Although acute promyelocytic leukemia (APL) has evolved to the AML entity with the best prognosis, typical 'early death' (ED) events still account for mortality rates of ∼20% in population-based ...studies. To investigate this poorly understood issue we performed whole transcriptome analysis of n = 7 APL ED cases compared to n = 7 APL cases with long term remission. We discovered the proteins S100A8/S100A9 and EFEMP1 as the most differentially expressed factors. In an independent cohort of n = 58 APL patients EFEMP1 over-expression was associated with a worse overall survival. Furthermore, a subgroup analysis of ED caused by hemorrhagic complications revealed an association of metallothioneins (MT1G/MT1E) with higher bleeding rates, ED events and negative prognostic effects on overall survival. Finally, we identified a novel TPM4-KLF2 fusion transcripts in 44/64 APL samples. In summary, we report a comprehensive transcriptomic analysis and novel potential biomarkers of ED biology, which highlight novel pathways in ED events in APL.
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Dostopno za:
DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
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Background: Hypomethylating agents (HMA) form the current standard treatment for patients with higher-risk myelodysplastic syndrome (HR-MDS) who are not eligible for allogeneic hematopoietic stem ...cell transplantation (HSCT). However, overall response rates (ORRs) remain low in patients receiving azacitidine (Aza), and median overall survival (OS) is reported as ~15 months (Sekeres et al. J Clin Oncol. 2017). In addition, there are few data on patient-reported outcomes (PROs) published in this population while on treatment. Venetoclax (Ven) is a selective, potent, orally bioavailable BCL-2 inhibitor, which has demonstrated synergy with HMA in preclinical studies of HR-MDS. From an ongoing, open-label, dose-escalation, Phase 1b study (NCT02942290) evaluating Ven+Aza for the treatment of treatment-naïve HR-MDS, we report the updated safety and efficacy in all treated patients and the exploratory analysis of key PROs in patients who received the recommended Phase 2 dose (RP2D).
Methods: Patients aged ≥18 years with treatment-naïve HR-MDS, International Prognostic Scoring System intermediate-2 or high, bone marrow blasts <20% at baseline, and an Eastern Cooperative Oncology Group (ECOG) score ≤2 were enrolled; patients with chronic myelomonocytic leukemia or therapy-related MDS and candidates for intensive chemotherapy or HSCT were excluded. Ven was initially given at a dose of 400 mg or 800 mg for 28 days in a 28-day cycle. Due to intolerance among patients with MDS, this was later amended to an escalating dose (100, 200, and 400 mg) for 14 days in a 28-day cycle. Aza was administered at 75 mg/m2 subcutaneously or intravenously on Days 1-7 of each 28-day cycle. The primary objectives of the study were to assess the Ven+Aza safety profile and to establish the RP2D. Key secondary objectives included assessment of ORR and OS. Safety and efficacy assessments were carried out on all patients who received ≥1 dose of study drug, and efficacy endpoints were evaluated according to the 2006 International Working Group response criteria, with OS analyzed using Kaplan-Meier methodology. PROs were exploratory and included the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core (EORTC QLQ-C30) scale.
Results: At data cutoff, December 31, 2019, 57 patients had received Ven+Aza, with a median follow-up of 13.0 months (95% confidence interval CI 11.3, 15.6 months). The majority of patients were male (75%); median age was 71 years (range 26-85 years); and 89% had ECOG score 0-1. All patients experienced ≥1 adverse event (AE), the most common being constipation (54%), neutropenia (51%), and nausea (51%). Grade ≥3 AEs were experienced by 97% of patients, with neutropenia (51%), febrile neutropenia (46%), and thrombocytopenia (30%) the most common. Febrile neutropenia was the most common serious AE (42%). The 30-day mortality rate was 2%. The ORR was 77%, including complete remission (CR) and marrow CR (mCR) achieved by 42% and 35% of patients (of whom 40% achieved mCR + hematological improvement), respectively; none achieved partial remission. Median OS was not reached (95% CI 16.2 months, not estimable; Figure 1). Median duration of response was 14.8 months (95% CI 12.9 months, not estimable). Median progression-free survival was 17.5 months (14.5, not estimable). Of the patients who received the RP2D of Ven 400 mg for 14 days/28-day cycle in combination with Aza, physical functioning, as measured by the EORTC QLQ-C30, was maintained through 48 weeks of treatment. In addition, clinically meaningful improvement in fatigue and dyspnea, as measured by the EORTC QLQ-C30, was achieved by the beginning of Cycle 5 and was maintained through Week 48 (Cycle 13; Figure 2).
Conclusions: The combination of Ven+Aza demonstrates promising efficacy, including response durability, and an acceptable safety profile for patients with HR-MDS. Maintenance in physical functioning and clinically meaningful improvement in dyspnea and fatigue were observed throughout the first 48 weeks, although these data are not yet mature and low patient numbers beyond Cycle 7 limit conclusions. Additional follow-up data and correlation with disease risk features including mutations will be presented at the meeting.
