ALBERT

Description: Background: For many years the ALFA Group has used high dose DNR, i.e 80 mg/m2/day for 3d as part of the induction regimen for untreated adult AML pts. As the equivalence of DNR and Ida is not known we conducted a phase III study to compare high dose DNR to Ida. We also tested the effect of IL2 for maintenance. Methods: Newly diagnosed AML, aged 50 to 70 years, were randomized to receive AraC 200 mg/m2/day IV x 7 d with either DNR: 80 mg/m2/d x 3 d (arm 1) or Ida: 12 mg/m2/d x 3 d (arm 2) or x 4 d (arm 3). Pts who failed could receive a salvage course with Mitoxantrone x 2 d and AraC1g/m2 12 hrs x 4d. Response was assessed after induction+/− salvage chemotherapy. CR pts received 2 consolidation courses according to the induction arm with DNR: 80 mg/m2 or Ida:12 mg/m2 for 1 day (first course) or 2 days (2nd course) and AraC:1g/m2/12 hrs x 4 days. Pts in CCR after the two consolidation courses were randomized to receive or not a maintenance immunotherapy with IL2: 5.106/m2 for 5 days monthly for12 months. Results: From 2001 to 2006, 468 pts were included (median age: 60 years). The 3 treatment arms were well matched for pretreatment characteristics. CR was achieved in 360/468 pts (77%): 109 (70%) pts arm 1, 129 (83%) arm 2, 122 (78%) arm 3 (p=0.02).70 pts, (45%) pts in the DNR arm reached CR after 1 course vs 97 (62%) and 90 (57%) in Ida arms (p= 0.006). Pts in Ida arms experienced more grade 3 or 4 mucositis (p=0.004) but no differences were observed between the 3 arms for duration of hospitalization, time to PMN or plts recovery, incidence of grade 3 or 4 infectious episodes and treatment related mortality. 3 year cumulative incidence of relapse was 69%, 63%, 62% resp in arms 1,2,3 (p=NS). 3 year EFS was 19%, 30%, 26% resp (p=0.06 for arm 1 vs arms 2 and 3). 3 year OS was 31%, 40% 41% resp in arms 1,2,3 (p=NS). Age (〈 or 〉60 years), sex, initial WBC counts, initial LDH (nl or 〉nl), DNR or Ida arms, need for a salvage course were not predictive for relapse, while 2yCIR was 43%, 64%, 77% among respectively fav, intermediate and unfav cytogenetic risk groups resp (p=0.0046). Of the 219 pts alive in CR after consolidations, 161 (73%) were randomized for maintenance. Only 22 of the 77 pts randomized for IL2 completed the 1 year treatment. 32 and 23 pts stopped IL2 resp because of relapse or intolerance. There were no differences in relapse or OS in both maintenance arms. Conclusion: Ida treatment even when compared to high doses of DNR yields higher CR rate and more CR after one course. This effect translated in slightly better EFS but not better CIR or OS. IL2 maintenance treatment at least as scheduled in this trial was difficult to apply and showed no impact on disease course.

