Analyzing Patient Characteristics Who Received (DA) EPOCH-R for High Risk Diffuse Large B-Cell Lymphoma: MD Anderson Cancer Center Experience

Abstract Background: Due to ~50% risk of relapse with standard therapy (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone, R-CHOP), an increasing number of patients with high risk diffuse large B-cell lymphomas (DLBCL) are being treated with dose-adjusted (DA) EPOCH-R (rituximab, etoposide, doxorubicin, vincristine, prednisone, cyclophosphamide). DA-EPOCH-R contains a 96-hour continuous infusion can be delivered either in the inpatient or outpatient setting, via use of ambulatory infusion pumps. Potential advantages of outpatient therapy include reduced inpatient burden for routine chemotherapy, less exposure to resistant bacterial infections, increased patient satisfaction, and reduced cost. The ability to administer outpatient DA-EPOCH-R is dependent on the ability of the healthcare facility to administer the regimen safely while maintaining dose adjustments and schedule. We hypothesize that patients who receive DA-EPOCH-R as an outpatient have similar outcomes and toxicity rates as patients who receive the regimen as an inpatient. We further hypothesize that there is a significant cost benefit for patients to receive DA-EPOCH-R as an outpatient. Methods: This was a retrospective database analysis of newly diagnosed consecutive DLBCL patients ≥ 18 years of age who received DA-EPOCH-R chemotherapy at MD Anderson Cancer Center between 2010 and 2014. Patients with double hit lymphoma defined as having a MYC and BCL2 or BCL6 translocation were excluded due to their aggressive nature. We descriptively analyzed demographic variables in this population including, age, gender, international prognostic index (IPI)) and outcome (overall response rates (ORR), complete response (CR), progression free survival (PFS), overall survival (OS), and hospital admission for neutropenic fever events). Additionally, we evaluated the number of outpatient cycles received in relation to survival outcomes and neutropenic fever events. Statistical analysis was done using Fisher's exact test or Chi-square test to evaluate the association between two categorical variables and Wilcoxon rank sum test was used to evaluate the difference in a continuous variable between patient groups. Kaplan-Meier method was used for time-to-event analysis including overall survival and progression free survival. The Log-rank test was used to evaluate the difference in time-to-event endpoints between patient groups. Results: A total of 196 patients had data available for analysis, with 138 patients (70.4%) receiving all cycles as an inpatient, while 58 patients (29.6%) received at least 1 outpatient cycle of DA-EPOCH-R (Table 1). Compared with patients who received no outpatient cycle, the patients who received any outpatient therapy were younger, had a lower proportion of high IPI, and experienced fewer episodes of febrile neutropenia. The median OS and PFS for the entire population has not been reached, with a median follow-up time for the censored observations of 2.78 years (range: 0.24 - 8.64 years). The difference in OS between the patients who had any outpatient therapy and no outpatient therapy was not significant by the log-rank test (p-value=0.11). The difference in PFS between the patients who had any outpatient therapy and no outpatient therapy was marginally significant for OS by the log-rank test (p-value=0.07). Our cost analysis for 6 cycles of inpatient DA-EPOCH-R is estimated to be ~$88K, or $14.6K/cycle. The cost savings incurred for chemotherapy only expenses for each outpatient cycle is at least $3.3K/cycle or $19.8K for a total of 6 cycles. Conclusion: DA-EPOCH-R is a highly effective regimen for treating aggressive DLBCL which can be administered in an outpatient setting safely, efficaciously, and in a cost-effective manner without any apparent effect on outcome or rate of admission for neutropenic fever. There can be savings of about of nearly $20K per patient for a 6-cycle course of therapy. In our series, patients who received outpatient therapy were younger and may have had greater social support, which could potentially confound results. This retrospective analysis supports the use of outpatient DA-EPOCH-R, but additional studies are warranted to evaluate which patients may benefit most. Disclosures Oki: Novartis: Research Funding. Nastoupil:Janssen: Other: Travel, Accommodations, Expenses, Research Funding; TG Therapeutics: Research Funding; Celgene: Honoraria; AbbVie: Research Funding. Fowler:Pharmacyclics, LLC, an AbbVie Company: Consultancy, Research Funding; Janssen: Consultancy, Research Funding. Wang:Asana BioSciences: Research Funding; Acerta: Consultancy, Research Funding; Dava Oncology: Honoraria; BeiGene: Research Funding; Kite Pharma: Research Funding; Juno Therapeutics: Research Funding; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Asana biosciences, Beigene, Celgene, Juno, Kite, Onyx, Pharmacyclics: Research Funding. Fayad:Seattle Genetics: Consultancy, Research Funding. Westin:Celgene: Membership on an entity's Board of Directors or advisory committees; Chugai: Membership on an entity's Board of Directors or advisory committees; Spectrum: Membership on an entity's Board of Directors or advisory committees; ProNAi: Membership on an entity's Board of Directors or advisory committees.

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Impact Of The Proportion Of Metaphases With Isolated Del(5q) On Clinical Outcomes In Lenalidomide (LEN)-Treated Patients With IPSS Low-/Int-1-Risk Myelodysplastic Syndromes (MDS) In MDS-003 and MDS-004

Blood ◽

10.1182/blood.v122.21.1538.1538 ◽

2013 ◽

Vol 122 (21) ◽

pp. 1538-1538

Author(s):

Aristoteles Giagounidis ◽

Alan List ◽

Eva Hellström-Lindberg ◽

Mikkael A. Sekeres ◽

Ghulam J. Mufti ◽

...

Keyword(s):

