ALBERT

Description: Vorinostat, formerly known as suberoyl anilide hydroxamic acid, (SAHA) is a histone deacetylase inhibitor with potent in vitro antileukemia activity. We conducted a phase I study of two dose schedules of vorinostat: oral three times a day (TID) x 14 days every 21 days; or oral twice a day (BID) x 14 days every 21 days. Patients with relapsed or refractory chronic and acute leukemia or myelodysplastic syndrome (MDS), with adequate renal, hepatic functions and performance status were eligible. Older patients with untreated AML/MDS were also eligible. Forty-one patients were registered and dosed. Median age was 54 years (range 18 to 90), 31 (76%) had AML, 4 (10%) CLL, 3 (7%) MDS, 2 (5%) ALL and 1 (2%) CML. The median number of prior therapies was 2 (range 0–7). The starting dose of the oral TID schedule was 100 mg po TID and it was increased in 50 mg po steps using a 3+3 design. As these patients were thrombocytopenic at baseline due to their underlying disease, thrombocytopenia was not considered to be a dose-limiting toxicity. A dose of 300 mg po TID was considered above the maximally tolerated dose (MTD) with 2 out of 3 patients developing grade 3 toxicity (nausea, vomiting and diarrhea). Subsequently, 7 patients were treated at a dose of 300 mg po BID x 14 days every 21 days. Two patients developed gastrointestinal toxicity (typhlitis) in the setting of profound neutropenia, and the dose was reduced in the next 6 patients to 200 mg po BID x 14 days. No excess toxicity was observed at that dose level. Subsequently, 6 more patients were treated at a dose of 200 mg po TID x 14 days (The MTD of 250 mg po TID X 14 days could not be further evaluated as the 50 mg capsule was no longer available). Only one out 6 patients developed grade 3 toxicity (fatigue). More frequently observed toxicities, regardless of causality, were nausea, vomiting, diarrhea, anorexia, headache, fatigue, typhlitis, and dyspepsia that resolved upon cessation of therapy. Laboratory abnormalities included pancytopenia, hyperglycemia, hypokalemia, hypocalcemia and hypophosphatemia. Overall 9 patients (21%) had objective evidence of response: 1 CR, 2 CRp (CR criteria but no recovery of platelet counts), 1 partial response and 5 complete marrow responses (blasts less than 5%). All responses were observed in patients with AML, and 5 (41%) of these responses were observed at a dose of 200 mg po tid. Histone acetylation was observed in all patients at all dose levels. In summary, the MTD of oral vorinostat is either 200 mg po TID or 200 mg po BID x 14 days every 21 days in patients with leukemia. Significant activity was observed at a dose of 200 mg po TID x 14 days in patients with AML. This single agent activity warrants additional investigation of the role of vorinostat in the therapy of AML and may be guided by the development of informative biomarkers.

Description: The availability of new and active agents for treatment of patients with CLL has led to an evolution in treatment from single-agent to combination regimens, resulting in improved response rates and possibly survival. The focus in developing new treatment regimens is to attain as high a complete remission (CR) rate as possible and to eliminate residual disease in bone marrow. The FCR regimen has significant activity in both chemotherapy-naïve and previously treated patients with CLL. Historic comparisons suggest a survival advantage for previously treated patients treated with FCR compared with F or FC. We combined alemtuzumab (A) with FCR to enhance the potentiation of mAb and chemotherapy in a phase II clinical trial for previously treated patients with CLL. The CFAR regimen consists of C-250mg/m2 day 3–5; F-25mg/m2 days 3–5; A-30mg days 1,3,5, and R-375–500mg/m2 day 2, each 28 days for 6 intended cycles. Methylprednisone 125 mg on day 1 and hydrocortisone 100 mg on days 2, 3, 5 were given with each course for mAb premedication. Allopurinol 300 mg daily was given for tumor lysis prophylaxis. Antibiotic prophylaxis was TMP-SMX DS twice daily 2–3 days/week and valacyclovir or valgancyclovir through all 6 cycles and 2 months after completion of treatment. Blood CMV antigen was monitored before each course. To date, 66 patients have been enrolled. There are 44 evaluable patients; 35 were male, 24 had Rai high-risk disease, the median # of prior treatments was 4 (1–9), 36% were fludarabine-refractory, 91% received prior R, 20% prior A, 16% had prior FC, and 48% had prior FCR. Pre-treatment karyotype of bone marrow cells was done in 38, 17 had complex abnormalities (7=17p-; 7=11q-); 16 were diploid. The median age=58yrs(41-79), ALC=428k/μL(.04–320), HGB=11.9g/dL(8.2–15.4), PLT=126k/μL(14–349), and β2m=4.5mg/L(2.5–11.3). The CR, PR, and OR rates for the 44 patients were 27%, 38%, and 65%, respectively. There were 2 early deaths and 2 could not be evaluated for response. Higher CR and OR rates were seen in fludarabine-sensitive patients. Higher OR but not CR rate was seen in earlier-stage patients. Elimination of minimal residual disease by flow cytometry (