Description: Abstract 3432 Introduction. Dasatinib 100 mg QD is now validated as a first line option in patients with chronic myelogenous leukaemia in chronic phase (CML in CP). Our hypothesis was that significant adverse events observed with dasatinib including fluid retention, pleural effusions and grade 3–4 cytopenias, may be driven by the level of the residual dosage of dasatinib (Cmin). We initiated an optimization study based on the monitoring of dasatinib plasma levels (Cmin and Cmax) in patients with CML in chronic phase newly diagnosed and treated with dasatinib as front line therapy. Patients and methods. Patients aged 18 years old or more were eligible if they were diagnosed with CML in CP for less than 3 months without having being exposed to tyrosine kinase inhibitors. Dasatinib was initiated at the daily dose of 100 mg QD. Dasatinib daily dose adaptation was randomized in patients with a Cmin over 3nM. For all other patients, dasatinib was given at the dose of 100 mg QD. The pharmacokinetic (PK) evaluation (Cmin and Cmax measurements) was performed after 7 to 10 days of therapy and then every 15 days in the treatment adaptation arm (until a level of Cmin under 3nM) and every 3 months therafter as in the non-adapted arm. Cmax was assessed 2 hours after dasatinib intake. Results. The results of the first 78 patients included in the trial from May 2009 to May 2010 are reported. Median age was 47 years (19 – 77) with a sex ratio M/F of 1.85. The Sokal score distribution was 51.9%, 30.7% and 17.4% for Low, intermediate and high risk respectively. Median Cmin and Cmax values were 2.1 nM (range 0.2–18.7) and 107.6 nM (range 20.5–353) at first PK analysis. The median Cmin value was significantly lower in patients with age 47y (1.6 nM versus 2.8 nM, p=0.0028). By contrast, the median Cmax value was comparable in both age groups. Efficacy analysis was performed on the 53 patients with a 3 months follow-up and on the 36 patients with a 6 months follow-up. The complete cytogenetic response (CCR) rates at 3 and 6 months were 83.3% and 90.9% respectively. At 3 and 6 months, the major molecular response (MMR) rates were 15.1% and 69.4%. All patients in cytogenetic failure had high Sokal score values (p=0.023). Median PK values at months 3 and 6 were not statistically different compared to initial PK values, suggesting a stable exposure to the treatment with time. With a median follow-up of 7.2 months, the rate of significant adverse events was 11.5%. Fluid retention (n=2) and pleural effusion (n=1) were observed in patients with high Cmin values (mean 3.7 nM). A trend was observed between the Cmax and response at month 3 (CCR, p=0.05 and MMR, p=0.08). Patients with lymphocytosis may have a higher MMR rate (p=0.07). Conclusion. Dasatinib 100 mg QD as first line therapy in CP CML provided a high rate of MMR and CCR rates. Pharmacokinetic parameters of dasatinib were different in aged patients. A trend was observed first between Cmax and responses and second between Cmin and fluid retention or pleural effusion. A complete analysis with correlation to response and safety will be presented on more patients with 6 and 12 months follow-up. Disclosures: Rousselot: Bristol Myers Squibb: Research Funding. Off Label Use: Dasatinib as first line therapy for CML.

Description: Abstract 109 Two previous studies conducted in the prerituximab era have demonstrated the superiority of the intensive chemotherapy regimen ACVBP over standard CHOP in DLBCL (Tilly H et al. Blood 2003;102:4284; Reyes F et al. N Eng J Med 2005;352:1197). In order to investigate the role of intensive chemotherapy associated with rituximab, the GELA initiated in 2003 a multicenter, phase III open-label, randomized trial comparing efficacy and safety of R-ACVBP vs R-CHOP in younger DLBCL patients with an age-adjusted IPI (aaIPI) of 1. Patients and methods: Patients between 18 and 59y with DLBCL and aaIPI=1 were eligible. R-ACVBP consisted of 4 induction courses given every 2 weeks: rituximab (375 mg/m2) on d1, doxorubicin (75 mg/m2) on d1, cyclophosphamide (1200 mg/m2) on d1, vindesine (2mg/m2) on d1 and 5, bleomycin (10 mg) on d 1 and 5, prednisone (60 mg/m2) from d1 to d5, and intrathecal methotrexate (IT) (15 mg) on d2, G-CSF from d6 to d13. Patients then received a sequential consolidation therapy: 2 courses of methotrexate (3 g/m2) plus leucovorin rescue, 4 courses of rituximab (375 mg/m2), etoposide (300 mg/m2) and ifosfamide (1500 mg/m2) on d1, and 2 courses of cytosine-arabinoside (100 mg/m2, SC) for 4 days, each consolidation course being administered at a 14-day interval. Standard R-CHOP was delivered every 3 weeks for 8 cycles along with IT methotrexate at d1 of the first 4 cycles. The primary objective was to evaluate the efficacy of R-ACVBP compared to R-CHOP as measured by the event-free survival (EFS). Secondary endpoints were response rate, progression free survival (PFS), disease-free survival (DFS) for complete responders, overall survival, neuro-meningeal relapse rate and toxicities. Results are presented on an intend-to-treat basis. Response to treatment was evaluated according to 1999 Cheson criteria. Results: From December 2003 to December 2008, 380 patients were randomized in 73 hematology/oncology departments of the GELA. One patient withdrew his consent the day of randomization and 379 received at least one day of study treatment, 196 with R-ACVBP and 183 with R-CHOP. Median age was 47y (18-59). Patient characteristics were well-balanced in terms of demography and baseline disease status: male gender, 59%; stage III-IV, 55%; elevated LDH, 44%; mass〉10 cm, 22%; B symptoms, 28%; number of extra-nodal sites 〉1, 26%; bone marrow involvement, 13%. Overall response rate was 90.3% in the R-ACVBP group and 88.5% in the R-CHOP group (p=0.57). Complete remission rate (CR+CRu), was 82.7% for R-ACVBP and 80.3% for R-CHOP (p=0.56). At the time of this final analysis, in June 2010, the median follow-up was 44 months. The 3-year EFS was 80.9% (95% confidence interval (CI) 74.5–85.9) in the R-ACVBP group and 66.7% (CI 59.2–73.2) in the R-CHOP group (p=0.0035, hazard ratio (HR) 0.559). Significant differences were also observed for PFS (86.8% at 3 years (CI 80.9–91.0) vs 73.4% (CI 66.1–79.3), p=0.0015, HR 0.482), DFS (91.3% at 3 years (CI 85.1–95.0) vs 80.3% (CI 72.8–85.9), p=0.0019, HR 0.393) and overall survival (92.2% at 3 years (CI 87.1–95.3) vs 83.8% (CI 77.2–88.6), p=0.0071, HR 0.439). Patients in the R-ACVBP group experienced more frequently a serious adverse event (42% vs 15% in the R-CHOP group). Grade 3–4 hematological toxicity was more frequent in the R-ACVBP group, with a higher proportion of patients receiving red cell (51% vs 7% for R-CHOP) or platelet transfusions (13% vs 1%) and/or experiencing febrile neutropenia (39% vs 9%). There were 3 deaths (1.5%) attributed to toxicity of study treatment in the R-ACVBP group and 2 (1.1%) in the R-CHOP group. Conclusions: Compared to standard R-CHOP, intensified immunochemotherapy with R-ACVBP significantly improves EFS, PFS, DFS and overall survival with increased but manageable hematological toxicity in younger patients with DLBCL. Disclosures: Coiffier: Roche: Honoraria, Research Funding; Genentech: Research Funding. Gisselbrecht:Roche: Research Funding. Bosly:Roche: Membership on an entity's Board of Directors or advisory committees. Tilly:Amgen: Honoraria.

Description: Dasatinib (Sprycel®, Bristol-Myers Squibb) is a potent multi-targeted kinase inhibitor (TKI) of BCR-ABL and SRC family kinases. Despite a 33% complete hematological response (CHR) rate in a Phase 2 study in patients with Philadelphia positive (Ph+) acute lymphoblastic leukaemia (ALL) intolerant or resistant to imatinib, the median duration of progression-free survival (PFS) was 3.3 months (Ottmann et al. Blood. 