Board Of Directors ◽

Clinical Outcomes ◽

Research Funding ◽

Rank Test ◽

Employment Equity ◽

Advisory Committees ◽

Log Rank Test ◽

Equity Ownership ◽

Baseline Characteristics ◽

Rbc Transfusion

Abstract Introduction The proportion of aberrant metaphases is prognostic for overall survival (OS) in MDS patients with trisomy 8 (Mallo M, et al. Leuk Res. 2011;35:834-6). The impact of the proportion of metaphases with del(5q) on clinical outcomes, including OS, disease progression and response to therapy with LEN in MDS remains undefined. In two large multicenter studies of LEN (MDS-003 and MDS-004) in RBC transfusion-dependent patients with International Prognostic Scoring System (IPSS) Low- or Intermediate (Int)-1-risk del(5q) MDS, RBC transfusion independence (TI) ≥ 8 weeks was achieved in 51–67% of patients (List A, et al. N Engl J Med. 2006;355:1456-65; Fenaux P, et al. Blood. 2011;118:3765-76). This retrospective analysis evaluated response to treatment, progression to acute myeloid leukemia (AML) and OS by proportion of del(5q) metaphases in patients with isolated del(5q) from the MDS-003 and 004 studies. Methods In order to allow sufficient patient numbers for analysis, ≥ 16 metaphases were evaluated for del(5q) by standard karyotyping (MDS-003 and MDS-004) and 200 interphase nuclei were evaluated by fluorescence in situ hybridization (FISH; MDS-004 only) using a probe for the commonly deleted region 5q31 (LSI EGR1/D5S721, Abbott, Wiesbaden, Germany). Patients received LEN on days 1–21 of each 28-day cycle (10 mg) or continuously (5 mg or 10 mg), or placebo. In MDS-004, patients randomized to placebo could cross over to LEN 5 mg by week 16. RBC-TI ≥ 26 weeks, time to AML progression and OS were analyzed by the proportion of del(5q) metaphases or interphases (≤ 60% vs > 60%) using standard karyotyping and FISH, respectively. Results Of the 353 patients from MDS-003 and MDS-004, 194 had isolated del(5q) by standard karyotyping; median proportion of del(5q) metaphases was 96% (range 4–100). Baseline characteristics including age, time from diagnosis, RBC transfusion burden, hemoglobin level, platelet and absolute neutrophil counts were comparable among patients with ≤ 60% (n = 21) and > 60% (n = 173) del(5q) metaphases. Rates of RBC-TI ≥ 26 weeks were similar across patients in the ≤ 60% and > 60% groups (P = 0.6515). Time to AML progression was comparable for patients in the ≤ 60% group versus the > 60% group (log-rank test P = 0.9802); 2-year rates were 22.2% (95% confidence interval [CI]: 7.7–54.5%) and 14.6% (95% CI: 9.9–21.2%), respectively. Time to AML progression was similar when analyzed with death without AML as competing risk (Gray’s test P = 0.5514). OS was longer in the > 60% versus the ≤ 60% group (log-rank test P = 0.0436); median OS was 3.7 years (95% CI: 3.0–4.2) and 2.4 years (95% CI: 1.5–4.9), respectively. In MDS-004, the proportion of del(5q) interphases was analyzed using FISH in 106 patients, including 46 with ≤ 60% and 60 with > 60%. When analyzed by FISH, rates of RBC-TI ≥ 26 weeks were similar across patients in the ≤ 60% and > 60% groups (P = 1.000). Time to AML progression and OS were similar across these groups (log-rank test P = 0.7311 and P = 0.8639, respectively) when analyzed by FISH. In the ≤ 60% and > 60% groups respectively, 2-year AML progression rates were 14.8% (95% CI: 6.9–30.1%) and 18.6% (95% CI: 10.4–32.0%), and median OS was 3.1 years (95% CI: 2.3–4.8) and 2.9 years (95% CI: 2.3–4.4). Time to AML progression was similar when analyzed with death without AML as competing risk (Gray’s test P = 0.8631). Conclusions In IPSS Low- or Int-1-risk MDS patients with isolated del(5q) treated with LEN in MDS-003 and MDS-004 studies, baseline characteristics, RBC-TI ≥ 26 weeks and AML progression were comparable in patients with > 60% versus ≤ 60% del(5q) metaphases. Although similar across groups when analyzed by FISH in a subset of patients, surprisingly, OS was longer in patients with > 60% del(5q) metaphases than in those with ≤ 60% del(5q) metaphases by standard karyotyping. However, the number of patients with ≤ 60% del(5q) metaphases was limited and no adjustment was made for multiple testing. These findings suggest that the number of cells with the isolated del(5q) abnormality measured by FISH does not impact clinical outcome in this RBC transfusion-dependent study population, but this finding could not be confirmed for OS by standard karyotyping. Disclosures: Giagounidis: Celgene: Consultancy, Honoraria, Membership on an entity’s Board of Directors or advisory committees. List:Celgene: Serve on Celgene Data Safety & Monitoring Committee Other. Hellström-Lindberg:Celgene: Membership on an entity’s Board of Directors or advisory committees, Research Funding. Sekeres:Celgene: Membership on an entity’s Board of Directors or advisory committees; Amgen: Membership on an entity’s Board of Directors or advisory committees. Mufti:Celgene: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding. Schlegelberger:Celgene: Consultancy. Morrill:Celgene: Employment, Equity Ownership. Wu:Celgene: Employment, Equity Ownership. Skikne:Celgene: Employment, Equity Ownership. Fenaux:Celgene: Honoraria.

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Early Allogeneic Stem Cell Transplantation and Use of Asparaginase during Induction Chemotherapy Appear to Improve Otherwise Poor Outcomes in Adult T-Cell Acute Lymphoblastic Leukemia/Lymphoma (T-ALL/T-LBL) Patients: A Multi-Institutional Review

Blood ◽

10.1182/blood.v126.23.4869.4869 ◽

2015 ◽

Vol 126 (23) ◽

pp. 4869-4869 ◽

Cited By ~ 1

Author(s):

Uma Borate ◽

Amanda Redden Hathaway ◽

Deniz Peker ◽

Bradford E Jackson ◽

Vamsi K Kota ◽

...

Keyword(s):

Board Of Directors ◽

Treatment Regimen ◽

Research Funding ◽

Lymphoblastic Leukemia ◽

Rank Test ◽

P Value ◽

Advisory Committees ◽

Treatment Regimens ◽

Genetics Research ◽

Institutional Review

Abstract Background: AdultT-cell acute lymphoblastic leukemia/lymphoma (T-ALL/T-LBL) is a rare, aggressive bone marrow malignancy with a historically poor prognosis despite use of various chemotherapies. Methods: After institutional review board approval, we compiled a database of all adult T-ALL/T-LBL cases at three large cancer centers between the years 2005-2015, treated at the physician's discretion. Data collected included patient demographics, tumor characteristics (white cell count at diagnosis, blast phenotype, FISH, cytogenetics, bone marrow involvement), treatment regimens and patient outcomes. Relapse-free survival (RFS) and overall survival (OS) were examined looking at medians and interquartile ranges of times to events. Kaplan Meier curves provided a graphical representation of the survival probability. Moreover, we provided estimates of the 50th percentile along with corresponding 95% confidence intervals (CIs). We also used Univariate and Multivariable Cox Regression to estimate unadjusted and adjusted Hazard Ratios (HRs) and their 95% CIs. Stratified analysis was also performed using the Mann-Whitney U-test to compare median survival times, and the Log-rank to compare survival curses for RFS and OS. Results: The final analysis included 95 adult patients. Median age at diagnosis was 32 (range 17-75). 71.6% of patients were male. 49.5% of patients were white, 14.7% were black, 6.3% were Hispanic, 7.4% were Asian and in 22.1% of patients the race was unknown. Multiple frontline treatment regimens were used with 60% of patients treated with Hyper-CVAD, an additional 5.3% of patients received Hyper-CVAD with asparaginase, 24.2% of patients were treated on a pediatric-based protocol, 4.2% on a clinical trial, and 6.3% received other regimens. In total, 40 patients (42.1%) received asparaginase at some point during treatment regimen with 27 patients (28.4%) receiving it in the initial treatment regimen. After induction therapy, 65 patients (68.4%) achieved remission. Twenty-eight patients (29.5%) underwent transplant (8 matched-related donors, 10 matched unrelated donors, 5 mismatched unrelated donor, 2 cord transplants, 2 autologous, and 1 haplo-identical transplant). Ten patients (10.5%) underwent transplant in first complete remission (CR1) while two patients (2.1%) proceeded to transplant with minimal residual disease following induction. Despite therapy, 59 patients (62.1%) had known disease relapse or progressive disease. 16 patients (16.8%) underwent transplant after disease relapse. At time of analysis, 57 patients (60.6%) died. In the entire cohort, median RFS was 12.9 months and median OS was 19 months. In patients with a very high white count (>100 x 103/cmm at presentation) there was a trend toward earlier relapse when compared to patients presenting with white counts in the normal range (HR 2.27, p-value 0.085). Patients who received asparaginase in their initial treatment regimen have statistically improved RFS (HR 2.65, p-value = 0.014) and OS (HR 2.3, p-value=0.017). When adjusting for the presence of the covariates of age, sex, and WBC, patients who received initial asparaginase still had significant improvement in RFS (HR 3.18, p-value 0.033). In overall survival, significant benefit was seen in the addition of asparaginase in patients under 40 (HR 3.4, CI 1.22-9.5), however in patients greater than 40, asparaginase use seemed to decrease survival (HR 0.24, CI 0.03-1), although this did not reach statistical significance. All patients who underwent transplant had an improvement in OS, with median survival in the transplant group of 27 months compared to 18.2 months in the non-transplanted patients (log-rank test p-value = 0.048). Patients who received a transplant in CR1 had a trend towards improvement in RFS of 6.3 months (17.8 months versus 11.5 months in non-transplanted patients; log-rank test p-value = 0.03). Conclusion: Overall, adult T-ALL/T-LBL has a poor prognosis. Our multi-institutional retrospective review showed that OS and RFS may be improved by incorporating asparaginase use in front line therapy and by transplanting patients in first CR. Our data is limited in that actual dosing of asparaginase was not examined and that relatively few patients > 40 yrs old received asparaginase (4 pts) or SCT (5 pts). More prospective studies are needed in older adult T-ALL/LBL patients using these approaches to possibly improve their outcomes. Disclosures Borate: Gilead: Speakers Bureau; Genoptix: Consultancy; Seattle Genetics: Research Funding; Novartis: Speakers Bureau; Amgen: Speakers Bureau; Alexion: Speakers Bureau. Hathaway:OnQ Health: Research Funding. Kota:Pfizer: Membership on an entity's Board of Directors or advisory committees; Leukemia Lymphoma Society: Research Funding. Shah:DeBartolo Institute for Personlaized Medicine: Research Funding; Rosetta Genomics: Research Funding; Acetylon Pharmaceuticals, INC: Membership on an entity's Board of Directors or advisory committees; Plexus Communications: Honoraria; Pharmacyclics: Speakers Bureau; Spectrum: Speakers Bureau; Bayer: Honoraria; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Janssen: Speakers Bureau; Seattle Genetics: Research Funding; SWOG: Consultancy; NCCN: Consultancy. Jillella:Leukemia Lymphoma Society: Research Funding. Heffner:Amgen: Consultancy. Erba:Novartis; Incyte; Celgene: Consultancy, Patents & Royalties; GlycoMimetics; Janssen: Other: Data Safety & Monitoring Committees; Seattle Genetics; Amgen: Consultancy, Research Funding; Millennium/Takeda; Celator; Astellas: Research Funding; Sunesis;Pfizer; Daiichi Sankyo; Ariad: Consultancy.