Description: Some studies suggest that HD IM may be more effective than standard dose in CP CML. Still, only a minority of patients (pts) may reach undetectable levels of Bcr-Abl transcripts, and the use of single agent therapy may eventually result in development of resistance. IFN is thought to be effective in CML due to its immunomodulatory properties and may be valuable for management of minimal residual disease. Pre-clinical studies suggest synergy with imatinib. GM-CSF combined with IFN is a potent stimulator of dendritic cells. We designed this randomized phase II study to investigate if adding PEG-IFN to imatinib may improve the rate of complete molecular responses and prolong remission duration. Pts with previously untreated CP CML started treatment with imatinib 800mg daily and randomized after 6 months (mo) of therapy to either continue HD IM alone or add PEG-IFN 0.5mcg/kg/week and GM-CSF 125 mg/m2 three times weekly. Pts were monitored with real-time PCR and cytogenetics (CG) every 3 mo for the 1st year and every 6 mo thereafter. Ninety-four pts have been registered to date: 49 randomized to IM alone and 45 to IM + PEG-IFN+GM. 70 (75%) have been followed for at least 6 months and 49 (52%) for 12 months. (First interim analysis done when 30 pts evaluable at 12 mo). Ten pts randomized to PEG-IFN did not start therapy (2 refused, 2 physicians decision, 6 off study before 6 mo because of noncompliance n=3, melanoma n=1, financial n=1, progressive disease n=1). Patient characteristics and response (intention to treat) are as follows: No./No. Evaluable (%) p value Overall IM alone IM+PEGIFN+GM Median age (range), y 48 (19–73) 46 (19–73) 50 (19–73) 0.12 Sokal (% low/int/high) 71/20/9 63/25/12 79/16/5 0.17 CG CR Overall 73/84 (87) 40/45 (89) 33/39 (85) 0.74 @ 12 mo 44/49 (90) 27/31 (87) 17/18 (94) 0.63 12 mo BCR-ABL/ABL

Description: Introduction: Response to first induction therapy is one of the most important prognostic factors in patients with adult myeloid leukemia (AML). Induction of CR or PR is the primary aim in these patients. Methods: Between 1993 and 2005 225 consecutive patients (median age: 48.4 yrs, range 16–60 yrs) treated within the AMLHD93 (n=45), AMLHD98A (n=157) and AMLSG 05-04 (n=23, still active) trials were evaluated. All patients had primary refractory AML after one cycle of ICE. The different salvage therapies were as follows: AMLHD93 sequential-HAM (S-HAM) for patients =55 years of age [cytarabine 3g/m2 bid., days 1–3, mitoxantrone 12mg/m2 days 2,3]; AMLHD98A: A-HAM [HAM with ATRA 45mg/m2 days 3–5, 15mg/m2 days 6–28]; AMLSG 05-04: GO-A-HAM [A-HAM with gemtuzumab ozogamicin 3g/m2 day 1]. Results: The distribution of the different salvage therapies was HAM n=21, S-HAM n=22, A-HAM n=117, GO-A-HAM n=23, other n=31 no further therapy n=11. Response according to salvage therapy was as follows: response GO-A-HAM A-HAM S-HAM HAM CR 11 (48%) 40 (34%) 5 (23%) 3 (14%) PR 4 (17%) 33 (28%) 5 (23%) 4 (19%) RD 6 (26%) 36 (31%) 12 (54%) 12 (57%) death 2 (9%) 8 (7%) 0 2 (10%) No CTC-grade 3-5 liver toxicity was seen in patients receiving GO-A-HAM. Multivariable analyses revealed that regimens containing ATRA (odds ratio 2.5, p=0.01) and cytogenetic subgroup [t(11q23) odds ratio 4.2 p=0.04 (n=13), non-complex high risk aberrations odds ratio 4.2 p=0.007 (n=34)] were associated with a significantly better response rate (subsuming CR and PR). 119 of 225 patients have received stem cell transplantation. No case of veno occlusive disease was in 10 so far transplanted pts who have had GO-A-HAM. Median survival was 10.7 months. Conclusions: Although retrospective in nature our study suggests that ATRA as adjunct to salvage chemotherapy in primary refractory AML patients improves the response rate. The addition of GO in a dosage of 3mg/m2 results in promising response rates without increasing toxicity.