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Garcia:Pfizer: Research Funding; Eli Lily: Research Funding; Genentech: Research Funding; AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding. Wei:Amgen: Consultancy, Honoraria, Research Funding; MacroGenics: Consultancy, Honoraria; Servier: Consultancy, Honoraria, Research Funding; Walter and Eliza Hall Institute: Other: former employee and receives a fraction of its royalty stream related to venetoclax; Pfizer: Honoraria; Genentech: Honoraria; Astra Zeneca: Honoraria, Research Funding; AbbVie Inc.: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Research Funding; Astellas: Consultancy, Honoraria; Janssen: Consultancy, Honoraria; Celgene: Consultancy, Honoraria, Research Funding. Borate:Genentech: Membership on an entity's Board of Directors or advisory committees; Daiichi Sankyo: Membership on an entity's Board of Directors or advisory committees; Takeda: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding; Jazz Pharmaceuticals: Research Funding; AbbVie: Other: Investigator in AbbVie-funded clinical trials; Pfizer: Membership on an entity's Board of Directors or advisory committees, Research Funding. Fong:Astellas: Honoraria; Pfizer: Honoraria; Novartis: Honoraria; Amgen: Honoraria, Research Funding, Speakers Bureau; AbbVie: Honoraria. Baer:Forma: Other: Institutional research funding; Astellas: Other: Institutional research funding; AbbVie: Other: Institutional research funding; Incyte: Other: Institutional research funding; Kite: Other: Institutional research funding; Oscotec: Other: Institutional research funding; Takeda: Other: Institutional research funding. Nolte:AbbVie: Other: Investigator on an AbbVie funded clinical trial. Jurcic:AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; BMS: Consultancy, Research Funding; Daiichi-Sankyo: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Arog Pharmaceuticals: Research Funding; Astellas: Research Funding; Forma Therapeutics: Research Funding; Genentech: Research Funding; Kura Oncology: Research Funding; PTC Therapeutics: Research Funding; Syros Pharmaceuticals: Research Funding; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding. Jacoby:Takeda: Consultancy; AbbVie: Research Funding; Jazz Pharmaceuticals: Research Funding. Hong:F. Hoffmann-La Roche: Current equity holder in publicly-traded company; Genentech, Inc.: Current Employment. Platzbecker:Geron: Consultancy, Honoraria; BMS: Consultancy, Honoraria; Amgen: Honoraria, Research Funding; Janssen: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Research Funding; AbbVie: Consultancy, Honoraria; Takeda: Consultancy, Honoraria. Odenike:Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Astex Pharmaceuticals, NS Pharma, Gilead Sciences, Janssen Oncology, Oncotherapy, Agios, CTI/Baxalta, Aprea: Other: Institutional research funding; Astra Zeneca: Research Funding; Incyte: Other: Institutional research funding; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Impact Biomedicines: Consultancy, Membership on an entity's Board of Directors or advisory committees; AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding. Cunningham:AbbVie: Research Funding; Amgen: Research Funding; Astex: Research Funding; Celgene: Research Funding; Janssen: Research Funding; Novartis: Research Funding; Principia Biopharma: Research Funding; Rigel Ilona: Research Funding. Zhou:AbbVie: Current Employment, Other: may hold stock or other options. Tong:AbbVie, Inc.: Current Employment, Other: may hold stock or other options. Hogdal:AbbVie: Current Employment, Other: may hold stock or other options. Kamalakar:AbbVie: Current Employment, Other: may hold stock or other options. Hutti:AbbVie Inc.: Current Employment, Other: may hold stock or stock options. Kye:AbbVie: Current Employment, Other: may hold stock or other options. Garcia-Manero:Novartis: Research Funding; Merck: Research Funding; Bristol-Myers Squibb: Consultancy, Research Funding; Amphivena Therapeutics: Research Funding; AbbVie: Honoraria, Research Funding; Helsinn Therapeutics: Consultancy, Honoraria, Research Funding; Genentech: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Astex Pharmaceuticals: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria, Research Funding; H3 Biomedicine: Research Funding; Jazz Pharmaceuticals: Consultancy; Acceleron Pharmaceuticals: Consultancy, Honoraria; Onconova: Research Funding.
Venetoclax is a BCL-2 inhibitor approved for use in CLL and in combination with azacitidine, decitabine, or low-dose cytarabine for the treatment of newly-diagnosed AML who are 75 years or older or who have comorbidities that preclude use of intensive induction chemotherapy; the current clinical trial reports use in MDS
Myelodysplastic Syndromes are oligo‐clonal stem cell disorders that are associated with cytopenias in the peripheral blood. Major causes for morbidity and mortality in myelodysplastic syndromes (MDS) ...patients are infections mostly due to bacteria or fungi. Beside leucopenia per se in affected patients, function of white blood cells particularly that of neutrophils seems to be impaired. Here we summarize the available data on infections in MDS patients in general and particularly those treated with 5‐azacitidine.
Introduction: Thrombocytopenia is a common complication among MDS patients. Thus, many patients are dependent on platelet (PLT) transfusions, which give short-term therapeutic relief but are also ...associated with considerable clinical risks. In this context, thrombopoietin receptor agonists (TRAs) are under investigation as alternative treatment option, albeit with the concern that these substances may promote adverse events in MDS. However, beside potential positive effects on thrombopoiesis in MDS patients the TRA Eltrombopag (EPAG) has also been shown to exert positive disease modifying effects in vitro (Roth et al., Blood 2012). Using a MDS xenograft model, we here investigate the efficacy of EPAG and its influence on clonal composition on primary patient derived MDS xenografts and present data from an ongoing study.