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Busulfan/Fludarabine- or Treosulfan/Fludarabine-Based Conditioning Regimen in Patients with Wiskott-Aldrich Syndrome Given Allogeneic Hematopoietic Cell Transplantation — an EBMT Inborn Errors Working Party and Scetide Retrospective Analysis

Blood ◽

10.1182/blood-2018-99-112394 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 2175-2175 ◽

Cited By ~ 2

Author(s):

Michael H. Albert ◽

Mary Slatter ◽

Andrew Gennery ◽

Tayfun Guengoer ◽

Henric-Jan Blok ◽

...

Keyword(s):

Stem Cell ◽

Board Of Directors ◽

Research Funding ◽

Rank Test ◽

Unrelated Donor ◽

Advisory Committees ◽

Secondary Procedure ◽

Log Rank Test ◽

Secondary Procedures

Abstract PV and AL contributed equally Multiple studies from the EBMT registry and others have shown excellent survival rates after allogeneic haematopoietic stem cell transplantation (HSCT)for Wiskott-Aldrich syndrome (WAS) patients (Ozsahin et al, Blood 2008). The importance of myeloid engraftment for full disease correction has also been demonstrated (Moratto et al, Blood 2011). However, the vast majority of HSCTs in these studies were performed with (oral) busulfan/cyclophosphamide-based conditioning and in the early 2000 years or before. In 2005, the inborn errors working party (IEWP) of EBMT and ESID first recommended busulfan/fludarabine (BuFlu) or treosulfan/fludarabine (TreoFlu) based conditioning for primary immunodeficiencies such as WAS, with some centers deciding to add thiotepa (TT) to the conditioning. We performed a retrospective analysis via the EBMT and SCETIDE registries of WAS patients transplanted between 01/01/20006 and 12/31/2016 with these two regimens. The primary objective was to compare the overall (OS) and event-free survival (EFS) after HSCT with either BuFlu±TT or TreoFlu±TT conditioning. Secondary objectives included the influence of either conditioning regimen on acute and chronic GVHD, the degree of donor chimerism, incidence of secondary procedures after HSCT (2nd HSCT, stem cell boost, DLI, gene therapy or splenectomy) and rates of disease-specific complications after HSCT. At the time of this interim analysis, 174 patients were included, 92 (53%) with BuFlu±TT and 82 (47%) with TreoFlu±TT conditioning with a median age of 1.57 years (range 0.21-29.96) at HSCT and a median follow-up of 32.9 months (range 1.5-128.9). The donor was an HLA-matched sibling (MSD) in 30, a matched related donor (MRD) in 5, a matched unrelated donor (MUD, 9/10 or 10/10) in 105, a mismatched unrelated donor (MMUD, <9/10) in 9 and a mismatched family donor (MMFD) in 25 (18 with ex-vivo T-cell depletion). Stem cell source was bone marrow in 93 (53%), peripheral blood in 62 (36%) and cord blood in 18 (10%). Two year overall survival (OS) of the entire cohort was 88.6% (95% confidence interval 83.5%-93.6%). There was no significant difference in OS between patients treated with BuFlu±TT or TreoFlu±TT conditioning (2-year OS 88.1% vs. 89.5%; log-rank test p=0.7). Patients aged >5 years had a worse OS as compared to those 5 years or younger at HSCT (74.9% vs. 90.8%; log-rank test p=0.005). The type of donor had no influence on OS: 96.4% for MSD/MFD, 86.8% for MUD/MMUD and 87.7% for MMFD (log-rank test p=0.4). Whole blood chimerism was complete (>90% donor) in 60/75 evaluable patients (80%) at last follow-up or before secondary procedure (if a patient had one), 39/40 (98%) in the BuFlu±TT group and 21/35 (60%) in the TreoFlu±TT group. Twenty-six patients required a secondary procedure: stem cell boost in 4 patients, donor lymphocyte infusion in 9, 2nd HSCT in 15 and splenectomy in 1. Twenty-two of these 26 (84.6%) are alive and 14 of 16 with available chimerism data have a complete donor chimerism (>90%donor) at last follow-up. The 2-year cumulative incidence (CI) of secondary procedures was higher at 33.9% in the TreoFlu±TT versus 12.8% in the BuFlu±TT group (Gray's test p=0.017), and 2-year EFS (secondary procedure or death as event) was 61.4% in the TreoFlu±TT and 75.0% in the BuFlu±TT group (log-rank test p=0.2). Grade II-IV acute GVHD had the same incidence in both groups (100 day CI 24.4% vs. 26.3%; Gray's test p=0.849) and chronic GVHD of any grade was borderline more frequent in the TreoFlu±TT group (2 year CI 17.2% vs 6.7%; Gray's test p=0.054). The cumulative incidence of disease-specific complications occurring more than 6 months post HSCT (severe infections, bleeding, autoimmunity) was not different between the two groups (6.5% vs. 6.4%; Gray's test p=0.92). There was no malignancy reported after HSCT except for one EBV-post-transplant lymphoproliferative disorder (PTLD) 2.7 months after HSCT. In summary, HSCT with either BuFlu±TT or TreoFlu±TT conditioning reliably cures almost 90% of patients with WAS regardless of donor type. WAS-related complications are very rare events more than 6 months post HSCT. More patients required secondary procedures after treosulfan-based than busulfan-based conditioning. These data confirm the feasibility and efficacy of the regimens currently recommended by the IEWP. Disclosures Slatter: Medac: Other: Travel assistance. Chiesa:Gilead: Consultancy; Bluebird Bio: Consultancy. Kalwak:Sanofi: Other: travel grants; medac: Other: travel grants. Locatelli:Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; bluebird bio: Consultancy; Bellicum: Consultancy, Membership on an entity's Board of Directors or advisory committees; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Miltenyi: Honoraria. Sykora:Aventis-Behring: Research Funding; medac: Research Funding. Zecca:Chimerix: Honoraria. Veys:Pfizer: Honoraria; Servier: Research Funding; Novartis: Honoraria.

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Results of a Phase I-II Clinical Trial of Oxaliplatin, Fludarabine, Cytarabine, and Rituximab (OFAR) Combination Therapy In Patients with Aggressive, Relapsed/Refractory Chronic Lymphocytic Leukemia (CLL) and Richter Syndrome (RS)

Blood ◽

10.1182/blood.v116.21.923.923 ◽

2010 ◽

Vol 116 (21) ◽

pp. 923-923 ◽

Cited By ~ 2

Author(s):

Apostolia Maria Tsimberidou ◽

William G. Wierda ◽

Sijin Wen ◽

William Plunkett ◽

Susan O'Brien ◽

...

