ALBERT

Description: Eradication of minimal residual disease (MRD) during the first months of treatment for patients (pts) with ALL is associated with improved disease-free survival (DFS). We hypothesized that Alemtuzumab, a humanized monoclonal antibody directed against CD52, might be an effective, novel agent for eradication of MRD in ALL based on data demonstrating strong CD52 expression in other lymphoid malignancies and in several ALL cell lines, and from case reports of clinical activity in advanced ALL. In CALGB 10102, to define the percentage of CD52+ cases and to demonstrate feasibility, we tested dose escalation of Alemtuzumab in sequential cohorts to a target dose of 30 mg administered sc 3X/week for 4 weeks (12 doses) during post-remission therapy. Pts are eligible to receive Alemtuzumab if lymphoblast CD52 expression at diagnosis is ≥ 10% as determined in a CALGB reference laboratory. The 10102 therapy is composed of monthly treatment modules outlined below: Treatment module sequence is: A,B,C, D, A, B, C followed by maintenance therapy for a total of 2 years. Antimicrobial prophylaxis for cytomegalovirus (CMV) (e.g. acyclovir 800 mg qid) and pneumocystis carinii is mandated. Weekly quantitative monitoring for CMV viremia is performed. 150 pts with untreated ALL have enrolled: Median age is 48 yrs. 124 (83%) pts have precursor-B; 19(13%) have precursor T-ALL and 7 (4%) have biphenotypic or bilineal ALL. Of 139 evaluable pts, 95 (68%) had CD52 ≥ 10%. By immunophenotype, 72% of precursor B and 61% of precursor T pts were eligible to receive Alemtuzumab. Phase I dose escalation was recently completed. Dose limiting toxicity (DLT) for Phase I was defined as the inability to proceed with protocol treatment within 6 weeks of the last dose of Alemtuzumab. Non-heme toxicities have been mild and sc Alemtuzumab administration was well tolerated. Hematologic and infectious toxicities are summarized below: Myelosuppression was transient and use of G-CSF was permitted during Module D. 2 pts were treated for CMV viremia due to rising CMV titers in 2 sequential assays. 6 other pts had transient CMV elevations during or immediately following completion of Alemtuzumab that did not require treatment. 22/24 phase I pts received all 12 doses of Alemtuzumab. There were 2 DLTs reported: 1 pt in cohort 2 due to CMV viremia requiring gancyclovir following completion of Alemtuzumab; and 1 pt in cohort 3 due to ANC 〈 1500 six weeks after Alemtuzumab (pt was not given G-CSF). Based on these Phase I data, the targeted dose of 30 mg Alemtuzumab was recommended for further study in the ongoing Phase II study. In summary, we report for the first time that CD52 is expressed in the majority of ALL cases and demonstrate the feasibility of employing Alemtuzumab in front-line therapy. Ongoing accrual to the phase II study will evaluate the efficacy of Alemtuzumab in eradication of MRD in adult ALL. Module A Module B Module C Module D (Alemtuzumab) Maintenance Cytoxan Cytoxan Methotrexate (IV, PO, IT) 10 mg* cohort 1 Vincristine Daunorubicin Cytarabine Vincristine 20 mg* cohort 2 Dexamethasone Vincristine Vincrisitne 6-MP 30 mg* cohort 3 6-MP Dexamethasone L-asparaginase *Phase I dose escalation Methotrexate L-asparaginase IT-Methotrexate Alemtuzumab cohorts N Myelosuppression (grades 3 or 4) Lymphopenia CMV viremia 10 mg 6 2 1 2 20 mg 10 1 1 4 30 mg 8 1 0 2

Description: In order to assess whether Pgp modulation with PSC833 improves disease-free (DFS) and overall (OS) survival in untreated patients (pts) with AML 〈 60 years, a phase 3 trial (CALGB 19808) was undertaken comparing two induction regimens: Ara-C (A), Daunorubicin (D), and Etoposide (E), with (ADEP) or without (ADE) PSC833. All pts received A 100 mg/m2 by CIV daily for 7 days. In ADE, D 90 mg/m2 and E 100 mg/m2 were each given daily by short IV infusion on days 1–3; the corresponding doses in ADEP were D 40 mg/m2 and E 40 mg/m2. PSC833 10 mg/m2 was given by CIV over 72 hrs after a loading dose of 2.8 mg/kg IV over 2 hrs. These doses were based on findings from parallel phase I trials that showed comparable efficacy and toxicity for the 2 regimens (JCO2004; 22:4290). Pts in complete remission (CR) received consolidation therapy according