Methods: Currently, samples from n=18 MDS patients (MDS del(5q)=2, MDS-MLD=6, MDS-RS-MLD=1 MDS-EB-1=2, MDS-EB-2=7) have been xenografted into NSG mice by intrafemoral co-injection of CD34+ hematopoietic stem cells and mesenchymal stromal cells using a modified protocol according to Medyouf et al., Cell Stem Cell 2014. Long term engraftment is assessed 12 weeks post-transplant by intrafemoral bone marrow (BM) biopsy and mice with positive human engraftment are subsequently treated with either EPAG (50mg/kg) or vehicle control for 18 weeks. During that time, the mice are bled every two weeks and BM aspiration is performed every six weeks. Human hematopoietic cells are FACS sorted. In peripheral blood, human PLTs are specifically and absolutely counted with a FACS assay based on hCD41+ cells and beads. To track clonal composition of MDS samples upon xenografting and EPAG treatment in comparison to placebo control, the original patient sample and the final MDS xenograft sample are being whole exome sequenced (WES). Interspersed time points are analyzed with a patient individual amplicon based deep sequencing approach (Mossner et al., Blood 2016) to calculate dynamics of variant allele frequencies (VAF) in dependency of treatment.
Results: To date, n=12 patient samples have been analyzed for human engraftment after 12 weeks post-transplant. Of these, n=7 (58%) have shown positive human engraftment and are being treated with EPAG versus placebo. To this end, one case has been completely followed up, including final molecular analysis. This MDS high risk case (MDS-EB-2) with a clinical PLT count of 29x109 PLT/L was transplanted into n=3 NSG mice. While two mice treated with EPAG survived the complete duration of the experiment, the placebo mouse died prematurely due to severe weight loss after 6 weeks of treatment. Further, EPAG treatment led to an initial rise of human PLT levels, while the placebo treated mouse presented a continuous decline of human PLTs, showing the efficacy of EPAG on human xenografts in the model. This observation has been confirmed in another case currently still under treatment. Molecular tracking by WES confirmed MDS patient specific molecular lesions in the MDS xenograft such as monosomy 7 and the disease related mutations CBL, DNMT3A and EZH2 with VAFs of 83%/43%/23% respectively. The monosomy 7 was detectable in all mice. CBL and DNMT3A exhibited similar VAFs in mouse EPAG1 (VAF=100%/54%), EPAG2 (VAF=100%/34%) and placebo (VAF=100%/50%). The EZH2 mutation was only detected in mouse EPAG2 (VAF=11%). Interestingly, the placebo mouse acquired a de novo mutation of U2AF1 (VAF=10%), which was not detectable in the initial patient sample or the EPAG treated mice. This spliceosomal mutation is associated with a higher risk of transformation to AML and shorter survival (Graubert et al., Nat Genet 2012; Makishima et al., Blood 2012).
Conclusions: Our data show first proof of principle results that new treatment options can be tested successfully in a preclinical murine xenograft model of primary MDS patient samples in a placebo controlled experimental setting. This approach allows the performance of patient individual substance testing that can segregate substance specific effects from natural disease progression in the same patient. Clinical parameters such as human PLT production and molecular clonal composition can be measured with a high confidence in vivo. Our current data show preliminary support for the hypothesis that EPAG may be efficacious in increasing PLT production in MDS patients without adversely influencing the underlying clonal composition.
Nowak:Novartis: Research Funding.
Highlights • Data regarding IC in MDS patients are controversial, but multiple analyses suggest a benefit including erythroid improvement and transfusion independence. • Patients should be informed ...in detail about the nature of gastrointestinal disturbances. • DFX dosing should be done pre-prandial in the evening for patients with GI side effects. • DFX should be initiated at low dose levels, e.g. 500 mg per day and escalation to target dose should be done in a timely fashion. • Target dose should be calculated based on serum ferritin and transfusion frequency.
Introduction: Next generation sequencing techniques have identified a large number of MDS associated acquired molecular lesions. However, translation of these possible molecular targets into new ...therapeutic strategies has been lagging behind. This is also due to a lack of functional experimental models of MDS, in which new hypotheses can be evaluated pre-clinically. Xenograft models in NSG mice have emerged as versatile preclinical platforms for investigation of functional pathomechanisms in MDS (1 Medyouf et al., 2014, 2 Rouault-Pierre et al., 2017). The limiting factor of these models is the low engraftment of patient-derived CD34+ hematopoietic stem cells (HSCs). Efficient humanized 3D scaffolds in immune-compromised mouse models have been established, enabling to increase engraftment rates of normal and malignant hematopoiesis (3 Reinisch et al., 2016, 4 Abarrategi et al., 2017). Therefore, we evaluated engraftment ability of IPSS low-risk, int-1 and high-risk-patient samples, in four different 3D scaffolds.
Methods: Currently we transplanted samples from 10 MDS patients in parallel into NSG mice testing the following conditions: A) Intrafemoral co-injection of CD34+ HSCs and MSCs according to 1. Subcutaneous implantation of 3D scaffolds. Gelfoam (B) and Bio-OSS (C) 4, Matrigel ossicles (D) 3 and primary human bone isolated after hip replacement, inserted with Gelfoam, preseeded in vitro with MSCs and mononuclear cells (MNCs) and injected in vivo with CD34+ HSCs 8 weeks after implantation (human bone ossicles) (E). Ossicles, bone marrow (BM), peripheral blood and spleens were analyzed 12 weeks after implantation of hematopoietic cells.