Keyword(s):

Phase I ◽

Board Of Directors ◽

Clinical Outcomes ◽

Median Survival ◽

Phase Ii ◽

Research Funding ◽

Response Rate ◽

Rank Test ◽

Advisory Committees ◽

Log Rank Test

Abstract Abstract 923 Background: To enhance the response rate with a decrease in myelosuppression that were observed with oxaliplatin, fluradabine, Ara-C, and rituximab (OFAR1) (Tsimberidou et al, J Clin Oncol, 2008;26:196), the daily dose of oxaliplatin was increased from 25 to 30mg, the daily dose of Ara-C was decreased from 1 g/m2 to 0.5 g/m2 and the optimal number of days of fluradabine and Ara-C administration was explored (OFAR2). Methods: OFAR2 consisted of oxaliplatin 30mg/m2 D1-4; fludarabine 30mg/m2; Ara-C 0.5g/m2; rituximab 375mg/m2 D3; and pelfigrastim 6mg D6. Fludarabine and Ara-C were given on D2-3 (level 1) D2-4 (level 2) or D2-5 (level 3) every 4 weeks. Tumor lysis, DNA virus, and PCP prophylaxis was administered. A “3+3” design was used (Phase I) and and the planned number of patients in the Phase II was 90 (CLL, 60; RS, 30). Results: Overall 102 patients (rel. CLL 67, RS 35) were treated. Twelve patients were treated in the Phase I portion of the study. Dose-limiting toxicities were noted in 2/3 patients at level 3 (G4 diarrhea and G4 sepsis). Level 2 was the maximum tolerated dose. Ninety patients (CLL, 60; RS, 30) were treated in Phase II portion of the study (age > 60 years 67%, 17p del 37.5%, 11q del 15%, 13q del 18%, +12, 17%; neg. 12.5%; unmutated IgVH 81.5%, ZAP70-positive 77%, and CD38 30%, 63%). Response in 80 of 90 patients (Phase II) is shown in Table (too early, n=10). The overall response rates in patients (Phase II) with 17p deletion and 11q deletion were 29% and 41%, respectively. Twenty-nine patients underwent SCT after OFAR2 (response status to OFAR2 at the time of SCT: CR, n=3; nPR, n=2; 15; no response, n=9). With a median follow-up of 20.8 months, the median survival was 19 months (95% CI, 13–37+) and the median FFS was 6 months (95% CI, 3.4 – 8.2). Overall, 238 cycles were administered. G3-4 neutropenia, thrombocytopenia, and anemia were noted in 67%, 74%, and 44% of patients (51%, 64%, and 25% of cycles); and G3-4 infections in 19% of patients. Clinical outcomes of OFAR2 were compared with those of OFAR1. In patients with RS, the overall response rate was 41% (11/27) with OFAR2 and 50% (10/20) with OFAR1 (p = 0.57, Fisher's test); the median survival with OFAR2 and OFAR1 was 8.3 months and 18+ months, respectively (p = 0.92, log-rank test); and the respective median FFS was 3.0 months and 4.1 months (p = 0.40, log-rank test). In patients with CLL, the overall response rate was 55% (29/53) with OFAR2 and 33% (10/30) with OFAR1 (p = 0.36, Fisher's test); the median survival with OFAR2 was 21.4 months and 13.8 months with OFAR1 (p = 0.19, log-rank test); and the respective median FFS was 6.6 months and 4.9 months (p = 0.69, log-rank test). Conclusion: OFAR2 induced response in 41% of patients with RS and 55% of patients with relapsed/refractory CLL in the phase II study. Antileukemic activity was also noted in patients with 17p deletion. Although the numbers of patients are small, OFAR1 was associated with a trend towards superior clinical outcomes in patients with RS compared to OFAR2; and OFAR2 was associated with a trend towards superior clinical outcomes compared to OFAR1 in patients with relapsed/refractory CLL. Disclosures: Tsimberidou: Sanofi: Membership on an entity's Board of Directors or advisory committees, Research Funding; ASCO: Career Development Award, Research Funding. Off Label Use: Drug: Oxaliplatin. Oxaliplatin combined with fludarabine, cytarabine, and rituximab has antileukemic activity in patients with relapsed/refractory Chronic Lymphocytic Leukemia and Richter Syndrome. Wierda:Genentech: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Micromet: Consultancy, Membership on an entity's Board of Directors or advisory committees; GlaxoSmithKline: Research Funding; Abbott Laboratories: Research Funding. O'Brien:Biogen Idec: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Genentech: Consultancy, Research Funding. Kipps:Sanofi Aventis: Research Funding. Jones:GlaxoSmithKline: Consultancy, Membership on an entity's Board of Directors or advisory committees; Abbott Laboratories: Research Funding.

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Bortezomib, Lenalidomide and Dexamethasone Vs. Lenalidomide and Dexamethasone in Patients (Pts) with Previously Untreated Multiple Myeloma without an Intent for Immediate Autologous Stem Cell Transplant (ASCT): Results of the Randomized Phase III Trial SWOG S0777

Blood ◽

10.1182/blood.v126.23.25.25 ◽

2015 ◽

Vol 126 (23) ◽

pp. 25-25 ◽

Cited By ~ 37

Author(s):

Brian Durie ◽

Antje Hoering ◽

S. Vincent Rajkumar ◽

Muneer H. Abidi ◽

Joshua Epstein ◽

...

Keyword(s):