2007;110:2309-2315). Second-generation TKI may thus have a place in the management of these patients. As a European consensus has been reached by the EWALL to adopt a common first-line chemotherapeutic schedule for elderly patients (aged 55 years or more) with Ph-positive ALL, this schedule was used here to test the addition of dasatinib. After a prephase with dexamethasone 10 mg/m2 d-7 to d-3, the induction phase consisted in IV injections of vincristine 1 mg combined with 2 days of dexamethasone 40 mg PO repeated weekly for 4 weeks followed by consolidation cycles including methotrexate 1000 mg/m2 IV d1 (500 mg/m2 over 70y) and asparaginase 10,000 UI/m2 IM d2 (5,000 UI/m2 over 70y) for cycles 1, 3 and 5 alternating with cytarabine 1,000 mg/m2/12h IV d1, d3, d5 (500 mg/m2 over 70y) for cycles 2, 4 and 6. Maintenance phase consisted in 6-MP 60 mg/m2/d and methotrexate 25 mg/m2/week orally 1 month every other month and dexamethasone/vincristine in 2 months intervals during the first year and in 3 months intervals during the second year. Dasatinib (provided by Bristol-Myers Squibb) was administered at 140 mg per day (QD) during the induction period in combination with chemotherapy and at 100 mg/d sequentially with the chemotherapy courses during consolidation and maintenance. BCRABL analysis was performed according to the European Leukemia Net recommendations in two centralized laboratories. A total of 22 patients were included from August 2007 to June 2008. Median age was 71 years (range, 61 to 83), sex ratio (M/F) was 0,46, and median follow-up was 5.8 months. The Ph+ chromosome was associated with complex abnormalities in 58% of cases and 84% of the patients were m-BCR. The CHR rate was 95.2% (20 out of 21 evaluable patients). The only case of induction failure was due to death. The rate of complete molecular remission (CMR) after induction was 33% in blood and 28% in bone marrow and MRD level continued to decrease with time. Only one relapse was observed before the consolidation phase. No other relapse occurred for the 13 patients in CHR still in study after a median follow-up of 3.6 months. One patient died during induction from invasive aspergillosis, 3 deaths occurred in CR, 2 before consolidation due to pulmonary embolism and physical deterioration, and one during maintenance from pneumonia. Serious adverse events (SAEs) were reported in 7 out of 22 patients during induction (31.8%) and in 2 out of 13 patients during maintenance and consolidation (15.3%). SAEs consisted in renal failure (n=3, 2 from acute lysis syndrome and 1 tubular necrosis), invasive aspergillosis (n=1), pulmonary embolism (n=2), pneumonia (n=1), atrial arythmia (n=2), pleural effusion (n=1), microangiopathy (n=1), cytolytic hepatitis (n=1) and physical deterioration (n=1). Eight patients discontinued the study after induction (35%). Primary reasons for discontinuation were SAEs (n=4), death (n=3) and relapse (n=1). The EWALL-PH-01 protocol is highly effective with a 95.2% RCH rate in elderly patients with Ph-positive ALL. Of importance, responses appeared to be durable and MRD level was decreasing over time. An expected 40% rate of SAEs was observed in this elderly population. Reduced doses of therapy are now applied for patients over 70y (20 mg for dexamethasone, 100 mg/d for dasatinib).

Description: Abstract 853 Introduction: Half of the cases of DLBCL occurs in patients over 65 years but very few data are available for patients over 80 years. These older patients however seem to respond as younger patients when treatment can be tolerated. In the aim to evaluate tolerance and efficacy of a reduced dosage chemotherapy regimen associated with rituximab in this population, the GELA initiated in 2005 a prospective, multicenter, phase II study. Patients and methods: Patients older than 80 years with untreated CD20+ DLBCL, Ann Arbor stage I with bulky mass to IV and a performance status (PS) of 0 to 2 were eligible. Patients were treated with mini-CHOP chemotherapy (cyclophosphamide: 400 mg/m2 D1; doxorubicine: 25 mg/m2 D1; vincristine: 1 mg total dose D1 and prednisolone 40 mg/m2 by oral route from D1 to D5) plus rituximab (375 mg/m2 D1) every 21 days for 6 cycles. GCSF was optional. The primary objective was to evaluate the efficacy of R-mini-CHOP as measured by the overall survival. Secondary endpoints were response rate, progression free survival (PFS), event-free survival (EFS), disease-free survival (DFS) for complete responders and toxicities. Survival results are presented on an intend-to-treat basis. Response to treatment was evaluated according to 1999 Cheson criteria. Results: One-hundred-and-fifty-patients (51 male, 99 female) were included in 38 centers of the GELA. The median age was 84 years (range 80–95). Seventy-five percent of patients had a stage III/IV. LDH level was