Results: Gelfoam and human bone ossicles showed significantly higher hCD45+cell numbers compared to intrafemoral injection analyzed by flow cytometry. Engraftment in those two conditions was similarly robust. However, Gelfoam scaffolds showed higher percentual engraftment levels ranging up to 70% as compared to human bone ossicles ranging from 0.2% to 27%. Interestingly, we found systemic engraftment of hCD45+cells outside the injected bone fragment in the BM, peripheral blood and spleen solely in mice, which received human bone ossicles. In all other methods, hCD45+ cells could only be detected within the ossicles themselves. This result could possibly be explained due to transplantation of MNCs in this condition. That hypothesis was supported by another set of experiments using human bone ossicles (n=10), which showed that colonization of the scaffold was similar when transplanting either CD34+ cells + MSCs, MNCs+MSCs or MNCs only but systemic engraftment could only be seen in MNC transplanted mice.
Conclusion: Our data show that hCD45+cells and MSCs from MDS BM were able to colonize humanized ossicle scaffolds. Gelfoam and human bone ossicles were the most promising novel methods to improve MDS xenograft models. For systemic engraftment, application of MNCs seems to be necessary.
Nolte:Novartis: Honoraria, Research Funding; Celgene: Honoraria, Research Funding.
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Introduction
Over-expression of the anti-apoptotic protein BCL-2 in MDS has been implicated in progression and drug resistance in MDS. Venetoclax (Ven), a selective, potent, orally bioavailable ...BCL-2 inhibitor, was recently approved in combination with HMAs or low dose cytarabine for the frontline management of older unfit pts with AML. In this study, we sought to evaluate the safety and efficacy of Ven in pts with R/R MDS.
Methods
This is an ongoing phase 1b, open-label, multicenter study in R/R MDS (NCT02966782). Key eligibility criteria include age ≥18 years, failure of HMA after receiving at least 4 cycles of Aza or 4 cycles of decitabine within the previous 5 years, marrow blasts <20%, and ECOG Performance status of ≤2. Cohort 1 (C1) pts received Ven monotherapy, either 400 mg (Arm A) or 800 mg (Arm B) per cycle (28 days) and Cohort 2 (C2) pts received Aza combined with escalating doses of Ven: 100, 200 and 400 mg daily for 14 of 28-day cycles. Aza was administered at the standard dose (75 mg/m2/day) for the first 7 days of each cycle.
The primary objectives were to evaluate the safety profiles and the recommended Phase 2 dose (RP2D) of Ven monotherapy and Ven+Aza. Key secondary objectives included a preliminary assessment of overall response rate (ORR, defined as complete remission CR+marrow complete remission mCR+partial response PR) , time to first response (TTR), progression-free survival (PFS), and overall survival (OS). We used the modified International Working Group 2006 criteria for response assessment (Cheson et. al., Blood, 2006).
Results
As of April 9, 2019, 46 pts 87% male, median age 76 years (range 44-91) were enrolled. C1 (Ven monotherapy) included 22 pts, C2 (combination therapy) included 24 pts. At baseline, 37 (80%) pts received at least one prior therapy, 2 (15%) pts received 2, and 1 (2%) patient received >3 therapies prior to enrollment in the study. Baseline bone marrow blasts were: ≤5% was observed in 16 (35%) pts, >5% and ≤10% in 23 (50%), and >10% in 7 (15%) pts respectively. Cytogenetics risk was evaluated in 27/46 pts and were as follows: Good 12 (44%), Intermediate 9 (33%), and Poor 6 (22%).
Overall, 9 pts discontinued study therapy (8 deaths, 1 withdrew consent). The most frequent treatment-emergent adverse events (TEAEs) included neutropenia, thrombocytopenia, nausea, and diarrhea (Table ). Infectious TEAEs included febrile neutropenia and pneumonia. Predominant Grade 3 and 4 TEAEs were hematological and included neutropenia (41%), thrombocytopenia (30%), leukopenia (24%), and anemia (15%). Serious TEAEs occurring in ≥2 pts were febrile neutropenia (n=8), pneumonia (n=6), thrombocytopenia (n=2), and epistaxis (n=2). Death on study occurred in 8 (17%) pts, of whom 6 died of progressive disease. Other causes of death were septic shock (n=1) and pneumonia (n=1).
Forty of 46 pts were response evaluable. Median follow-up time was 4.7 mos (range: 3.7-6.3 mos). In C1, ORR was 7% (1/16). Stable disease was observed in 75% (12/16) pts. Median TTR was 1.6 mos (range: 1.6-1.6 mos). Median PFS was 3.4 mos (95% CI: 1.9-5.2 mos) and 6-mos estimate for OS was 57% (95% CI: 22%, 81%).
In C2, ORR was 50% (12/24 pts). Of those, 13% (3/24) had CR and 38% (9/24) had mCR. Stable disease was observed in 31% (10/24) pts. Median PFS, and OS were not reached. The 6-mos estimate for PFS was 76% (95% CI: 50%, 89%) and estimated OS at 9-mos was 83% (95% CI: 55%, 95%). Finally, 4 pts came off study to receive allogeneic stem cell transplantation.
Conclusion
Ven monotherapy and combination Ven+Aza were well tolerated in pts with R/R MDS and most AEs were manageable. Although the study is still ongoing, the 6-mos OS estimate of 57% in monotherapy pts compares favorably to historical controls. In addition, the ORR observed with combination therapy, and the observed 9-mos OS rate of 83% also compare favorably with historical data. Updated data on safety and efficacy, including data on RP2D, will be presented at the meeting.
