results. A male predominance was observed (male/female: 66%/34%) with a median age of 70 years (range 38-85). The median dose of 5-AZA received was 135 mg/day (range 105-150) after a median time from diagnosis of 2.3 months (range 0.1-119). Median duration of therapy was 9.5 cycles (range 1-77) with a median time on treatment of 8.5 months (range 1-86.7). OS of the whole cohort was 66.1% (CI 95% 57.2-76.4) at 1 year and 38.3% (CI 95% 29.4-49.9) at 2 years. Seventy-seven patients (70%) performed four cycles of therapy. According to the IWG criteria, 42 patients (54.5%) achieved a complete remission (CR), 11 (14.2%) a partial remission (PR), 17 (22.4%) maintained a stable disease (SD), 2 (2.5%) and 5 (6.4%) presented a progression disease (PD) and a failure, respectively. The 2-year OS was 68% in patients who obtained a CR/PR, 20% in patients with SD and 16% in patients with PD/failure (p<0.001). No differences in terms of OS were observed for gender (p=0.622) and age at baseline (<65years, 65-75 and >75 years, p=0.075). The baseline bone marrow blasts percentage did not impact on OS and PFS (OS, p=0.867; PFS, p=0.611). According to the Revised International Prognostic Score (R-IPSS), 22 (20%), 46 (42.8%) and 42 (38.2%) patients were classified as intermediate, high and very high-risk patients, respectively. We identified that the very high-risk group had an inferior 2-year OS (17%) compared to intermediate-group patients (64%, p<0.001). Indeed, we did not find significant difference according to the IPSS stratification (intermediate 42% vs high-risk 22%, p=0.253). Transfusion-independency at baseline was identified as a favorable prognostic factor on 1-year (66.8%) and 2-year OS (43.4%) compared to patients with transfusion dependency (36.4% and 22.2% if they required 1 unit/month or more than 1 unit at baseline at 2 years, p<0.001). After four cycles received, the persistence of bone marrow blasts >10% identified patients with a worse outcome, with a 2-year OS of 9.4% compared to 60.3% for patients with 0-5% blasts and 44.7% for patients with 5-10% blasts (p=0.002). The occurrence of one infection during the first four cycles impacted on the 2-year OS (31.6% vs 58.3% in patients without, p=0.032). We applied a dynamic prognostic score according to age, cytogenetic risk, transfusion need, number of 5-AZA cycles performed and type of response after the fourth cycle (Table 1): the combination of these variables identified 3 categories of risk with a significantly different 2-year OS: low-risk (72.3%), intermediate (19.8%) and high-risk (8.9%) (p<0.001, Fig. 1). Conclusions. Our results in a large and consecutive MDS cohort treated outside of clinical trials defined prognostic factors, such as transfusion dependency, persistence of >10% blasts after four cycles and absence of infections, capable of identifying patients with a good outcome. A prognostic score is proposed that requires independent validations in similar cohorts of patients. Disclosures Rizzo: Sapienza University, Rome: Other: Resident in Hematology. Foà:NOVARTIS: Speakers Bureau; CELTRION: Other: ADVISORY BOARD; GILEAD: Speakers Bureau; JANSSEN: Other: ADVISORY BOARD, Speakers Bureau; ROCHE: Other: ADVISORY BOARD, Speakers Bureau; CELGENE: Other: ADVISORY BOARD, Speakers Bureau; AMGEN: Other: ADVISORY BOARD; ABBVIE: Other: ADVISORY BOARD, Speakers Bureau; INCYTE: Other: ADVISORY BOARD. Breccia:Pfizer: Honoraria; Novartis: Honoraria; BMS: Honoraria; Incyte: Honoraria.