elevated in 69% of patients. Age-adjusted (aa) IPI was 2–3 in 66% of patients. One-hundred-twenty-nine patients completed the first three cycles and 108 received the whole regimen. The Dose-Intensity for patients who completed the three first cycle was 100% and 96.8% for doxorubicine and cyclophosphamide respectively. Thirty-six percent of patient received at least one injection of GCSF. The overall response rate was 74%, including 40% of complete response and 23% of unconfirmed complete response. At the time of this analysis, in July 2010, the median follow-up time was 20 months. The 2-year overall survival was 58.9% [95% CI: 49.3–67.2%]. The two-year estimated PFS, EFS and DFS were 47.4% [95% CI: 38.1–56.2%], 44.8% [95% CI : 35.7–53.6%] and 56.6% [95% CI : 49.3–67.2%] respectively. Hematological toxicity was the most common side effect. Grade 3–4 neutropenia was observed in 39% of the patients and grade 3–4 thrombocytopenia in 7%. Eleven patients (7%) experienced at least one episode of febrile neutropenia. Overall patients experienced a median of 4 nights of hospitalization during treatment phase (range 0–46). Thirty patients died during the treatment evenly distributed between treatment toxicity (6.7%) lymphoma (6.7%) and intercurrent causes (6.7%). In a univariate analysis, PS 0 or 1, aaIPI 0 or 1, number of extra-nodal sites 35g/l, mass 35 g/l were significantly associated with a longer survival. Conclusion: In patients over 80 years with DLBCL and a good performance status, immunochemotherapy with R-mini-CHOP appears to be safe and effective, indicating that a substantial proportion of very old patients could indeed be cured. This regimen could be considered as a platform for the introduction of new drugs in the first line treatment of this population. Disclosures: No relevant conflicts of interest to declare.

Description: Abstract 172 Background. Dasatinib (Sprycel®) is a potent inhibitor of BCR-ABL and SRC family kinases. Based on the rapid and clinically meaningful activity observed when dasatinib was used as a single agent a consensus has been reached by the EWALL (European Working Group for Adult ALL) to conduct an international study evaluating the combination of dasatinib and low-intensity chemotherapy in patients with Ph+ ALL aged 55 years or more. Patients and Methods. After a prephase with dexamethasone 10 mg/m2 d-7 to d-3, dasatinib was administered at 140 mg QD (100 mg in patients over 70y) during the induction period in combination with IV injections of vincristine 1 mg and dexamethasone 40 mg 2 days (20 mg over 70y) repeated weekly for 4 weeks. Consolidation cycles consisted of dasatinib 100 mg/d administered sequentially with methotrexate 1000 mg/m2 IV d1 (500 mg/m2 over 70y) and L-asparaginase 10,000 UI/m2 IM d2 (5,000 UI/m2 over 70y) for cycles 1, 3 and 5 and cytarabine 1,000 mg/m2/12h IV d1, d3, d5 (500 mg/m2 over 70y) for cycles 2, 4 and 6. Maintenance phase consisted of dasatinib alternating with 6-MP and methotrexate orally every other month and dexamethasone/vincristine once every 2 months for up to 24 months. Patients were molecularly monitored by a central laboratory for BCR-ABL RTQ-PCR and T315I resistance mutation ASO RTQ-PCR. Results. Seventy one patients were included from August 2007 to study termination in May 2010. Median age was 69.1 years (range: 58–83). Median follow-up was 16.3 months. At diagnosis, the Ph chromosome was associated with other abnormalities (complex, -7, Ph duplication or others) in 64.5% of cases. The CR rate after induction was 90% and 55.7% of the patients achieved a BCR-ABL/ABL ratio ≤0.1% at the time of CR. Failure to achieve CR was mainly related to death (n=5.7%). Serious adverse events (SAEs) during induction were infections (11%), elevated transaminases (7%), hemorrhage (5.6%), renal failure due to tumor lysis syndrome (4.2%) and cardiovascular events (5.6%). Only 2 pleural effusions were observed. During consolidation and maintenance, most frequent SAEs were infections (33.3%). One pleural effusion was observed. Nineteen patients relapsed after a median response duration of 19.2 weeks and 12 of them died. Thirteen patients presented mutations in the BCR-ABL TK domain at relapse (12 T315I, 1 