to cytogenetic risk (ASH2001, 688a) and were then randomized to a phase 3 immunotherapy sequence comparing interleukin-2 with observation. The Pgp modulation portion of the trial ended when PSC833 became unavailable after 302 of a planned 600 pts had been randomized. Prior myelodysplasia or therapy-related AML were exclusion criteria. The median age was 45 years; the arms were comparable with respect to cytogenetic risk groups (Core-Binding Factor (CBF) leukemia vs. others). Response by intent-to-treat on the part of 296 evaluable pts and toxicity data are tabulated below. The median follow-up is 2.2 years. None of the differences in CR rate, OS, or DFS are statistically significant. ADE (n=149) ADEP (n=147) CR 77% 78% CR - CBF AML 100% (21/21) 100% (25/25) CR With One Induction Course 89% 88% Induction Mortality 7% 7% Median OS (months) 21 20 Median DFS (months) 19 15 Median OS -pts ≤ 45 yrs (months) 29 Not Reached Median DFS pts ≤ 45 yrs (months) Not Reached 13 Grade 3 and 4 Toxicities Dysphagia/Esophagitis 6% 17% Stomatitis 9% 24% Bilirubin 6% 25% Rash 1% 10% Left Ventricular Function 2% 1% The high dose daunorubicin regimen was given safely, without excess induction mortality or cardiotoxicity. Hepatotoxicity due to ADEP consisted of generally reversible hyperbilirubinemia. PSC833 did not cause significant neurotoxicity. Compared with the induction regimen used in the previous group study in this pt population in which 474 pts received D 45 mg/m2 x 3 days and A 200 mg/m2 x 7 days without E or PSC833, (CALGB 9222, Blood2005; 105:3420), the CR rates in this study were higher (78% vs 72%), the number of pts achieving CR with 1 induction higher (89% vs. 77%), and the induction mortality comparable (7% vs 9%). These preliminary findings suggest that similar outcomes occur following an induction regimen using 2.25-fold higher D and 2.5-fold higher E doses (ADE) relative to a regimen employing a Pgp modulator (ADEP). PSC833 is known to delay the hepatic clearance of D and E. These data cannot distinguish between the possibilities that PSC833 augments the anti-leukemia activity of the lower dose ADE regimen or whether there is, in fact, no clinically meaningful dose-response relationship with D and E within the evaluated dose ranges. The findings of this trial to date suggest that Pgp-mediated drug efflux may not be the major or sole mechanism of drug resistance in AML or that PSC833 is an inadequate inhibitor of Pgp activity or both.

Description: Patients (pts) with leukemia who relapse after myeloablative allogeneic stem cell transplantation have a poor prognosis due to reduced tolerance and suboptimal responses to salvage therapies. Select pts who respond to salvage and achieve prolonged remissions may benefit from second transplantations. We hypothesized that less toxic conditioning, as well as advancements in supportive care and salvage therapies, may improve outcomes when pts relapse after transplantation. Among 72 pts with high risk and refractory leukemias consecutively enrolled to receive a RIST from 2002–05, we describe outcomes for the 31 pts who relapsed. The preparative regimen consisted of fludarabine 30 mg/m2/d IV (D-7 to D-3), Campath-1H 20 mg/d IV (D-7 to D-3), melphalan 140 mg/mg2 IV (D-2) and tacrolimus for post-transplantation immunosuppression. Of the 31 pts who relapsed after transplantation, 23 had AML/MDS, 3 had CML, 2 had ALL, 2 had leukemic phase of mantle cell lymphoma and 1 had mast cell leukemia (MCL). Only 4 pts had achieved a complete remission (CR) at initial transplantation. 16 pts (52%) had HLA-identical sibling donors, 1 (3%) had a mismatched related donor and 15 (47%) had unrelated donors. The median age was 51 years (range 20–68), and the median time from initial transplantation to relapse was 4 months (range 1–14). After relapse the median follow-up for survivors was 6.6 months (range 2–28) and the median overall survival (OS) was 7.8 months (95% CI, 4.2–13.5) (Figure 1). The median whole blood or marrow donor chimerism at relapse was 71% (range 0–99%). The median marrow blast percentage at relapse was 21% (range 0–99%); 8 pts had 100 days after transplantation (n=9, P=.02) and marrow blast count