Standard Consolidation/Maintenance Chemotherapy Is Consistently Superior to a Single Autologous Transplant for Adult Patients with Acute Lymphoblastic Leukemia: Results of the International ALL Trial (MRC UKALL XII/ECOG E2993)

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 3314-3314
Author(s):  
Jacob M. Rowe ◽  
Georgina Buck ◽  
Anthony V Moorman ◽  
Martin S Tallman ◽  
Susan M Richards ◽  
...  
Keyword(s):  
Overall Survival ◽  
High Risk ◽  
Maintenance Therapy ◽  
Phase I ◽  
Detailed Analysis ◽  
Phase Ii ◽  
Autologous Transplantation ◽  
Allogeneic Transplant ◽  
Autologous Transplant ◽  
Standard Risk

Abstract The International ALL trial, conducted jointly by the MRC in the UK and ECOG in the US (UKALL XII/E2993), recruited 1929 patients between 1993 and 2006. All patients aged 16 to 64 years with newly diagnosed ALL, received the identical two phases of induction therapy. Patients with an HLA-identical sibling were assigned to a sibling allogeneic transplant and those who were Ph-positive could also get an unrelated-donor transplant. Patients who did not have a donor were to be randomized between a single autologous transplant, after conditioning with etoposide/total body irradiation, versus consolidation/maintenance therapy for 2.5 years. Following randomization, but prior to receiving the assigned or randomized therapy, all patients received intensification with 3 cycles of high-dose methotrexate. After excluding patients assigned to an allogeneic transplant, 1028 patients were eligible for randomization but, as in other major transplant studies, only 457 were randomized. The rationale underlying the randomization was based on the fact that protracted consolidation/maintenance therapy in adults, extrapolated from the pediatric experience, had never been prospectively evaluated in the era of intensive chemotherapy. Given that the mortality from autotransplant is not higher than chemotherapy (Goldstone et al. Blood. 2008), it was postulated that if a single autologous transplant is at least as good as standard protracted chemotherapy that may make it the preferable option, except possibly in females in whom fertility may be an issue. The overall survival and the event-free survival were significantly superior among the chemotherapy patients (p = .05) as previously reported (Goldstone et al. Blood. 2008). Because the literature contains reports suggesting a trend in favor of autologous transplantation in some patients with ALL (Dhédiu et al. Leukemia, 2006), an analysis was performed to see if any subgroup of patients could be identified in whom: 1. chemotherapy may not be superior to autologous transplant and 2. autologous transplant may be superior. The table lists a detailed analysis of overall survival looking at various age groups, B- versus T-lineage, the rapidity with which a complete remission was achieved –after phase I or only after phase II of induction. Detailed analysis was also performed by cytogenetics looking at those with standard risk versus those with high risk abnormalities [ t(9;22), t(4;11), t(8;14)] and low hypodiploidy/near triploidy or a complex karyotype (Moorman et al. Blood. 2007)]. In all groups, the chemotherapy group was at least as efficacious as the autograft group, and in some was even significantly superior to autologous transplantation. There is no evidence that other risk factors, such as relapse rate or treatment-related mortality, influenced these overall survival data. In addition, the tests for heterogeneity were not significant across any group. In conclusion, the overall survival was longer in patients randomized to chemotherapy, although the superiority was not statistically significant in most of the groups. There is no clinical indication for autologous transplantation at any age and particularly this should not be considered for patients over age 50, those with high-risk cytogenetics or T-lineage, and late remitters, for whom it might appear most attractive. Overall Survival (OS) at 5 years in 457 Randomized Patients Chemo Auto Subgroups n OS n OS P (log rank) Age (years) < 20 50 58% 43 46% > 0.1 20–29 61 52% 70 43% > 0.1 30–39 46 39% 46 32% > 0.1 40–49 38 31% 35 31% > 0.1 50 + 33 38% 35 31% > 0.1 B-lineage 169 46% 158 35% 0.03 T-lineage 45 54% 54 49% > 0.1 Time to CR phase I 193 48% 190 41% 0.1 phase II 26 36% 29 19% 0.08 Cytogenetics standard-risk 109 51% 122 44% > 0.1 high-risk 29 23% 27 7% 0.02

scholarly journals Orderly Process of Sequential Cytokine Stimulation Is Required for Activation and Maximal Proliferation of Primitive Human Bone Marrow CD34+ Hematopoietic Progenitor Cells Residing in G0

Blood ◽  
1997 ◽  
Vol 90 (2) ◽  
pp. 658-668 ◽  
Author(s):  
Amy C. Ladd ◽  
Robert Pyatt ◽  
Andre Gothot ◽  
Susan Rice ◽  
Jon McMahel ◽  
...  
Keyword(s):  
Cell Cycle ◽  
Bone Marrow ◽  
Phase I ◽  
Progenitor Cells ◽  
Phase Ii ◽  
Hematopoietic Progenitor Cells ◽  
Hematopoietic Progenitor ◽  
Cd34 Cells ◽  
Cytokine Stimulation ◽  
Phase Iv