Multiple Myeloma ◽

Adverse Events ◽

Board Of Directors ◽

Research Funding ◽

Phase Iii ◽

Rank Test ◽

P Value ◽

Advisory Committees ◽

Significance Level ◽

Grade 3

Abstract Background: Lenalidomide with dexamethasone (Rd) is a standard of care for patients with previously untreated multiple myeloma. SWOG S0777, a randomized phase III trial, has compared Rd with bortezomib, lenalidomide and dexamethasone (VRd). The primary end point is progression-free survival (PFS) using a pre-specified one-sided stratified log rank test at a significance level of 0.02. The stratification factors are International Staging System (ISS) stage (I, II or III) and intent to transplant (yes or no), a total of 6 strata. Overall response rate (ORR), overall survival (OS) and safety are secondary end points. Methods: This analysis includes 474 patients evaluable for survival endpoints: 232 patients were randomized to Rd and 242 patients to VRd. Rd patients received lenalidomide 25 mg/day on days 1-21 and dexamethasone 40 mg/day on days 1, 8, 15 and 22 of a 28-day cycle. VRd patients received lenalidomide 25 mg/day on days 1-14 and dexamethasone 20/mg/day on days 1, 2, 4, 5, 8, 9, 11 and 12 plus bortezomib 1.3 mg/m2 IV push on days 1, 4, 8 and 11 of a 21-day cycle. All patients received aspirin 325 mg/day and VRd patients received HSV prophylaxis per institutional standard. Induction was six 28-day cycles of Rd and eight 21-day cycles of VRd followed by Rd maintenance for all patients until progression, unacceptable toxicity or withdrawal of consent. Initial analyses utilized the pre-specified one-sided stratified log rank test. Results: Data are presented for VRd followed by Rd throughout. Between 2008 and 2012, 525 patients from 48 institutions were randomized. Fifty-one patients, 29 randomized to Rd and 22 randomized to RVd, were ineligible for the following reasons: missing, insufficient or early or late baseline labs (40); not meeting requirements of measurable disease (6); inadequate marrow function (1); inadequate creatinine clearance (1); prior malignancy (1); prior therapy (1); and more than 2 weeks of prior steroid therapy (1). The pre-specified significance level of 0.02 was reached in the log rank testing. The stratified hazard ratio (HR) was 0.742 (96% Wald confidence interval: 0.579, 0.951), and the one-sided stratified log rank p-value for PFS (VRd vs. Rd) was 0.0066. The OS was improved for VRd vs. Rd with HR = 0.666; two-sided log-rank p-value = 0.0114. The PFS and OS survival charts are displayed below. Median PFS was 43 months (VRd) versus 31 months (Rd). Median OS was not reached (VRd) versus 63 months (Rd). Patient characteristics were well-matched between VRd and Rd with the exception of fewer women (37% vs. 47%: P = 0.033) and fewer older patients (≥ 65 years 38% vs. 48%: P = 0.042) receiving VRd. With univariate Cox regression analysis correlates of better PFS/OS were: use of VRd (HR 0.72/0.65; P = 0.006); hemogoblin ≥10 g/dl (HR 1.17/1.43; P = 0.2/0.026) and lower ISS disease stage (HR 1.35/1.98; P = 0.014/< 0.001). The ORR for VRd was 71.07% versus 63.79% for Rd. The adverse events by CTC category and toxicity category were fairly well balanced. The most common hematologic adverse events (≥ Grade 3 and at least possibly attributable to therapy) were low hemoglobin (RVd=13%; Rd=16%), leukopenia (RVd=14%; Rd=16%), lymphopenia (RVd=23%; Rd=18%), neutropenia (RVd=19%; Rd=21%), and thrombocytopenia (RVd=18%; Rd=14%). The most common non-hematologic adverse events (≥ Grade 3 and at least possibly attributable to therapy) were: fatigue (RVd=16%; Rd=14%), sensory neuropathy (RVd=23%; Rd=3%), hyperglycemia (RVd=7%; Rd=11%), thrombosis/embolism (RVd=8%; Rd=9%), hypokalemia (RVd=9%; Rd=6%), muscle weakness (RVd=7%; Rd=4%), diarrhea (RVd=8%; Rd=2%), and dehydration (RVd=8%; Rd=2%). As expected ≥ Grade 3 neuropathy was more frequent with VRd (24% vs. 5%: P < 0.0001). Sixteen patients experienced a second primary malignancy, 7 (3%) on VRd and 9 (4%) on Rd. Conclusion: The addition of bortezomib to lenalidomide dexamethasone for induction therapy in previously untreated myeloma results in a statistically significant and clinically meaningful improvement in PFS as well as better OS. VRd had an acceptable safety and tolerability profile despite increased neurotoxicity and represents a potential new standard of care. Support: NIH/NCI/NCTN grants CA180888, CA180819, CA180821, CA180820; and in part by Millennium Pharmaceuticals, Inc., The Takeda Oncology Company, for provision of study drug. Figure 1. Figure 1. Figure 2. Figure 2. Disclosures Durie: Johnson & Johnson: Consultancy; Takeda: Consultancy; Onyx: Consultancy; Celgene: Consultancy. Abidi:Millennium: Research Funding. Epstein:University of Arkansas for Medical Sciences: Employment. Reu:Takeda/Millennium: Research Funding; Novartis: Research Funding; Celgene: Research Funding. Orlowski:BioTheryX, Inc.: Membership on an entity's Board of Directors or advisory committees; Janssen Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Research Funding; Spectrum Pharmaceuticals: Research Funding; Onyx Pharmaceuticals: Consultancy, Research Funding; Bristol-Myers Squibb: Consultancy, Research Funding; Millennium Pharmaceuticals: Consultancy, Research Funding; Acetylon: Membership on an entity's Board of Directors or advisory committees; Genentech: Consultancy; Forma Therapeutics: Consultancy; Array BioPharma: Consultancy, Research Funding. Barlogie:Dana Farber Cancer Institute: Other: Travel Stipend; International Workshop on Waldenström's Macroglobulinemia: Other: Travel Stipend; ComtecMed- World Congress on Controversies in Hematology: Other: Travel Stipend; European School of Haematology- International Conference on Multiple Myeloma: Other: Travel Stipend; Celgene: Consultancy, Research Funding; Millennium: Consultancy, Research Funding; Myeloma Health, LLC: Patents & Royalties: Co-inventor of patents and patent applications related to use of GEP in cancer medicine licensed to Myeloma Health, LLC; Multiple Myeloma Research Foundation: Other: Travel Stipend.

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Serum 2-Hydroxyglutarate Allows Early Prediction of Response during Induction Chemotherapy in Acute Myeloid Leukemia with IDH Mutation

Blood ◽

10.1182/blood.v126.23.3833.3833 ◽

2015 ◽

Vol 126 (23) ◽

pp. 3833-3833 ◽

Cited By ~ 1

Author(s):

Christophe Willekens ◽

Angelo Paci ◽

Serge Koscielny ◽

Alice Marceau ◽

Jean-Baptiste Micol ◽

...

Keyword(s):

Board Of Directors ◽

Myeloid Leukemia ◽

Research Funding ◽

Wilcoxon Test ◽

P Value ◽

Idh Mutation ◽

Advisory Committees ◽

Missing Value ◽

The Difference ◽

Acute Myeloid

Abstract Introduction: Mutations in IDH1 and IDH2 genes are found in 15% to 20% of patients with acute myeloid leukemia (AML). Mutated IDH enzymes produce in excess the D stereoisomer 2-hydroxyglutarate (2-HG) in leukemic cells, which can act as a biomarker predictive of the presence of IDH1 and IDH2 mutations. Total serum 2-HG (D and L stereoisomers) >2µM and ratio D/L 2-HG >2.5 are strong predictors of the presence of IDH1/2 mutations at diagnosis (Janin et al; JCO 2014). We measured 2-HG levels in serial samples of 47 patients with IDH1/2 mutations during induction or first salvage therapy to determine whether 2HG can serve as a surrogate marker of treatment efficacy. Methods: Between 2007 and 2015, 47 AML patients with IDH1 or IDH2 mutation received intensive chemotherapy as induction therapy (n=42) or as first salvage regimen (n=5) in our center (Table 1). Genomic DNA was extracted from BM samples using conventional procedures. IDH1-(codon R132) and IDH2- targeted (codons R140 and R172) regions were amplified by PCR with primers containing Ion Torrent adapters and unique barcodes to generate libraries. Pooled amplicons libraries were clonally amplified on Ion Spheres using the Ion Xpress Template 200 Kit. All available serum samples (n=394) prior and during induction/salvage chemotherapy were analyzed for total 2-HG, D-2-HG and L-2-HG by reverse-phase liquid chromatography coupled to mass spectrometry. We studied the serum 2-HG values (D-2-HG and ratio D/L 2-HG) evolution during IC according to complete remission (CR) evaluated at the end of IC. When a patient had a missing value for 2-HG, the missing value was replaced by the last available observation (up to 7 days before the missing value). At each day we tested the difference between the dosage values of the responders and the non-responders with non-parametric Wilcoxon 2-sided tests. The analyses were done with SAS software (version 9.3; SAS Institute, Cary, NC). Table 1. Patients and treatment characteristics: AML at diagnosis / RR AML (N) 42 / 5 Median age (years) 58.2 (23.1 - 75.7) Sex ratio (M/F) 23/24 Conventional cytogenetic: - Normal karyotype - Trisomy 8 - Monosomy 7 39 (83%) 3 (6%) 2 (4%) Associated gene mutations: - NPM1- FLT3-ITD- FLT3-TKD 24 (51%) 10 (21%) 5 (11%) IDH mutation: - IDH1 R132 (N) - IDH2 R140 (N) - IDH2 R172 (N) 8 (17%) 32 (65%) 7 (15%) Intensive treatment: - "3+7" regimen - Intensified induction chemotherapy - High-dose cytarabine based chemotherapy 24 (51%) 19 (40%) 4 (8%) Results: Complete remission (CR) 1 was obtained in 35/42 patients (83%) and CR2 in 3/5 (60%) after IC. All (8/8) IDH1 -R132 mutated patients achieved CR1, 25/28 (89%) IDH2 -R140 mutated patients and 3/4 achieved CR1 and CR2 respectively; 2/6 (33%) IDH2 -R172 mutated patients and 0/1 achieved CR1 and CR2, respectively. Median serum 2-HG values before IC were as follow: total 2-HG 10.9 µM (range: 2.1-135.5); D-2-HG 10.7 µM (range: 1.7-132.6) and ratio D/L 36.9 (range: 3.9-131.2). Median number of serum 2-HG values per patient was 7 (range: 5-10). Serum D-2-HG and ratio D/L 2-HG evolution according to CR status after IC began to differ significantly at day 5 after IC (Wilcoxon test P=0.02, Figure 1). The difference between responders and non-responders increased overtime (Wilcoxon test P<10-3 at day 21). At day 21, a ratio D/L 2-HG ≥2.5 and D-2-HG ≥2µM were correlated with the absence of CR (Fisher's exact P = 0.02 for each). Despite the very limited statistical power of the comparisons due to a limited number of patients in the no response group (n=9), the comparisons achieved a very high statistical significance. Conclusion: The oncometabolite 2-HG can act as a biomarker to monitor early response to conventional IC in AML patients with IDH1/2 mutations. D-2-HG and ratio D/L 2-HG measurements are rapid, robust, non-invasive and can predict IC failure in these patients, allowing selection of patients who could potentially benefit from early salvage treatment or IDH inhibitors. Figure 1. D-2-HG and ratio D/L 2-HG evolution according to response to IC (CR) and p-value Wilcoxon tests. Figure 1. D-2-HG and ratio D/L 2-HG evolution according to response to IC (CR) and p-value Wilcoxon tests. Figure 2. Figure 2. Figure 3. Figure 3. Disclosures Ribrag: Celgene: Research Funding; Gilead: Membership on an entity's Board of Directors or advisory committees; Esai: Membership on an entity's Board of Directors or advisory committees, Research Funding; Pharmamar: Honoraria, Membership on an entity's Board of Directors or advisory committees; Servier: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. De Botton:Agios pharmaceuticals: Research Funding.