Description: For the past decade, survival (S) for adults with ALL has remained at 30–40% despite achieving high complete remission (CR) rates of 70–90%. CALGB 19802 was designed to test the hypothesis that dose intensification of daunorubicin (D) and cytarabine (Ara-C) could improve disease-free survival (DFS) and that aggressive high dose intravenous (IV), oral (PO) and intrathecal (IT) methotrexate (MTX) could replace cranial irradiation (RT) for central nervous system (CNS) prophylaxis. Treatment consisted of 6 monthly courses of intensive therapy followed by 18 mos of maintenance. In pts 〈 60 yrs, the D dose during induction and in post-remission therapy was increased in cohorts from 45 mg/m2 on days 1–3 (used in prior CALGB ALL studies) to 60 and then to 80 mg/m2/day X 3. In pts ≥ 60 yrs, D was increased from 30 to 60 mg/m2/day X 3. High-dose Ara-C and CNS prophylaxis with IV, PO, and IT MTX were given in post-remission modules for all pts with a goal of targeting serum methotrexate levels to be 1–2 μM at 30 hours following the IV MTX infusion. No cranial RT was given. From 1/99–1/01, 163 adults with untreated ALL were enrolled. Median age was 40 yrs (range, 16–82) and 33 (20%) were ≥ 60 yrs old; 61% were male. Of 127 centrally reviewed cases, 100 (79%) were precusor B-cell; 19 (15%) precursor T-cell; and 8 (7%) were bilineal or biphenotypic. A large proportion, 46 (46%) of 100 centrally reviewed and evaluable cases, had poor risk cytogenetics as defined in prior CALGB studies: 31 with t(9;22), 7 with t(4;11), 6 with −7 and 2 with +8. With a median follow-up of 4.4 years, the S and, especially DFS, for pts 〈 60 yrs was improved for those who received D at 80 mg/m2 vs 60 mg/m2. The outcome of all 163 evaluable pts is summarized below: CR (%) 3 yr DFS [95% CI] 3 yr S [95% CI] OVERALL 128 (78.5) 32% [24–41] 36% [29–44]     AGE/ D DOSE     〈 60/ 60 mg/m2 36 (92%) 24% [11–39] 35% [20–50]      30,000/μl nor adverse cytogenetics were significantly associated with worse outcomes. Higher levels of minimal residual disease (MRD) using quantitative clone specific PCR following induction therapy was predictive of inferior DFS (p = .02). In conclusion, omission of CNS irradiation did not result in higher CNS relapse rates than what has been reported in prior CALGB studies; furthermore, adjustment of MTX dosing to achieve targeted serum MTX levels may reduce the risk of CNS relapse. Younger pts who received 80 mg/m2 D had improved DFS and S. However, in contrast to other reports, the differences were not statistically significant. Thus, risk-adapted approaches to eradication of MRD using new agents and/or biologically targeted therapies should be incorporated into front-line treatment of ALL.

Description: Conditioning regimens using in vivo alemtuzumab (Campath-1H, humanized anti-CD52) are characterized by low rates of acute and chronic GVHD, but may also result in delayed immune reconstitution. Optimization of such regimens will depend on an understanding of the relation between alemtuzumab exposure, immune reconstitution and GVHD. We have conducted a prospective study of fludarabine 30 mg/m2/d x 5 days, melphalan 140 mg/m2 x 1 day and alemtuzumab 20 mg/d x 5 days as conditioning for related and unrelated allografts. Using an enzyme-linked immunosorbent assay (ELISA), we determined serum free and total Campath levels in 46 patients with hematologic malignancies (45) or sickle cell disease (1) on day 0, day 7, day 14, day 28, day 50, day 75, day 100, day 150 and at one year after transplant (HSCT). 26 (57%) had a matched sibling donor, 16 (35%) a matched unrelated donor (MUD) and 4 (9%) a mismatched related or unrelated donor. 44 pts engrafted and are included in the analysis. Median follow up for survivors was 2.8 years. Grade II–IV aGVHD occurred in 8 pts after a median of 42 days (range 22 to 60). Eight pts developed cGVHD after a median of 107 days (range 89–140). 