Abstract Bone marrow (BM) CD34+ cells residing in the G0 phase of cell cycle may be the most suited candidates for the examination of cell cycle activation and proliferation of primitive hematopoietic progenitor cells (HPCs). We designed a double simultaneous labeling technique using both DNA and RNA staining with Hoechst 33342 and Pyronin Y, respectively, to isolate CD34+ cells residing in G0(G0CD34+ ). Using long-term BM cultures and limiting dilution analysis, G0CD34+ cells were found to be enriched for primitive HPCs. In vitro proliferation of G0CD34+ cells in response to sequential cytokine stimulation was examined in a two-step assay. In the first step, cells received a primary stimulation consisting of either stem cell factor (SCF), Flt3-ligand (FL), interleukin-3 (IL-3), or IL-6 for 7 days. In the second step, cells from each group were washed and split into four or more groups, each of which was cultured again for another week with one of the four primary cytokines individually, or in combination. Tracking of progeny cells was accomplished by staining cells with PKH2 on day 0 and with PKH26 on day 7. Overall examination of proliferation patterns over 2 weeks showed that cells could progress into four phases of proliferation. Phase I contained cytokine nonresponsive cells that failed to proliferate. Phase II contained cells dividing up to three times within the first 7 days. Phases III and IV consisted of cells dividing up to five divisions and greater than six divisions, respectively, by the end of the 14-day period. Regardless of the cytokine used for primary stimulation, G0CD34+ cells moved only to phase II by day 7, whereas a substantial percentage of cells incubated with SCF or FL remained in phase I. Cells cultured in SCF or FL for the entire 14-day period did not progress beyond phase III but proliferated into phase IV (with &lt;20% of cells remaining in phases I and II) if IL-3, but not IL-6, was substituted for either cytokine on day 7. G0CD34+ cells incubated with IL-3 for 14 days proliferated the most and progressed into phase IV; however, when SCF was substituted on day 7, cells failed to proliferate into phase IV. Most intriguing was a group of cells, many of which were CD34+, detected in cultures initially stimulated with IL-3, which remained as a distinct population, mostly in G0 /G1 , unable to progress out of phase II regardless of the nature of the second stimulus received on day 7. A small percentage of these cells expressed cyclin E, suggesting that their proliferation arrest may have been mediated by a cyclin-related disruption in cell cycle. These results suggest that a programmed response to sequential cytokine stimulation may be part of a control mechanism required for maintenance of proliferation of primitive HPCs and that unscheduled stimulation of CD34+ cells residing in G0 may result in disruption of cell-cycle regulation.

scholarly journals Outcomes with sequential FLT3-inhibitor-based therapies in patients with AML

2020 ◽  
Vol 13 (1) ◽  
Author(s):  
Musa Yilmaz ◽  
Mansour Alfayez ◽  
Courtney D. DiNardo ◽  
Gautam Borthakur ◽  
Tapan M. Kadia ◽  
...  
Keyword(s):  
Overall Survival ◽  
Phase Ii ◽  
Median Overall Survival ◽  
Second Generation ◽  
Single Agent ◽  
Response Rates ◽  
Flt3 Inhibitor ◽  
Flt3 Inhibitors ◽  
First Time

Abstract Background Second-generation FLT3-inhibitors (FLT3i) demonstrated single-agent composite CR rates (CRc) of 45–55% in patients with relapsed/refractory (R/R) FLT3-mutated AML in phase II/III trials. However, > 85% of patients treated were prior FLT3i naïve. The response rates to sequential FLT3i exposure remain poorly defined. Methods We retrospectively reviewed patients with FLT3-mutated AML between November 2006 and December 2019. Results In frontline patients treated with a FLT3i (cohort 1), the CRc rates and median overall survival (OS) with the first (n = 56), second (n = 32), and third FLT3i-based (n = 8) therapy were 77%, 31%, and 25%, and 16.7 months, 6.0 months, and 1.4 months, respectively. In patients receiving a FLT3i-based therapy for the first time in a R/R AML setting (cohort 2), the CRc rates and median OS were 45%, 21%, and 10%, and 7.9 months, 4.0 months, and 4.1 months with the first (n = 183), second (n = 89), and third/fourth (n = 29) FLT3i-based therapy, respectively. In cohort 1, CRc rates with single-agent FLT3i (n = 21) versus FLT3i-based combinations (n = 19) in second/third sequential FLT3i exposures were 19% versus 42%, respectively. In cohort 2, the CRc rates with single-agent FLT3i (n = 82) versus FLT3i-based combinations (n = 101) in first FLT3i exposure were 34% versus 53%, respectively, and those with single-agent FLT3i (n = 63) versus FLT3i-based combinations (n = 55) in second/third/fourth sequential FLT3i exposures were 13% versus 25%, respectively. Conclusion CRc rates drop progressively with sequential exposure to FLT3i’s in FLT3-mutated AML. In all settings, CRc rates were higher with FLT3i-based combinations compared with single-agent FLT3i therapy in similar FLT3i exposure settings.