Description: Prognosis has improved in newly diagnosed adult ALL using dose-intense multiagent regimens. Outcome of 185 patients (pts) treated with Hyper-CVAD (fractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone) showed 91% CR rate with 5-yr. survival of 39% and low induction mortality (Kantarjian et al. JCO 18:547, 2000). Outcome remains poor in ALL salvage. Following leads in pediatric ALL, we hypothesized that “augmentation” of hyper-CVAD (AHCVAD) with vincristine, dexamethasone, and L-asparaginase during induction and consolidation may improve prognosis in adult ALL salvage. To evaluate efficacy and safety of AHCVAD we conducted a phase II study, in which pts received up to 8 courses of HCVAD alternating with methotrexate/high-dose cytarabine. Each course was augmented by L-asparaginase 20,000 units i.v. and vincristine 2 mg i.v. at days 1, 8, and 15 each, and dexamethasone 80 mg i.v./p.o. on days 1–4 and 15–18. From June 2003 to June 2005, 29 pts with relapsed/refractory ALL were treated. Median age was 32 yrs (range 14–70). Twenty-two pts (76%) had pre-B ALL (1 isolated CNS disease), 6 (21%) T cell ALL (2 with isolated extramedullary disease), and 1 (3%) pt had mature B ALL. Karyotype was diploid in 11 (44%) and abnormal in 14 (56%) pts (1 Ph+ ALL). No information is available in 4 pts. Median number of prior regimens was 1 (1–4). Median remission duration to initial induction regimen was 9 mos (0–68). Three pts were primary refractory. Of 29 pts, 22 are evaluable for response (2 too early, 5 off study for toxicity or pt. choice). Eight pts (37%) achieved CR, 1 (5%) PR, and 2 (10%) hematologic improvement (HI) for an OR of 52%. Six pts were able to proceed with stem cell transplant (5 CR, 1 HI). Of 29 pts evaluable for toxicity, 5 (17%) died on study from infectious complications. Uncomplicated neutropenic fever was common. Three pts (10%) were intolerant to L-asparaginase and had to be taken off study early. In summary, AHCVAD has activity in ALL salvage. However, asparaginase-related toxicities and neutropenic complications remain frequent and may limit the usefulness of this approach to selected patient populations.