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The Transcriptional Signature of Kinases Inhibited by the Multi-Targeted Kinase Inhibitor AS703569 Is Associated with Clinical Outcome in Multiple Myeloma (MM): Anti-MM Activity of AS703569 in Preclinical Studies.

Blood ◽

10.1182/blood.v114.22.730.730 ◽

2009 ◽

Vol 114 (22) ◽

pp. 730-730

Author(s):

Jake Delmore ◽

David N. Cervi ◽

Douglas McMillin ◽

Efstathios Kastritis ◽

Jana Jakubikova ◽

...

Keyword(s):

Overall Survival ◽

Board Of Directors ◽

Research Funding ◽

Kinase Inhibitor ◽

Rank Test ◽

Preclinical Studies ◽

Advisory Committees ◽

Transcriptional Signature ◽

Log Rank Test

Abstract Abstract 730 Multi-targeted kinase inhibitors, when associated with manageable toxicity, offer the therapeutically desirable option of targeting, through a single chemical entity, several pathways that may contribute to the complexity and heterogeneity of molecular lesions harbored by neoplasias such as multiple myeloma (MM). However, intractable questions often emerge while prioritizing for preclinical studies different multi-targeted agents with extensive and/or only partially overlapping of sets of known targets. We have hypothesized that the potential therapeutic relevance of a multi-targeted inhibitor may be reflected on the prognostic relevance of its targets' transcriptional signature. We applied this concept in the case of the orally bioavailable multi-targeted kinase inhibitor AS703569, which targets (with IC50 in low nM range) all 3 Aurora kinase (AK) isoforms as well as various other kinases (e.g. cSRC, FGFR1, Flt3, Fyn, Lyn, Rsk1-3, Yes, Axl, et.c.) and evaluated the transcriptional signature of AS703569 kinase targets (with IC50 <10 nM) in MM cells of patients receiving Bortezomib as part of Phase II/III trials (specifically SUMMIT/APEX). We observed that patients with high transcriptional signature of AS703569 targets had inferior progression-free and overall survival (p=0.005 and p=0.012, log-rank test) and also validated that, in a study of tandem autologous transplant, a subset of patients with high levels of this AS703569 target transcriptional signature also have inferior overall survival (p=0.032, log-rank test) compared to cases with low levels of the signature. These observations supported the notion that the kinome space targeted by AS703569 is enriched for targets associated with adverse clinical outcome in MM. In preclinical assays, we observed that AS703569 decreased the viability of MM cell lines and primary CD138+ MM tumor cells in a time- and dose-dependent manner, with IC50 values <50 nM for the majority of cell lines tested; and without evidence of cross-resistance with established anti-MM agents. Combinations of AS703569 with dexamethasone, doxorubicin, or bortezomib did not exhibit antagonism, suggesting that AS703569 can be incorporated in regimens with these established anti-MM drug classes. Interestingly, in vitro compartment-specific bioluminescence imaging (CS-BLI) assays showed that against MM cells which respond to stromal cells with increased proliferation and survival, the anti-MM activity of AS703569 is more pronounced when these MM cells are co-cultured with bone marrow stromal cells than in conventional cultures in isolation. This indicated that AS703569 is capable of overcoming the protective effects that BMSCs confer to MM tumor cells and prompted in vivo validation studies in our orthotopic SCID/NOD model of diffuse MM bone lesions established by i.v. injection of MM-1S-GFP/Luc cells monitored by whole body bioluminescence imaging. AS703569 (50 mg/kg p.o. once weekly)-treated mice had longer overall survival than vehicle-treated mice (median 50.0 days, 95% C.I. 40.3-59.7 days vs. 39.0 days, 95% C.I., 35.4-42.6 days, p=0.019, log-rank test). An alternative schedule of AS703569 at 16.7 mg/kg 3 times/week also resulted in longer overall survival (median 54.0 days, 95% C.I. 33.2-74.8 days, p=0.023, log-rank test). These data indicate that AS703569 exhibits anti-MM activity in vitro and in orthotopic in vivo MM models, and suggests that this multi-targeted inhibitor merits considerations for further preclinical studies, as well as potential clinical studies in MM, especially given the otherwise adverse outcome associated with the inhibitor's target transcriptional signature. Disclosures: Laubach: Novartis: Consultancy, Honoraria. Rastelli:EMD Serono: Employment. Clark:EMD Serono: Employment. Sarno:EMD Serono: Employment. Richardson:Millenium: (Speakers' Bureau up to 7/1/09), Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Celgene: (Speakers' Bureau up to 7/1/09), Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Anderson:Millennium: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Mitsiades:Millennium: Consultancy, Honoraria; Novartis : Consultancy, Honoraria; Bristol-Myers Squibb : Consultancy, Honoraria; Merck & Co: Consultancy, Honoraria; Kosan Pharmaceuticals: Consultancy, Honoraria; Pharmion: Consultancy, Honoraria; PharmaMar: Patents & Royalties; Amgen: Research Funding; AVEO Pharma: Research Funding; EMD Serono : Research Funding; Sunesis Pharmaceuticals: Research Funding.

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High MYC Expression Predicts Poor Survival Outcomes in IDH1/2 Mutant AML Patients

Blood ◽

10.1182/blood-2021-147030 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 2377-2377

Author(s):

Virginia Olivia Volpe ◽

Nicole D. Vincelette ◽

Onyee Chan ◽

Chetasi Talati ◽

Kendra Sweet ◽

...

Keyword(s):