Phase II Evaluation of the Tyrosine Kinase Inhibitor MLN518 in Patients with Acute Myeloid Leukemia (AML) Bearing a FLT3 Internal Tandem Duplication (ITD) Mutation.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 1792-1792 ◽  
Author(s):  
Daniel J. De Angelo ◽  
Richard M. Stone ◽  
Mark L. Heaney ◽  
Stephen D. Nimer ◽  
Ronald Paquette ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Steady State ◽  
Phase Ii ◽  
Plasma Concentrations ◽  
Remission Induction ◽  
Western Blots ◽  
Adequate Treatment ◽  
The Mean ◽  
Trough Plasma ◽  
Bone Marrow Blasts

Abstract MLN518 is a small molecule inhibitor of FLT3, PDGFR and c-Kit that is currently being evaluated as a therapy for AML. Previous phase I evaluation of MLN518 showed that it inhibits the phosphorylation of both wild-type and ITD-mutated FLT3 in patients’ leukemic blasts with an IC90 in the range of 100–175 ng/mL. Anti-leukemic activity was also observed, with decreases in both peripheral and bone marrow blasts. Dose-limiting toxicity, consisting of reversible general muscular weakness and/or fatigue was associated with trough plasma MLN518 concentrations > 1000 ng/mL. We are now conducting a phase II study of MLN518 in patients with relapsed or refractory AML and in untreated patients with AML considered unfit for standard AML therapies. Eligibility requires demonstration of the FLT3 ITD mutation in the patient’s blasts. All patients are treated with MLN518 at an initial dose of 525 mg po bid, with provision for dose reduction if MLN518-associated weakness occurs. Twenty patients have been treated with MLN518 in this study, eighteen of whom are currently evaluable (2 patients have recently started therapy). Toxicities associated with MLN518 therapy have included weakness/fatigue, QTc prolongation (relationship to MLN518 uncertain), and nausea and vomiting. MLN518 plasma concentration-time data for the first fourteen patients demonstrates that all patients achieved steady-state trough plasma concentrations > 150 ng/mL. Both inter- and intra-subject variability (%CV) in trough steady-state concentrations were < 30%. Assessment of total and phosphorylated FLT3 in leukemic blasts isolated from peripheral blood was possible in 4 patients. Western blots from blasts obtained before and after MLN518 dosing demonstrated either partial or complete inhibition of FLT3 phosphorylation with MLN518 plasma concentrations > 130 ng/mL. Of the eighteen evaluable patients, response could not be assessed in three because intercurrent illness and/or MLN518-associated toxicity precluded adequate treatment with MLN518 (≥ 14 days). Seven patients experienced progressive AML without evidence of any anti-leukemic effect. Two patients had stable disease for ≥ 50 days and subsequently underwent bone marrow transplantation. Although no complete or partial remissions have been observed, 6 patients have demonstrated evidence of an anti-leukemic effect with decreases in both peripheral and bone marrow blasts of 1-3 months duration. In these 6 patients the mean decrease in the absolute peripheral blast count was 92%, with a range of 85–100%. The mean decrease in the bone marrow blast percentage was 62%, with a range of 44–94%. We conclude that MLN518 has anti-leukemic activity in FLT3 ITD-mutated AML and should be further evaluated as a component of remission-induction and/or maintenance therapy in this disease.