Description: T-LGL is a clonal indolent lymphoid leukemia characterized by accumulation of large granular T-cells and cytopenias. We have identified 21 patients with T-LGL who were seen at the MD Anderson Cancer Center between 1997 and 2005. The median age at diagnosis was 53.5 years (range 34 to 72) without a male or female predilection. Fourteen patients (67%) were asymptomatic at diagnosis. Five patients (24%) presented with fatigue secondary to anemia; 1 (5%) had symptomatic splenomegaly and 1 presented with a diverticular abscess. Eighty percent of the patients presented with anemia with median hemoglobin of 9.9g/dl (range 7.4 to12.9 g/dl), 47% with neutropenia with a median absolute neutrophil count of 975/ul (range 110 to 5600/ul), and 38% had thrombocytopenia with a median platelets count of 61.5 x 109/l (range18 to 135 x 109/l). Six patients (29%) had splenomegaly, 3 (14.2%) had hepatomegaly and 1 had retroperitoneal lymph node enlargement on CT. During the course of follow-up (median 19 months, range 2–78 months), 11 patient (52%) developed constitutional symptoms. Six patients had recurrent infections including upper respiratory infections, pneumonia, and folliculitis unrelated to initiation of treatment. Associated autoimmune conditions included rheumatoid arthritis in 3 patients (14%) and hemolytic anemia in one patient. Only two patients had cytogenetic abnormalities, both including abnormalities involving chromosome 6. Monoclonal T cell receptor gamma chain gene rearrangements were detected by PCR analysis in 17 of 18 evaluable patients. Immunophenotypic studies revealed 16 patients to be CD4−/CD8+, 3 CD4−/CD8−, 1 CD4+/CD8+, and 1 CD4+/CD8−. CD56 was positive in 1 patient and none expressed CD26. Five patients (24%) have required no therapy, and remain asymptomatic with a median follow up of 67 months (range 5 to 78). Three patients received erythropoietin or G-CSF with some improvement. Nine patients (43%) were treated with cyclosporine, 2 achieving a response, 2 with stable disease, 3 with progression, and 2 were lost follow up. One of the 3 patients with disease progression had splenectomy and 1 was treated with infliximab; both responded. Combination of pentostatin and alemtuzumab was used in 2 patients with no improvement in the cytopenias; therapy was discontinued in both due to worsening of cytopenias and infections. Other treatment modalities included alemtuzumab alone in 1 patient with no improvement, fludarabine in 1 with minor response, combination of fludarabine and cyclophosphamide in 1 with minor response, methotrexate in 2 with no response and splenectomy in 3 with response and no requirements for further intervention. We conclude that T-LGL generally has an indolent course with no need for active therapy; patients with progressive cytopenias or refractory disease may benefit from splenectomy. New treatment modalities are needed.

Description: Hyper-CVAD is effective therapy for adult ALL [Kantarjian et al, JCO18:547, 2000; Kantarjian et al, Cancer101:2788, 2004]. Intensive chemotherapy with hyper-CVAD (fractionated cyclophosphamide, vincristine [VCR], doxorubicin and dexamethasone) was alternated with high dose methotrexate and cytarabine every 21 days for 8 courses with G-CSF and prophylactic antibiotics, followed by maintenance with POMP (6-MP, methotrexate, VCR, prednisone). Complete response (CR) rate was 92% with 3-year disease-free survival (DFS) rates 38% overall. A modified hyper-CVAD regimen was developed to address the following: (1) higher induction mortality in patients (pts) aged 60 or older (17% versus 3%); (2) longer DFS reported with early anthracycline intensification; (3) worse survival with CD20 expression (excluding Burkitt’s [BL] and lymphoblastic lymphoma [LL] subtypes); (4) CNS relapse rate of 6% and 1% in low and high risk pts, respectively and (5) late relapses after completion of therapy. Modifications to Hyper-CVAD Parameter Hyper-CVAD Modified Hyper-CVAD Laminar air flow rooms No For age ≥ 60 yrs or poor PS Dose-intensive anthracycline No C2 Liposomal DNR & cytarabine Rituximab No For CD20 ≥ 20 Intrathecal treatments 4–16 6–8 Maintenance (POMP) 2 years 3 years Intensifications (MTX, asparaginase) Months 7 & 11 Months 6,7 & 18,19 with hyper-CVAD Newly diagnosed or primary refractory (1 course only) pts were eligible. BL and Ph+ ALL pts were excluded. From May 2000 to December 2001, 77 pts were treated with the modified regimen detailed above (9 courses of intensive chemotherapy). The program was then modified further with elimination of course 2 anthracycline intensification. An additional 80 pts were treated with hyper-CVAD with or without rituximab (8 courses of intensive chemotherapy). The median age for these 157 pts was 40 yrs (range, 15–83) with 20% aged ≥ 60 yrs; 57% were males. Overall response rate was 94% in the evaluable pts (8 too early) with no difference by CD20 expression (49% were CD20+). No induction deaths were observed in the elderly subgroup (2 younger pts with induction deaths). Outcome with anthracycline intensification appeared worse, particularly in the CD20 negative group. The addition of rituximab appeared to improve DFS in CD20 positive group (with or without anthracycline intensification) compared with hyper-CVAD alone (2 yr DFS 90% versus 65%, p=.03); however, overall survival in the CD20 positive group was influenced by deaths in CR (10%) in elderly patients related to GNR sepsis or pneumonia during the intensive phase. Additional accrual and follow-up is needed to further define the role of rituximab in non-Burkitt’s adult ALL.