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Zeidan:Ariad: Honoraria; Agios: Honoraria; Abbvie: Consultancy, Honoraria, Research Funding; Takeda: Consultancy, Honoraria, Research Funding; Otsuka: Consultancy, Honoraria, Research Funding; ADC Therapeutics: Research Funding; Jazz: Honoraria; Pfizer: Consultancy, Honoraria, Research Funding; Novartis: Honoraria; Astellas: Honoraria; Daiichi Sankyo: Honoraria; Cardinal Health: Honoraria; Seattle Genetics: Honoraria; BeyondSpring: Honoraria; Acceleron Pharma: Consultancy, Honoraria, Research Funding; Boehringer-Ingelheim: Consultancy, Honoraria, Research Funding; Trovagene: Consultancy, Honoraria, Research Funding; Incyte: Consultancy, Honoraria, Research Funding; Celgene Corporation: Consultancy, Honoraria, Research Funding; Medimmune/AstraZeneca: Research Funding. Pollyea:Celyad: Consultancy, Membership on an entity's Board of Directors or advisory committees; Astellas: Consultancy, Membership on an entity's Board of Directors or advisory committees; Diachii Sankyo: Consultancy, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees; Abbvie: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Takeda: Consultancy, Membership on an entity's Board of Directors or advisory committees; Agios: Consultancy, Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees; Forty-Seven: Consultancy, Membership on an entity's Board of Directors or advisory committees; Gilead: Consultancy, Membership on an entity's Board of Directors or advisory committees. Garcia:Abbvie: Research Funding; Genentech: Research Funding. Brunner:Novartis: Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Astra Zeneca: Research Funding; Forty Seven Inc: Membership on an entity's Board of Directors or advisory committees; Jazz Pharma: Membership on an entity's Board of Directors or advisory committees. Roncolato:St. George Hospital: Employment. Borate:Novartis: Consultancy; Takeda: Consultancy; Pfizer: Consultancy; Daiichi Sankyo: Consultancy; AbbVie: Consultancy. Odenike:Astra Zeneca: Research Funding; Astex Pharmaceuticals: Research Funding; Agios: Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; CTI/Baxalta: Research Funding; NS Pharma: Research Funding; Gilead Sciences: Research Funding; Incyte: Research Funding; AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees; Janssen Oncology: Research Funding; Oncotherapy: Research Funding. Bajel:Amgen: Honoraria, Speakers Bureau; Novartis: Honoraria; AbbVie: Honoraria; Pfizer: Honoraria. Watson:Amgen: Other: Travel grant; Roche: Other: Travel grant. Götze:AbbVie: Membership on an entity's Board of Directors or advisory committees. Nolte:Novartis: Honoraria, Research Funding; Celgene: Honoraria, Research Funding. Tan:AbbVie Inc: Other: Investigator in AbbVie funded trial. Hong:Roche: Equity Ownership; Genentech Inc.: Employment, Equity Ownership. Dunbar:AbbVie Inc: Employment, Other: Stock/stock options. Zhou:AbbVie Inc: Employment, Other: Stock/stock options. Gressick:AbbVie Inc: Employment, Other: Stock/stock options. Ainsworth:AbbVie Inc: Employment, Other: Stock/stock options. Harb:AbbVie Inc: Employment, Other: Stock/stock options. Salem:AbbVie: Employment, Other: Stock/stock options. Hayslip:AbbVie Inc: Employment, Other: Stock/stock options. Swords:AbbVie Inc: Employment, Other: Stock/stock options. Garcia-Manero:Amphivena: Consultancy, Research Funding; Helsinn: Research Funding; Novartis: Research Funding; AbbVie: Research Funding; Celgene: Consultancy, Research Funding; Astex: Consultancy, Research Funding; Onconova: Research Funding; H3 Biomedicine: Research Funding; Merck: Research Funding.
Venetoclax is a BCL-2 inhibitor that is FDA-approved in some indications. This presentation will focus on venetoclax for treatment in myelodysplastic syndromes, which is not an approved indication.
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Introduction
Hypomethylating agents (HMAs), azacitidine (Aza) or decitabine, are standard treatment (Tx) for patients (pts) with higher-risk myelodysplastic syndrome (HR-MDS) not candidates for ...immediate allogeneic hematopoietic stem cell transplantation (HSCT). However, complete remission was only reported for 17% receiving Aza, and only half the pts are alive after 2 yrs (Fenaux et. al., 2009).
Venetoclax (Ven), a selective, potent, orally bioavailable BCL-2 inhibitor, has been shown to synergize with HMAs in preclinical studies in HR-MDS (Jilg et. al., 2016) and clinical studies in AML (DiNardo et. al., 2016), suggesting that the combination of Ven+Aza may be a promising approach for HR-MDS Tx. This ongoing, open-label, Phase 1b, dose-escalation study is evaluating the safety and preliminary efficacy of Ven+Aza for Tx-naive HR-MDS.