Phase I Study of the Combination of 5-Azacitidine Sequentially with High-Dose Lenalidomide in Higher-Risk Myelodysplastic Syndrome (MDS) and Acute Myelogenous Leukemia (AML)

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 2613-2613 ◽  
Author(s):  
Guillermo Garcia-Manero ◽  
Naval G. Daver ◽  
Gautam Borthakur ◽  
Marina Konopleva ◽  
Farhad Ravandi ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Phase I ◽  
Conflicts Of Interest ◽  
Single Agent ◽  
Myelogenous Leukemia ◽  
High Dose ◽  
Significant Activity ◽  
Monosomy 7 ◽  
Prior Therapy ◽  
Bone Marrow Blasts

Abstract Abstract 2613 The hypomethylating agents are standard of care in patients with higher risk MDS and used frequently in older AML. A number of strategies, including combination approaches, are being developed to improve results of single agent hypomethylating agent. For instance the combination of 5-azacitidine and lenalidomide (LEN) has been shown to be safe and active in a phase I trial (Sekeres JCO 2010; 28:2253–8). Recently the use of high dose LEN (50 mg orally daily) has been reported to have significant activity in older AML (Vij Blood. 2011;117:1828–33). We hypothesized that sequential combination of 5-azacitidine followed by LEN could be safe and active in patients with higher risk MDS and AML. To test this concept, we developed a phase I/II protocol of such combination. Here, we present results from the completed phase I portion of the study. Patients with refractory or relapsed AML and MDS (bone marrow blasts more than 10%) of any age or untreated patients older than 60 years with AML or MDS who refused or were not eligible for frontline therapy were eligible. Adequate performance status, liver function and renal function were requiered. All study participants were registered into RevAssist® program. Females of childbearing potential were required to have a negative pregnancy test. 5-azacitidine was administered at 75 mg/m2 IV daily for 1 to 5 day on a 28 day cycle. LEN was administered on day 6 for 5 or 10 days. The phase I portion of the study design followed a classic “3+3” design and only LEN was dose escalated. 28 patients were registered in the study. The following doses of LEN were used: 10 (N=5), 15 (N=3), 20 (N=3), 25 (N=3), 50 (N=4), 75 mg (N=3) orally for 5 days and 75 for 10 days (N=7). Median age was 65 (range 31 to 79); 19 patients had AML and 9 had MDS or CMML. Median baseline WBC was 1.95 K/μL (range 0.1 to 19.1), median platelet count 68 K/μL (4 to 328), median bone marrow blasts 23% (range 11% to 84%), 8 had diploid cytogenetics and 20 others including 5q- (8 patients), monosomy 5 (5 patients) and monosomy 7(7 patients), del 17 (4 patients), t(9:11)(2 patients) and t(3;5)(2 patients). FLT-3 and N-RAS mutations were seen in 2 patients each and NPM-1 mutation in 1 patient. 22 patients had received prior therapy. A total of 88 cycles of therapy have been administered with a median of 1.5 cycles (range 1 to 10). No dose limiting toxicity was documented and the maximal tolerated dose was therefore not reached. At the 75 mg × 10 days dose, one patient died unexpectedly and subsequently 6 additional patients were treated with no additional severe toxicities observed. Common non-hematological toxicities were fatigue, loss of appetite, constipation, skin rash, fevers and weight loss. Of 6 patients that had not received prior therapy, 5 were evaluable for response and 3 (60%) achieved a complete response at doses of 25 and 50 mg of LEN. No response was observed in previously treated patients but 9 (47%) had stable disease. In conclusion, the combination of 5-azacitidine with high dose LEN up to 75 mg orally × 10 days is safe in patients with AML/MDS. The study continues now in a phase II extension of N=40 patients with LEN at a dose of 50 mg daily × 10 days. Disclosures: No relevant conflicts of interest to declare.