15/41 (37%) at risk pts developed CMV reactivation. The half-life of free alemtuzumab (fA) was 26 days after HSCT with wide interpatient variation in fA pharmacokinetics (e.g. Coefficient of variation was 138% on day 0). On day 0, 1 patient had an undetectable level of fA. By day 28, 50, and 100, there were 6 (14.6%), 12 (35.3%), and 13 (52%) pts with undetectable fA, respectively. Figure 1 shows the fitted means and 95% confidence intervals of fA over time. Using log-rank and Cox proportional hazard models, there was no association between fA on day 0, day 28, or the last available fA, and development of acute GVHD. However, pts with higher average free and total Campath levels in the first month had a lower risk of developing cGVHD (p=0.02). The median fA concentration in the first month for pts with cGVHD was 0.32 (inter-quarter range IQR: 0.22–0.41), as compared with 0.97 (IQR: 0.23–3.31) in those without cGVHD. No significant association between absolute lymphocyte count and fA concentration was found after adjusting for time (p=0.28). Finally, among pts at risk, a higher fA concentration on day 0 (p=0.002), and in the first month (p=0.003) was significantly associated with CMV viremia. In summary, the estimated half-life of serum fA is 26 days after HSCT, but with considerable interpatient variability. Higher concentrations of fA were associated with a decreased incidence of cGVHD, but an increased risk of CMV reactivation. In contrast to a previous preliminary analysis, no association existed between fA and lymphocyte reconstitution. Variation in alemtuzumab pharmacokinetics may predict important clinical outcomes, such as cGVHD and CMV reactivation. Future studies are warranted to determine an optimal alemtuzumab exposure that hastens immune reconstitution while minimizing chronic GVHD. Fig 1. Fitted Mean Free Campath and 95% CI Fig 1. Fitted Mean Free Campath and 95% CI

Description: Background: AP23573 is a novel non-prodrug rapamycin analog that inhibits mTOR, a downstream effector of the PI3K/Akt and nutrient-sensing pathways. In phase I clinical trials, AP23573 completely inhibited in vivo mTOR activity in peripheral blood mononuclear cells (PBMCs) as measured by decreased phosphorylation of the mTOR target protein 4E-BP1. Because the mTOR pathway has been implicated in the pathobiology of hematologic malignancies, this study is undertaken in this patient population to determine the safety and efficacy of AP23573 treatment. In addition, correlative studies in PBMC and bone marrow samples will examine if tumoral mTOR pathway status predicts clinical response. Methods: Eligible patients with relapsed or refractory hematologic malignancies are being enrolled, stratified into 5 disease specific groups and given AP23573 12.5 mg I.V. daily x 5 days (QDx5) every 2 weeks. Enrollment into each group is proceeding according to a Simon’s two-stage design with a minimum of 21 patients per group and an overall maximum enrollment of 205. Efficacy is being assessed according to standard response criteria at the end of each 4-week cycle (leukemia patients) or every two cycles (lymphoma patients). In addition, pharmacodynamic (PD)/biomarker samples for correlative studies are collected during Cycle 1. Results: At this time, a total of 51 patients have been enrolled. There are 35 males and 16 females with a median age of 61 years (range 31–83). Best or most recent response to treatment by disease cohort is shown below (5 are too early for response evaluation). Disease Cohort (N) PR HI SD PD PR: Partial Response, HI: Hematologic Improvement, SD: Stable Disease, PD: Progressive Disease Cohort 1: AML/MDS (26) 2 6 18 Cohort 2: ALL (2) 2 Cohort 3: AMM (7) 2 3 2 Cohort 4: CLL (9) 4 3 Cohort 5: T-cell Lymphoma (2), MCL (5) 2 2 AP23573 is generally well tolerated with the most prevalent mild or moderate treatment-related adverse events (AEs) being nausea, mucositis, hyponatremia, pruritis, rash, and hypokalemia. Serious, possibly treatment-related AEs include diarrhea, mucositis, hypertriglyceridemia, neutropenic sepsis, dyspnea, syncope, pleural effusion and pneumonia. Analysis of correlative PD/biomarker studies is in progress. Conclusions: QDx5, every other week administration of AP23573 has an acceptable side-effect profile with potential efficacy in some patients with advanced stage hematologic malignancies. Indications of anti-cancer activity have been observed in 4 of the 5 disease cohorts with 19 of the 46 evaluable patients (41%) showing at least stable disease. Patient enrollment, treatment and correlative biomarker analyses continue.