Methods
The study (NCT02942290) initially included a 3-arm randomized cohort. Data from this cohort included 10 pts treated with Ven (400 mg or 800 mg for 28 days) + Aza and 2 pts treated with Aza alone. Following two deaths (Ven 400 mg=1/5 and Ven 800 mg=1/5), the study was amended to a dose-escalation and safety expansion design to determine the recommended Phase 2 dose (RP2D) of Ven+Aza. Key inclusion criteria were age ≥18 yrs, no prior therapy for MDS, IPSS score of ≥1.5, bone marrow blasts <20%, ECOG score of ≤2, and excluded pts with chronic myelomonocytic leukemia and pts who were candidates for undergoing intensive chemotherapy or allogeneic HSCT. In the dose escalation portion, cohorts were enrolled with escalating doses of Ven administered orally for the first 14 days of each 28-day cycle with cohorts from 100 mg daily up to 400 mg daily. Pts started at 100% of the prescribed Ven dose without intraindividual ramp up. Aza was administered at the std dose (75 mg/m2, subcutaneously or IV) from Day 1-7 per 28-day cycle. Primary study objectives were to evaluate safety and determine the RPTD schedule of Ven+Aza. Key secondary efficacy outcomes include objective response rate (ORRcomplete remission (CR) + marrow complete remission (mCR) + partial remission), progression free survival (PFS), time to response (TTR), duration of response (DOR), and overall survival (OS).
Results
As of April 9, 2019, 59 pts have been treated and dose-escalation is complete. These included 12 pts in the initial randomized cohort. The dose-escalation cohort included 25 pts (Ven 100 mg=8, Ven 200 mg=9, Ven 400 mg=8) and the safety expansion included 22 pts. Results are presented for all 59 pts 75% male, median age 71 yrs (range 26-85). At baseline, 15 (25%) pts had an overall IPSS score of 1.5, 29 (49%) had a score of 2, 8 (14%) had a score of 2.5, 6 (10%) had a score of 3.0, and 1 (2%) pt had a score of 3.5. Eleven (19%) pts had intermediate and 24 (41%) pts had poor baseline cytogenetic risk.
In treated pts, the most common treatment-emergent adverse events (TEAE's) were anemia, neutropenia, and thrombocytopenia (Table). Common gastrointestinal symptoms were constipation, nausea, diarrhea, and vomiting. Infection was predominantly febrile neutropenia. Predominant Grade 3 or 4 AEs included neutropenia (61%), thrombocytopenia (39%), leukopenia (31%), and anemia (20%). Major SAEs were febrile neutropenia (31%). There were 10 deaths of which 4 were due to infections (pneumonia-2, neutropenic sepsis-1 and septic shock- 1). Other causes of death were multiorgan failure (n=1), respiratory failure (n=1), progressive disease (n=3), and unexplained death (n=1). Twenty pts discontinued the study including 10 who underwent transplantation.
Among 57 pts evaluable for response, the ORR with (CR) was documented in 18, mCR in 22 , and stable disease (SD) in 11. Disease progression was observed in 2 pts. Median TTR for ORR was 1.0 mos (range 0.7-3.5 mos). At this data cut, the median time to FU was 4.3 mos (range 3.3-6.5 months). Median DOR, PFS and OS were not reached. With this short follow up, the 12-mo estimates for DOR for ORR was 74% (95% CI: 34%, 92%) and PFS was 59% (95% CI: 31%, 79%). The 18-mo estimate for OS was 74% (95% CI: 50%, 87%). Among 56 pts eligible for hematological improvement (HI), 28 (50%) patients achieved HI as either HI-erythroid, HI-platelet, or HI-neutrophil.
Conclusion
The combination therapy of Ven+Aza demonstrated a tolerable safety profile and promising efficacy in pts with HR-MDS. The maximum tolerated dose of Ven without dose-limiting toxicities was determined to be 400 mg in this HR-MDS population.
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Wei:Pfizer: Honoraria; Astellas: former employee, Honoraria; Novartis: Honoraria, Research Funding; AstraZeneca: Honoraria, Research Funding; AbbVie: Honoraria, Research Funding; Amgen: Honoraria, Research Funding; Servier: Honoraria, Research Funding; Walter and Eliza Hall Institute: Other: former employee, Patents & Royalties: receives a fraction of its royalty stream related to venetoclax; Macrogenics: Honoraria; Celgene: Honoraria, Research Funding; Genentech: Honoraria; Janssen: Honoraria. Garcia:Abbvie: Research Funding; Genentech: Research Funding. Borate:Pfizer: Consultancy; AbbVie: Consultancy; Takeda: Consultancy; Novartis: Consultancy; Daiichi Sankyo: Consultancy. Fong:Novartis: Speakers Bureau; Pfizer: Consultancy, Speakers Bureau; Amgen: Consultancy, Research Funding, Speakers Bureau; Astellas: Consultancy. Baer:Al Therapeutics: Research Funding; Kite: Research Funding; Takeda: Research Funding; Astellas: Research Funding; Abbvie: Research Funding; Forma: Research Funding; Incyte: Research Funding. Nolte:Novartis: Honoraria, Research Funding; Celgene: Honoraria, Research Funding. Peterlin:AbbVie Inc: Consultancy; Astellas: Consultancy; Jazz Pharma: Consultancy; Daiichi-Sankyo: Consultancy. Jurcic:Incyte: Consultancy; AbbVie Inc: Consultancy; Celgene: Consultancy, Research Funding; Novartis: Consultancy; Astellas: Research Funding; Syros Pharmaceuticals: Research Funding; Actinium Pharmaceuticals: Research Funding; Daiichi Sankyo: Research Funding; Genentech: Research Funding; Forma Therapeutics: Research Funding; Kura Oncology: Research Funding. Garcia-Manero:Amphivena: Consultancy, Research Funding; Helsinn: Research Funding; Novartis: Research Funding; AbbVie: Research Funding; Celgene: Consultancy, Research Funding; Astex: Consultancy, Research Funding; Onconova: Research Funding; H3 Biomedicine: Research Funding; Merck: Research Funding. Hong:Roche: Equity Ownership; Genentech Inc.: Employment, Equity Ownership. Platzbecker:Novartis: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria, Research Funding; Abbvie: Consultancy, Honoraria. Odenike:Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Agios: Research Funding; Oncotherapy: Research Funding; Astra Zeneca: Research Funding; Incyte: Research Funding; Gilead Sciences: Research Funding; Janssen Oncology: Research Funding; NS Pharma: Research Funding; CTI/Baxalta: Research Funding; Astex Pharmaceuticals: Research Funding; AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees. Dunbar:AbbVie Inc: Employment, Other: Stock/stock options. Zhou:AbbVie Inc: Employment, Other: Stock/stock options. Harb:AbbVie Inc: Employment, Other: Stock/stock options. Tanwani:AbbVie Inc: Employment, Other: Stock/stock options. Wolff:AbbVie Inc: Employment, Other: Stock/stock options. Jacoby:Celgene: Speakers Bureau; Novo Nordisk: Consultancy; Jazz Pharma: Membership on an entity's Board of Directors or advisory committees.