Let-7a, Mir-17 and Mir-20a Expression Levels in CD34+ Bone Marrow Cells of Patients with Myelodysplastic Syndromes (MDS) Are Associated with Established Prognostic Factors, Supporting Their Implication in the Pathogenesis of the Disease,

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 3792-3792 ◽  
Author(s):  
Christos K Kontos ◽  
Vassiliki Pappa ◽  
Diamantina Vasilatou ◽  
Maria-Angeliki S Pavlou ◽  
Frida Kontsioti ◽  
...  
Keyword(s):  
Gene Expression ◽  
Bone Marrow ◽  
Prognostic Factors ◽  
High Risk ◽  
Mirna Expression ◽  
Who Classification ◽  
Low Risk ◽  
Expression Levels ◽  
Cd34 Cells ◽  
Bone Marrow Blasts

Abstract Abstract 3792 Introduction: MicroRNAs are single, small non-coding RNA molecules of approximately 21–26 nucleotides, which regulate the expression of numerous genes. miRNAs may act either at the post-transcriptional or the post-translational level to repress gene expression; still, upregulation of gene expression has been noticed in some cases as a direct effect of miRNA function. The importance of miRNAs in carcinogenesis is emphasized by the association of cancers with alterations in miRNA expression. Many miRNAs, including let-7a and those of the miR-17-92 cluster (miR-17, miR-20a, etc.), have been shown or are predicted to affect the activities of targeted mRNAs encoding proteins that have oncogenic or anti-oncogenic functions. let-7a downregulates KRAS, while miR-17 and miR-20a downregulate E2F1. Both these proteins are overexpressed in myelodysplastic syndromes (MDS) and have been shown to be involved in the pathobiology of the disease. Purpose: In the current study, we examined the prognostic value of let-7a, miR-17 and miR-20a levels in MDS and their potential as novel molecular biomarkers. Furthermore, we investigated the protein expression levels of validated targets of these three miRNAs in bone marrow CD34+ cells of MDS patients. Material and Methods: We evaluated 43 patients with MDS (34 men, 9 women) with a median age of 73 years (range 45–87). According to WHO classification, 12 patients (27.9%) were diagnosed with RA, 6 (13.9%) RCMD, 8 (18.6%) with RAEB-I, 7 (16.3%) with RAEB-II, 8 (18.6%) with AML, and 2 (4.7%) with CMML. According to IPSS, 13 patients (32.5%) had low risk, 14 (35.0%) intermediate I risk, 6 (15.0%) intermediate II, and 7 (17.5%) high risk disease. WPSS classification was: 8 (23.5%) very low risk, 5 (14.7%) low risk, 8 (23.5%) intermediate, 9 (26.5%) high risk, and 4 (11.8%) very high risk. We isolated CD34+ cells from bone marrow mononuclear cells from MDS patients, as well as from peripheral blood of donors of CD34+ cells for stem cell transplantation, using magnetic beads. Extraction of small RNA-containing total RNA from CD34+ cells was performed and cDNA of let-7a, miR-17 and miR-20a was synthesized using specific primers. miRNA expression levels were determined using quantitative real-time PCR, the TaqMan® chemistry and the relative quantification (2−ΔΔCT) method. The snoRNA RNU48 was used as reference gene. Furthermore, total protein was extracted from CD34+ cells using a lysis buffer and subsequently quantified using the Bradford assay. Western blot analysis was carried out for MYC, E2F1, Cyclin D1 (CCND1), BCL2 and KRAS, while Actin was used as reference protein. Results: In MDS patients, let-7a expression levels were 0.053–506.1 copies/RNU48 copies, while miR-17 and miR-20a expression levels were 0.005–2694.5 and 0.003–3116.7 copies/103RNU48 copies, respectively. No significant differences were found between patients and controls regarding let-7a, miR-17 and miR-20a expression. let-7a underexpression was associated with high (>10%) bone marrow blasts percentage (P =0.036), presence of WHO classification subtypes with poor prognosis (RAEB-I, RAEB-II and AML) (P =0.020), and high IPSS (P =0.037). Furthermore, miR-17 underexpression was related to high (>10%) bone marrow blasts percentage (P =0.008), intermediate and/or high risk karyotype (P =0.018) and high IPSS (P =0.016). Moreover, miR-20a underexpression was associated with high IPSS (P =0.037) and WPSS (P =0.013). Interestingly, protein expression levels of all targets analyzed in the current study were shown to be lower in samples overexpressing let-7a, miR-17 and/or miR-20a, in comparison with the corresponding protein levels noticed in specimens showing lower expression of these three miRNAs. Conclusion: To the best of our knowledge, this is the first study showing that expression levels of let-7a, miR-17 and miR-20a are associated with established prognostic factors in MDS, including IPSS and WPSS. Furthermore, these three miRNAs seem to be implicated in the pathogenesis of the disease, most probably by finely tuning the expression of target proteins that are involved in highly important molecular pathways, therefore affecting key cellular functions, such as cell cycle control, apoptosis, cell proliferation, and regulation of gene expression. Undoubtedly, further studies are needed to confirm the present findings and clarify their association with the pathogenesis of different MDS subgroups. Disclosures: No relevant conflicts of interest to declare.