Board Of Directors ◽

Research Funding ◽

Categorical Variables ◽

Myeloid Differentiation ◽

Rank Test ◽

Cancer Center ◽

Survival Outcomes ◽

Poor Survival ◽

Advisory Committees ◽

Inhibitor Treatment

Abstract Background In AML, IDH1/2 somatic mutations can be frequent in patients at about 20%. Physiologically, IDH1/2 catalyze isocitrate conversion to alpha-ketoglutarate (α-KG). α-KG is an activating co-factor for ten-eleven translocation 2 (TET2), an important epigenetic regulator which converts 5mC to 5hmC in the genomic DNA ultimately turning on the myeloid differentiation. In contrast, mutant IDH1/2 proteins promote α-KG conversion to 2-hydroxyglutarate (2-HG), an onco-metabolite. In pre-clinical studies, 2-HG inhibits TET2 activity by suppressing 5mC-to-5hmC conversion and thus allowing AML development and maintenance. Clinical trials of IDH1/2 inhibitors demonstrated promising outcomes in IDH1/2 mut AML patients. However, a substantial fraction of patients fail to respond to IDH1/2 inhibitors in AML. Our recent preclinical studies have shown MYC prevents the normal myeloid differentiation and cell death by suppressing IDH1/2-TET2 signaling. We evaluated if high MYC expression is associated with poor survival outcomes in IDH1/2 mut AML patients treated with Ivosidenib or Enasidenib Patients and Methods Patients diagnosed with AML at Moffitt Cancer Center between 2013-2020 were evaluated. IDH1/2 mutation status was assessed via next generation sequencing and those with documented IDH1/2 mut were included for the analysis. Clinical and demographic data were retrospectively extracted from the medical records. Pre-treatment MYC protein levels were assessed by immunohistochemistry staining using BM biopsy specimens. Statistical analyses were performed using GraphPad Prism (v.7.03) and SPSS (v.24.0). Baseline characteristics were compared by chi square (categorical variables) and t- test (continuous variables). Survival estimates were calculated using the Kaplan-Meier method from date of diagnosis and groups were compared using log-rank test. Multivariate survival analysis was performed by means of Cox proportional hazards regression Results A total of 28 (IDH1 mut, n=11; IDH2 mut, n=18; IDH1/2 mut, n=1) patients were included in the study. Median age at AML diagnosis was 66 years and 60% of patients were male. Twelve (42%) patients had secondary AML and 9 (32%), 11 (39%), and 6 (21%) patients had favorable, intermediate, and adverse risk, respectively, at AML diagnosis. A total of 17 (60.7%) and 6 (21.4%) patients received intensive chemotherapy and hypomethylating agents as their 1 st-line therapy. Among 28 patients, 22 (78.5%) and 6 (21.4%) patients had low and high MYC expression (≥5% by IHC staining), respectively, prior to IDH1/2 inhibitor treatment. Median number of treatments prior to IDH1/2 inhibitors was 3 (1-6) and the median duration of IDH1/2 inhibitor treatment was 3.2 (0.3-30) months (IDH1 mut, 3.3 [0.3-30] months; IDH2 mut, 2.5 [0.7-14.5] months). Treatment response was assessed in 27 patients and 11 (40.7%) had CR/CRi (high vs. low MYC, 20 vs. 45.5%, p=.6185). The median PFS was shorter in high MYC patients (1.6 vs. 4.4 months, HR=2.348, p=.0515). The median OS was also significantly shorter in high MYC patients (2.5 vs. 8.5 months, HR=5.971, p<.0001). Conclusion In our study, we demonstrated that high MYC expression was associated with significantly shorter PFS and OS in IDH1/2 mut AML patients. In consistent with our recent studies that showed MYC represses IDH1/2 and TET2 expression in AML, this study suggests that MYC may play an important role in the resistance mechanism of IDH1/2 inhibitors. Additional studies with larger cohorts are warranted to further confirm and validate these findings. Disclosures Talati: Jazz: Speakers Bureau; Astellas: Speakers Bureau; BMS: Honoraria; AbbVie: Honoraria; Pfizer: Honoraria. Sweet: Bristol Meyers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; AROG: Membership on an entity's Board of Directors or advisory committees; Gilead: Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Astellas: Consultancy, Membership on an entity's Board of Directors or advisory committees. Kuykendall: Pharmaessentia: Honoraria; Celgene/BMS: Honoraria; Incyte: Consultancy; Abbvie: Honoraria; Blueprint: Honoraria; Novartis: Honoraria, Speakers Bureau; Protagonist: Consultancy, Research Funding. Komrokji: Geron: Honoraria; Acceleron: Honoraria; Novartis: Honoraria; Agios: Honoraria, Speakers Bureau; Abbvie: Honoraria, Speakers Bureau; BMS: Honoraria, Speakers Bureau; JAZZ: Honoraria, Speakers Bureau. Sallman: Bristol-Myers Squibb: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Intellia: Membership on an entity's Board of Directors or advisory committees; Magenta: Consultancy; Syndax: Membership on an entity's Board of Directors or advisory committees; AbbVie: Membership on an entity's Board of Directors or advisory committees; Incyte: Speakers Bureau; Takeda: Consultancy; Shattuck Labs: Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Kite: Membership on an entity's Board of Directors or advisory committees; Agios: Membership on an entity's Board of Directors or advisory committees; Aprea: Membership on an entity's Board of Directors or advisory committees, Research Funding. Padron: Kura: Research Funding; Incyte: Research Funding; BMS: Research Funding; Stemline: Honoraria; Blueprint: Honoraria; Taiho: Honoraria.

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Renal Response in Carfilzomib (K)- Versus Bortezomib (V)-Treated Patients (Pts) with Relapsed or Refractory Multiple Myeloma (RRMM) in the Real-World Practice Setting

Blood ◽

10.1182/blood-2018-99-113519 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 3253-3253

Author(s):

Shaji K. Kumar ◽

Alan Fu ◽

Khalid Mezzi ◽

Megan Braunlin ◽

Christopher Kim ◽

...

Keyword(s):

Renal Function ◽

Board Of Directors ◽

Research Funding ◽

Post Treatment ◽

Rank Test ◽

Employment Equity ◽

Advisory Committees ◽

Renal Response ◽

Log Rank Test ◽

Equity Ownership

Abstract Introduction: Renal impairment (RI) is a classic clinicopathological feature of MM, is associated with poor prognosis and shorter survival (Eleutherakis-Papaiakovou Leuk Lymphoma 2007), and can complicate drug dosing and limit treatment options. In clinical trials, the proteasome inhibitors K and V have demonstrated efficacy in RRMM pts with RI, with superior efficacy observed in K-treated pts (Dimopoulos Blood 2017). K and V have also been observed to improve renal function in RRMM pts (Dimopoulos Clin Lymphoma Myeloma 2009; Dimopoulos Blood Advances 2017). However, few studies have investigated the real-world effectiveness of K- and V-based regimens in renal rescue. This study aimed to describe and compare renal response rates in RRMM pts treated with K + dexamethasone (Kd) and V + dexamethasone (Vd) in oncology clinics. Methods: The Oncology Services Comprehensive Electronic Records (OSCER) database (Lau Clin Epidemiol 2011) contains electronic medical records (EMR) from community- and hospital-affiliated oncology clinics in the United States. MM pts aged ≥18 who entered an OSCER clinic Jan 2012‒Feb 2018; initiated Kd or Vd treatment as line 2 (2L), 3L, or 4L; and had baseline renal impairment (Modification of Diet in Renal Disease Study estimated glomerular filtration rate [eGFR] <50 mL/min from the most recent baseline serum creatinine measurement) were included. Index date was the date of Kd or Vd initiation. The baseline period was 60 d prior to index to 30 d post-index. Follow-up was 30 d after index date to 60 d after completion of the same line. Primary outcome was renal response during follow-up. Renal response was defined according to the International Myeloma Working Group criteria (Dimopoulos J Clin Oncol 2016): complete response (RCR; baseline eGFR <50 mL/min and best post-treatment eGFR ≥60 mL/min), partial response (baseline eGFR <15 mL/min and best post-treatment eGFR 30‒59 mL/min), minor response (baseline eGFR <15 mL/min and best post-treatment eGFR 15‒29 mL/min, or baseline eGFR 15‒29 mL/min and best post-treatment eGFR 30‒59 mL/min). Renal response rates in Kd- and Vd-treated pts were evaluated using the Kaplan-Meier method and log-rank test. Incidence rate ratios (IRR) and 95% confidence intervals (CIs) were calculated for renal overall response (ROR) and RCR using multivariate Cox proportional hazard models adjusted for baseline covariates (demographics, Eastern Cooperative Oncology Group Performance Status, International Staging System stage, baseline renal function, V use in 1L, time from MM diagnosis to line initiation, use of intravenous bisphosphonates, and baseline serum calcium, serum free light chain ratio, lactate dehydrogenase, and whole blood hemoglobin measurements). Missing baseline values were estimated by multiple imputations. Results: 543 Kd-treated and 1005 Vd-treated pts were included. Baseline characteristics were similar between cohorts, with no difference in baseline eGFR stages. More Kd pts were <65 yrs of age at MM diagnosis. Median time from diagnosis to line initiation was longer in Kd pts (Kd: 17.1 mos; Vd 16.1 mos). V-based regimens were the most common therapies in 1L. Median (interquartile range) treatment duration was 4.4 (2.3-8.3) mos for Kd and 4.3 (2.1-8.3) mos for Vd. Pts treated with Kd at 2L were more likely than those treated with Vd to achieve both ROR (51.4% [178/346] vs 39.6% [327/825]; log-rank test p<0.0001) and RCR (26.6% [92/346] vs 22.2% [183/825]; log-rank test p=0.0229). This pattern persisted when 3L and 4L pts were included, (ROR: 48.4% [263/543] vs 39.8% [400/1005]; log-rank p<0.0001; RCR: 26% [141/543] vs 22.1% [222/1005]; log-rank p=0.0084) (Figures 1A and 1B). Following adjustment for potential baseline confounders, 2L Kd pts were 45% more likely to achieve ROR (IRR, 95% CI: 1.45, 1.18‒1.78) and 68% more likely to achieve RCR (1.68, 1.24‒2.28) vs 2L Vd pts (Figure 2). Kd pts in 2‒4L were 36% more likely to achieve ROR (1.36, 1.15‒1.62) and 52% more likely to achieve RCR (1.52, 1.19‒1.94). Conclusions: Using one of the most complete oncology EMR databases available, we found that RRMM pts with baseline RI treated with Kd had higher rates of overall and complete renal response, and were more likely to have a renal response, compared with pts treated with Vd. A limitation of the study is that we could not account for all concomitant medications or comorbidities that affect renal function, as some may not be captured in OSCER. Disclosures Kumar: AbbVie: Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding; KITE: Membership on an entity's Board of Directors or advisory committees, Research Funding. Fu:Amgen: Employment, Equity Ownership. Mezzi:Amgen: Employment, Equity Ownership. Braunlin:Amgen: Employment. Kim:Amgen: Employment, Equity Ownership. Iskander:Amgen: Employment, Equity Ownership. Niesvizky:Amgen Inc.: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Janssen: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; Takeda: Consultancy, Research Funding. Jagannath:Celgene: Consultancy; Novartis: Consultancy; Merck: Consultancy; Medicom: Speakers Bureau; Multiple Myeloma Research Foundation: Speakers Bureau; Bristol-Myers Squibb: Consultancy. Boccia:Sandoz: Consultancy; Celgene: Speakers Bureau; Abbvie: Speakers Bureau; Genentech: Research Funding, Speakers Bureau; Amgen: Research Funding, Speakers Bureau; BMS: Research Funding; Pfizer: Consultancy; AstraZeneca: Research Funding, Speakers Bureau. Raje:Celgene: Consultancy; Janssen: Consultancy; Merck: Consultancy; Takeda: Consultancy; AstraZeneca: Research Funding; Research to Practice: Honoraria; Medscape: Honoraria; BMS: Consultancy; Amgen Inc.: Consultancy.