Venetoclax is a BCL-2 inhibitor that is FDA-approved in some indications. This presentation will focus on venetoclax for treatment in myelodysplastic syndromes, which is not an approved indication.
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Multidrug-resistant bacterial pathogens (MRP) such as extended-spectrum beta-lactamase producing enterobacteriaceae (ESBL), vancomycin-resistant enterococci (VRE) and methicillin-resistant ...staphylococcus aureus (MRSA) are an emerging challenge in allogeneic hematopoietic cell transplantation (HCT). However, to our knowledge there are no data in the existing literature on the prevalence of MRP and of the impact of these multidrug-resistant pathogens on the outcome after allogeneic HCT. Thus, it was the purpose of this study to systematically analyze the issue of MRP in patients who underwent allogeneic HCT.
PATIENTS AND METHODS: From 06/2010 to 12/2013 a total number of 72 (F: n=23; M: n=49) consecutive patients who received the first allogeneic HCT at our institution were retrospectively analyzed. The underlying diseases were AML (n=44), ALL (n=5), CML (n=4), MPN (n=2), lymphoma (n=5), MDS (n=9), and multiple myeloma (n=3). The conditioning regimen was myeloablative in 23 patients and reduced intensity in 49 patients. Patients were transplanted with peripheral blood stem cells (n=69) or bone marrow (n=3) from matched siblings (n=19), matched unrelated (n=45), mismatched (n=5) or haploidentical donors (n=3). As baseline investigation before commencing with the conditioning all patients underwent a comprehensive screening for MRP, i.e. ESBL, VRE and MRSA. For that reason swabs from nose, throat, axilla, urethra and anus as well as stool and urine were collected. The same screening was performed at discharge from hospital after allogeneic HCT and in case of a new admission into our institution. In addition routine microbiological investigations such as bacterial cultures from blood, urine, swabs, stool or central venous catheters were performed whenever clinically needed. Multidrug-resistant gram negative bacteria were categorized as 4MRGN (resistant to cephalosporins, piperacillin, fluorochinolones and to carbapenems) or as 3MRGN (resistant to 3 of these 4 antimicrobial drug groups). The primary endpoint of this analysis was day 100 non relapse mortality (NRM). Secondary endpoints were NRM and overall survival (OAS) two years post HCT.
RESULTS: 23 out of 72 patients (32%) were colonized by multidrug-resistant bacterial pathogens (MRP+ group) either at baseline (baseline MRP+ group, n=13, 18%) or at any other time point until day 100 post transplantation. Four patients were positive for two MRP either simultaneously at baseline (n=1) or at different time points (n=3). Detected MRP (n=27) were as follows: 3MRGN Escherichia coli or Klebsiella pneumonia (n=11), 4MRGN Pseudomonas aeruginosa (P. aeruginosa, n=4), 3MRGN P. aeruginosa (n=2), 4MRGN Stenotrophomonas maltophilia (n=1), 3MRGN Citrobacter freundii (n=1), VRE (n=7) and MRSA (n=1). Out of these 23 patients 7 patients developed an infection with MRP after HCT: Septicemia with 3MRGN Escherichia coli (n=3), septicemia with 3MRGN Klebsiella pneumonia (n=1), septicemia with P. aeruginosa (4 MRGN n=2, 3MRGN n=1) and one patient with VRE septicemia and 4MRGN P. aeruginosa pneumonia. Out of the 4 patients with multidrug-resistant P. aeruginosa infection three died transplant related (two of these patients had been already colonized with 4MRGN P. aeruginosa at baseline). However, 2-year OAS of MRP colonized versus non-colonized patients was essentially the same (66.6% versus 63.0%, median follow up 23.8 months range 7.0 to 48.0 months). Day 100 NRM was higher in the baseline MRP+ group and in the entire MRP+ group in comparison with non-multidrug-resistant bacterial pathogens colonized patients (23.1% and 17.4% versus 10.2%, not statistically significant ns). Data for 2 year NRM were 32.7%, 22.2% and 17.1% (ns), respectively. The increased NRM of MRP+ patients was mainly due to the high NRM of patients infected by multidrug resistant P. aeruginosa.