Overall Survival in Acute Erythroleukemia According to Pathologic Features.

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 2597-2597
Author(s):  
Xiaohui Zhang ◽  
Alan F List ◽  
Rami Komrokji ◽  
Jeffrey E Lancet ◽  
Lynn Moscinski ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Overall Survival ◽  
Myeloid Leukemia ◽  
Median Overall Survival ◽  
De Novo ◽  
High Grade ◽  
Bone Marrow Biopsies ◽  
Pathologic Features ◽  
Marrow Cellularity ◽  
Acute Myeloid

Abstract Abstract 2597 Background: Acute erythroleukemia (AEL) is a rare subtype of acute myeloid leukemia (AML), comprising less than 5% of all AML, with a historically poor prognosis. According to the 2008 World Health Organization (WHO) classification, it is characterized by the presence of more than 50% erythroid precursors in the entire cellularity and more than 20% myeloblasts in the non-erythroid cell population. The clinical and pathologic features of this subtype have not been clearly defined, and due to the lack of sufficient clinical data, there are concerns that the current categorization might not truly reflect the differences among the cases and the distinction from myelodysplastic syndromes (MDS) and acute myeloid leukemia with myelodysplasia-related changes (AML-MRC). We reviewed ten years of AEL cases from the Moffitt Cancer Center (MCC), as well as high grade MDS and AML-MRC with erythroid predominance (>50% of marrow cells), and compared outcome of these cases according to disease subcategory. Methods: Cases from the MCC data base from 2001 to 2011 were reviewed, identifying 77 cases with a bone marrow aspirate fulfilling the WHO criteria for AEL, and 23 cases of high grade MDS with erythroid predominance of more than 50% of cellularity. Pure erythroid leukemia cases were excluded. Upon further review, of the 77 AEL cases, 22 cases (28.5%) were de novo AEL, 27 cases (35%) evolved from antecedent MDS (MDS-AEL), and 28 cases (36.4%) were re-categorized into AML-MRC as shown by subsequent bone marrow biopsies. Pathological data of serial bone marrow biopsies and clinical data were collected. Patient survival was analyzed with Kaplan-Meier method from the date of diagnosis until death from any cause or last follow up visit. Survival curves were compared by the logrank test. Results: The median overall survival of 22 cases of de novo AEL is 25 months, while the median overall survival of 27 cases of MDS-AEL and 28 cases of AML-MRC are both 14 months. Patients with de novo AEL had better prognosis than those with AML-MRC (p=0.03). There were no significant statistical differences in overall survival between de novo AEL and MDS-AEL, or between MDS-AEL and AML-MRC (p=0.49 and 0.2, respectively). The 23 cases of high grade MDS with erythroid predominance have a median survival of 51 months, compared to 26 months for all the analyzed cases of AML with myelodysplastic features, including MDS-AEL and AML-MRC, when the survival durations were calculated from the date of initial MDS diagnosis. When comparing this group of high grade MDS with MDS-AEL or AML-MRC, the differences were not statistically different (p=0.34). We next analyzed survival of the AEL patients according to blast percentage. In this study, an arbitrary myeloblast count threshold of 10% of the overall marrow cellularity was used. Although myeloblast count did not significantly impact survival, when the cases were subcategorized based on the blast counts of serial bone marrow biopsies including those that did not meet the criteria for AEL, survival was significantly better in the patients with blast counts consistently lower than 10% of all bone marrow cellularity (p=0.03). In addition, patients with normal karyotype had significantly better survival than those with complex karyotypes (p=0.0017). Conclusion: Our findings suggest that there are overlapping features among high grade MDS, AEL and AML-MRC. Serial bone marrow biopsies are more critical in establishing a diagnosis and predicting prognosis than blast percentage calculations on a single marrow. Indicators such as complex cytogenetic changes and appropriate blast percentage threshold are necessary to further refine the classification. Disclosures: No relevant conflicts of interest to declare.

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