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Patient Characteristics and Outcomes in Adolescents and Young Adults (AYA) with Acute Myeloid Leukemia (AML): Princess Margaret Cancer Centre Experience

Blood ◽

10.1182/blood-2019-125449 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 2609-2609

Author(s):

Muhned Alhumaid ◽

Georgina S Daher-Reyes ◽

Wilson Lam ◽

Arjun Law ◽

Tracy Murphy ◽

...

Keyword(s):

Board Of Directors ◽

Older Patients ◽

Myeloid Leukemia ◽

Research Funding ◽

Age Groups ◽

Treatment Strategies ◽

Patient Characteristics ◽

Cancer Center ◽

Advisory Committees ◽

Disease Behavior

Introduction: Clinical outcomes of acute myeloid leukemia (AML) in adolescents and young adults (AYA) are rarely reported as an isolated subgroup. Treatments vary little across age groups, and treatment intensity depends upon comorbid conditions and performance status. Optimal treatment strategies focused on disease behavior, biological factors, and the distinct needs of this subset of AML patients remain elusive. The purpose of this retrospective analysis is to determine the characteristics and outcomes of AYA AML patients treated at a specialized adult leukemia cancer center in comparison to older adults with AML (40-60 years). Methods: A retrospective analysis was performed on all patients treated at Princess Margaret Cancer Center from 2008-2018. Patients with acute promyelocytic leukemia were excluded. Clinical characteristics, treatment strategies, and survival outcomes were recorded for all patients. Overall survival (OS) and disease-free survival (DFS) rates were calculated using the Kaplan-Meier product-limit method and the impact of covariates were assessed using the Log-rank test. Finally, we compared the outcomes of AYA patients treated at our centre between 2015-2018 with older patients. Results: A total of 175 patients aged 18-39 were identified. Patient characteristics are shown in (Table 1). Cytogenetic were available in 163 patients. Based on MRC criteria, 27 (16%) were favorable risk, intermediate in 95 (54%), adverse in 39 (22%), and missing/failed in 14(8%). NPM1 status was available in 110 patients of whom 38 (35%) were positive. FLT3-ITD was available in 67 patients with 24 (36%) positive. Both mutations were present in 13 (54%) patients. There were no significant differences in terms of risk stratification based on cytogenetic and molecular markers based on age (18-29 vs.30-39) (P= 0.98). Most patients 172 (98%) received induction, 157 (91%) with 3+7, and 15 (9%) with FLAG-IDA. Complete remission (CR) was achieved in 133 (77%) after first induction [120 (76%) after 3+7 and 11 (73%) after FLAG-IDA]. Induction related mortality was low (2%). Of the 39 who did not achieve CR, thirty-four patients received re-induction (13 FLAG-IDA, 16 NOVE-HiDAC, 5 others) with CR in 21 (62%). Overall, 154 (89.5%) achieved CR1. Sixty-four (42%) proceeded to hematopoietic stem cell transplantation (HSCT) in CR1. 59 (38%) patients relapsed in CR1 with 8 (12%) relapsing post HSCT. Fifty-five (5 post HSCT) patients received reinduction with 30 (51%) (2 after HSCT) achieving CR2. Fifteen patients received HSCT in CR2. OS and DFS at 2 years were 62% (95% CI 0.53-0.69) and 50% (95% CI 0.41-0.57), respectively. Stratified by cytogenetic risk, OS was 81% for favorable risk, 61% for intermediate, and 50% for adverse risk (P=0.0001), respectively. DFS in these groups was 85%, 57%, and 46 % (P=0.0025), respectively. We further compared outcomes in the 18-29y and 30-39y age groups. The OS was 61.9% compared to 62.5% (P=0.91) and DFS of 52.1% compared to 47% (P=0.65) respectively. On univariate analysis for OS and DFS, cytogenetic risk stratification was the only significant variable (P=0.0004 and P=0.0042). We then compared the outcomes 67 sequential patients aged I8-39 treated from 2014-2018, with those of 176 sequential patients aged 40-60 treated during the same period (table 2). OS at 2 years was not statistically higher in the younger group compared to the older group (66.7% vs. 61.2%, P=0.372). While relapse rate was lower in older patients (15.5% vs. 22.6%, P=0.093), NRM was higher in older patients (29.7% vs. 18.8%,P=0.094). Conclusion: AYA pts. occupy a unique niche amongst AML as a whole. While treatment responses have improved in general, there may be potential for further gains in these patients. Increased tolerance for more intense treatment strategies as well as the incorporation of novel agents into standard treatment protocols may provide a means to optimize care in AYA patients. Finally, research is needed to elucidate biological mechanisms and predictors of disease behavior instead of arbitrary, age-stratified treatment schema. Disclosures McNamara: Novartis Pharmaceutical Canada Inc.: Consultancy. Schimmer:Jazz Pharmaceuticals: Consultancy; Medivir Pharmaceuticals: Research Funding; Novartis Pharmaceuticals: Consultancy; Otsuka Pharmaceuticals: Consultancy. Schuh:Astellas: Honoraria, Membership on an entity's Board of Directors or advisory committees; AbbVie: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: 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; Teva Canada Innovation: 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; Agios: Honoraria; Jazz: Honoraria, Membership on an entity's Board of Directors or advisory committees. Maze:Pfizer Inc: Consultancy; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees. Yee:Astellas: Membership on an entity's Board of Directors or advisory committees; Millennium: Research Funding; Takeda: Membership on an entity's Board of Directors or advisory committees; Astex: Research Funding; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Merck: Research Funding; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; MedImmune: Research Funding; Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees; Hoffman La Roche: Research Funding. Minden:Trillium Therapetuics: Other: licensing agreement. Gupta:Incyte: Honoraria, Research Funding; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Sierra Oncology: Honoraria, Membership on an entity's Board of Directors or advisory committees.

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