F317L), no mutation was detected in 3 patients and results are pending in 3 patients. T315I ASO RTQ-PCR analysis during follow-up was predictive for relapse. The rise of the T315I signal over 0.1% was always associated with relapse and occurred 1 to 3 months before relapse in 6 of the 12 T315I cases and concomitantly in the 6 remaining patients. Four patients received RIC allogenic stem cell transplantation and were censored at the time of SCT. Median RFS and OS were 22.1 and 27.1 months, respectively. Cytogenetics findings at diagnosis were good predictors for RFS: the median RFS for patients with isolated Ph was not reached while it was 19.2 months in patients with additional cytogenetic abnormalities (p=0.03)). Molecular BCR-ABL transcript level after induction had no effect on RFS. However, a BCR-ABL ratio ≤0.1% after induction and then confirmed during consolidation was significantly associated with a better RFS (5.1 months versus not reached, p=0.006). Conclusions. Dasatinib combined with low-intensity chemotherapy is highly effective in elderly patients with Ph-positive ALL with a 90% CR rate and a 22.1 months RFS. Cytogenetics at diagnosis is a strong predictive factor for RFS. Most relapses were associated with the T315I mutation. Serial monitoring for T315I allowed us to predict for hematological relapse and may offer an opportunity to adapt therapy before relapse. Disclosures: Rousselot: Bristol Myers Squibb: Research Funding. Off Label Use: Dasatinib as first line therapy in Ph ALL.

Description: Since 2003, 204 patients (pts) younger than 66 yrs with untreated active MM were randomly assigned to receive a 4 month treatment with Dex/Thal (n=100) or with a VAD-like regimen (n=104). Then, all pts were intended to proceed to peripheral blood stem cell (PBSC) mobilization using cytoxan 4 g/m2 + G-CSF 5 μg/kg and to receive high dose therapy (HDT) with melphalan 200 mg/m2 and autologous PBSC support. Pts in the Dex/Thal arm received orally Thal for 3 mths at a fixed dose of 200 mg/d combined with Dex, 40 mg/d for 4 days every other wk for 2 mths and then monthly for 2 mths. Pts in the VAD arm received the same Dex regimen plus 3 courses of 4 days continuous infusions of Doxorubicin (9 mg/m2/d for 4 days) and Vincristine (0.4 mg/d for 4 days), 4 wk apart. Anticoagulation prophylaxis wasn’t systematically given. Main characteristics of pts included in both arms were similar, including age (mean 55.1 yr in the Dex/Thal arm vs 56.4 yr in the VAD arm), MM stage (stage III 78% vs 85%), isotype (IgA: 21% vs 32%, p=.55), serumβ2m (mean 5.2 mg/L vs 3.9 mg/L, p=.24) serum creatinine (≤300 μmol/L in all pts) and albumin levels. Data were analyzed in an intent to treat basis. Primary objective was the achievement of at least a very good partial response (VGPR), defined as a decrease in serum and urine monoclonal immunoglobulin by 90% or greater. In both arms, 91% of pts proceeded to PBSC mobilization, PBSC harvests were similarly successful and 83% of pts received HDT and autotransplant. Before PBSC collection, 24.7% and 7.3% of pts were in VGPR in the Dex/Thal arm and in the VAD arm, respectively (p=.0027). Before HDT, VGPR rate was 34.7% in the Dex/Thal arm as compared to 12.6% in the VAD arm (p=.002). At 6 mths post transplant, the benefit of Dex/Thal wasn’t further observed with VGPR rates of 44.4% in the Dex/Thal arm and 41.7% in the VAD arm (p=.87). Six pts died in the Thal/Dex arm (including 4 early deaths, within 4 mths post randomization) as compared to 9 pts in the VAD arm (including 3 early deaths). Venous thrombosis or pulmonary embolism were recorded in 22.8% of pts in the Dex/Thal arm and in 7.5% in the VAD arm (p=.004). A symptomatic peripheral neuropathy was observed in 17.4 % and 12.9% of pts, respectively (p=.42). Otherwise, toxicity profile were similar in both groups. Before PBSC mobilization, mean duration of hospitalization, whatever the cause, was 8.3 days in the Dex/Thal arm as compared to 20 days in the VAD arm (p=.0001). This randomized study confirms that oral Dex/Thal is an effective first line treatment for symptomatic MM, and supports its use as an induction regimen which could be preferred to infusional VAD in candidates for HDT.