Description: Imatinib (STI571), a tyrosine kinase inhibitor, is becoming the new standard of care for patients with chronic and advanced phase CML. However, the treatment for blast crisis (BC) CML is less effective. Resistance to Imatinib develops in all phases, particularly in BC CML emphasizing the need for alternative therapies. Eg5, a microtubule-associated motor protein plays an important role in establishing a bipolar spindle during mitosis and is essential for cell cycle progression. Eg5 was recently found to be highly expressed in BC CML by microarray analysis (Oncogene22:3952–3963, 2003). In this study, we examined the regulation of Eg5 by Bcr-Abl tyrosine kinase signaling and tested Eg5 as a potential therapeutic target in BC CML and Imatinib resistant CML. We found that Eg5 is expressed in all Philadelphia chromosome positive (Ph+) CML cell lines and in BC CML patient samples. Inhibition of Bcr-Abl activity by Imatinib downregulated Eg5 expression in Imatinib sensitive KBM5 cells (a cell line derived from the blasts of a BC CML patient) and HL-60p185 cells (HL-60 cells transfected with Bcr-Abl fusion protein p185), but not in Imatinib resistant KBM5-STI571 cells and Bcr-Abl negative HL-60 cells suggesting that Eg5 is a downstream effector of Bcr-Abl and is regulated by Bcr-Abl tyrosine kinase signaling in Ph+ cells. Blocking Eg5 expression by its antisense oligonucleotide (Eg5-AS) induced G2/M cell cycle block, and subsequent cell death in both Imatinib sensitive KBM5 cells and Imatinib resistant KBM5-STI571 cells. At 48 hrs, 15.8±5.5% of KBM5 cells and 22.7±10.7% of KBM5-STI571 cells were blocked in G2/M in Eg5-AS treated cells compared to 3.5±1.9% and 7.6±1.4%, respectively, of the mismatched oligonucleotide (Eg5-NS) treated cells. Induction of cell death was observed at 72 hrs (29.1±1.9% in KBM5 and 29.4±1.1 % in KBM5-STI571 cells in Eg5-AS treated compared to 12.5±0.28% and 13.7±1.6% of Eg5-NS treated cells). Metaphase arrest due to disruption of bipolar spindle formation, loss of mitochondrial membrane potential, and caspase activation were observed in both cell lines. Similarly, inhibition of Eg5 activity by a small molecular inhibitor, S-trityl-L-cysteine, induced cell cycle block and cell death indistinguishably in Imatinib sensitive KBM5 and Ba/F3Bcr-Ablwt cells and in Imatinib resistant KBM5-STI571, Ba/F3Bcr-AblE255K, and Ba/F3Bcr-AblT315I cells. Treatment of Scid mice starting 7 days after injection of KBM5 cells with Eg5-AS, 25 mg/kg, 3 times a week for 3 weeks, significantly prolonged the survival of the animals (64 days vs. 49 days of Eg5-NS treated mice, p=0.0344). The effect of Eg5 inhibition on survival of Scid mice harboring Imatinib resistant KBM5-STI571 cells is currently under investigation. Our studies suggest that Eg5 is a downstream target of Bcr-Abl tyrosine kinase. Inhibition of Eg5 expression or its activity blocks cell cycle progression and induces cell death regardless of cell response to Imatinib. Eg5 could be a potential new critical therapeutic target for the treatment of Imatinib resistant CML and BC CML.