CONCLUSIONS: Colonization or infection with 3MRGN gram negative non-P. aeruginosa enterobacteriaceae or by VRE has no negative impact on the outcome after allogeneic HCT. Thus allogeneic HCT of patients colonized by MRP is feasible. However, patients colonized by multidrug-resistant P. aeruginosa seem to have a dismal outcome. Allogeneic HCT of these patients should be considered with care. We therefore suggest to include screening for MRP in the pretransplant recipient work up particularly to identify patients colonized by multidrug-resistant P. aeruginosa.
No relevant conflicts of interest to declare.
Central venous catheters (CVCs) are extensively used in patients undergoing hematopoietic cell transplantation (HCT) or induction chemotherapy for acute leukemia. In these patients CVCs are placed ...routinely either via internal jugular (IJV) or subclavian veins (SCV). Several studies have compared rates of complications between both insertion sites, particularly in the intensive care unit setting. However, to our knowledge there are no data in the literature comparing the insertion sites IJV versus SCV in patients undergoing allogeneic HCT or high dose therapy for hematologic malignancies. Thus, it was the purpose of this study to analyze systematically complications of CVCs at the different insertion sites in these patients.
Patients and methods: All consecutive patients who were treated in the unit for adult HCT at our institution from 01/2011 to 06/2013 were included into this retrospective analysis. Inclusion criterion was insertion of a CVC due to allogeneic HCT, autologous HCT or induction therapy for AML or ALL. 3-lumen standard CVCs (Arrow, Reading, PA) were placed after informed consent either via the IJV or the SCV. CVCs were inserted by experienced physicians after disinfection by 70% propanolol under full barrier precautions. The insertion site was chosen at the responsible physician´s own discretion. CVCs were covered by chlorhexidine gluconate impregnated dressings, either as transparent polyurethane (Tegaderm CHG, 3M, Saint Paul, MN) or as sponge dressing (Biopatch, Ethicon, Cincinnati, OH). No patient received a systemic antibiotic prophylaxis. Reasons for premature removal of CVCs were suspected or proven CVC-related blood stream infection (BSI), progression of local infections at the insertion site, or any other CVC related severe adverse event. End points of this study were local infections, fever, BSI, duration of catheterization per CVC, congestion of the CVC, thrombosis, pneumothorax and suspected or proven catheter related deaths.
Results: During the study period 255 CVCs were placed in 170 consecutive patients median age: 59 years (range 19-79), F: n=63; M: n=107 due to allogeneic HCT (65 patients, 101 insertions), autologous HCT (30 patients, 33 insertions) or induction therapy for AML or ALL (75 patients, 121 insertions). Underlying diseases were AML (n=102), ALL (n=9), MDS (n=15), MPN (n=4), lymphoma (n=21) or plasma cell neoplasia (n=19). Out of the 255 CVSs 155 (61%) were sited via the IJV and 100 (39%) via the SCV. Among the 101 CVCs in the allogeneic HCT group 60 (60%) were placed in the IJV and 41 (41%) in the SCV. The median duration of catheterization/per CVC for the entire group was 16 days (range 3-49, IJV: 17, SCV: 15 days, ns). The corresponding data for the allogeneic HCT group were 18 (IJV) and 17 day (SCV). The events fever or local infection occurred in 75% (45/60) of IJV- and in 95% (39/41) of SCV-CVCs (p=0.0084) in the allogeneic HCT group. Moreover, in SCV-CVCs these events arose significantly earlier (median time to event 7 vs. 10 days in the IJV (p=0.012). Focusing only on the event local infection the results were also superior for the IJV-CVCs: 28/60 (47%) vs. 29/41(71%) for SCV-CVCs (p=0.026). For the entire cohort of CVCs data were similar: The events fever or local infection occurred in 127/155 (82%) of IJV- and 95/100 (95%) of SCV-CVCs (p=0.025). Median time to these events were 8 (IJV) vs. 10 days (SCV, p=0.0009). For local infections alone the differences were even more pronounced: 81/155 (IJV: 52%) vs. 81/100 (SCV: 81%, p<0.0001). There were no significant differences in the frequency of BSI between the insertion sites entire group: IJV 46/155 (30%), SCV 20/100 (20%); allogeneic HCT group: IJV 14/60 (23%), SCV 12/41 (29%). Thrombosis or pneumothorax occurred only once, both with SCV-CVCs. Congestion of CVCs occurred in 20% (31/155) IJV- and in 24% (24/100) of SCV-CVCs (ns), respectively. Data for allogeneic HCT were 25% (15/60) in IJV- and 27% (11/41) in SCV-CVCs (ns). Out of the entire cohort 10 patients (7 x allogeneic HCT, 3 x induction therapy) died with an inserted CVC. 5 of them died due to BSI and therefore potentially CVC-related (3 x IJV, 2 x SCV).
Conclusions: In contrast to earlier studies on patients without hematologic malignancies these data demonstrate clearly that CVCs placed in the SCV are not superior. Moreover, local infections and fever occurred significantly earlier and more frequent in SCV-CVCs in patients undergoing allogeneic HCT.
No relevant conflicts of interest to declare.
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