Description: Abstract 666 Background. Dasatinib (Sprycel®, Bristol-Myers Squibb) is a potent multi-targeted kinase inhibitor (TKI) of BCR-ABL and SRC family kinases. The EWALL group for adult ALL decided to run a study at the European level evaluating the combination of dasatinib and chemotherapy for Philadelphia positive (Ph+) ALL patients (pts) aged 55 and over. Aim. To analyse efficacy of Dasatinib combined to low intensity chemotherapy and to test factors associated with outcome. (EudraCT 2006–005694-21). Methods. After prephase, dasatinib was administered at 140 mg QD (100 mg over 70y) during the induction period in combination with weekly vincristine (VCR) 1 mg IV and dexamethasone (DEX) 40 mg for 2 days (20 mg over 70y) for 4 weeks. Consolidation Disclosures: Rousselot: BMS, Novartis: Research Funding. Gambacorti-Passerini:BMS, Novartis: Research Funding.

Description: Abstract 6 Aim. GO is a potent antibody-directed chemotherapy against CD33 antigen. Two MRC and SWOG Phase 3 studies have compared standard CT alone or combined with one single GO infusion (at 3 and 6 mg/m2, respectively) in younger adults with AML with contradictory results (Burnett, JCO 2011; Petersdof, Blood 2009). We have shown in relapsed AML Phase 2 studies that fractionated infusion of GO 3 mg/m2 on day 1, 4 and 7 was effective and might be safely combined to standard 3+7 DNR/AraC induction (Taksin, Leukemia 2007; Farhat, AJH, accepted). Here, we report the results of the prospective open label randomized multicentric Phase 3 ALFA 0701 trial (ClinicalTrial.gov ID, NCT00927498) designed to evaluate the efficacy and safety of adding this fractionated GO schedule to standard front-line chemotherapy in older AML pts. Methods. Eligible patients (pts) were adults aged 50–70 years old with previously untreated de novo AML. Pts were randomized to receive induction with DNR 60 mg/m2/d on day 1–3 and AraC 200 mg/m2/d CI on day 1–7, without (DA arm) or with GO at 3 mg/m2/d on day 1, 4 and 7(DAGO arm). Pts with persistent marrow blasts at day 15 received additional DNR 35 mg/m2/d on day 1–2 and AraC 1g/m2/12h on day 1–3. Pts achieving CR/CRp received two consolidation courses with DNR 60 mg/m2/d on day 1 and AraC 1 g/m2/12h on day 1–4, ± GO at 3 mg/m2/d on day 1 according to the randomization arm. The primary study objective was event-free survival (EFS). The study was designed to detect a 25% to 40% EFS gain at 3 years, (two-sided test, power 80%, type I error 5%). Secondary objectives were response rate, disease-free survival (DFS), overall survival (OS), and safety. Results. From March 2008 to November 2010, the required sample of 280 pts (median age, 62 years) was enrolled. Nine pts did not satisfy for inclusion criteria and were excluded from analysis. Cytogenetics was favorable (N=9), intermediate (N=177), adverse (N= 57), not done/failure (N=28). Overall, 52 pts had a favorable NPM1+ w/o FLT3-ITD genotype. The two treatment arms were well matched for all pre-treatment characteristics including age, sex, ECOG-PS, WBC, cytogenetics and molecular characteristics. CR+CRp was achieved in 220/271 pts (77%): 100/134 (75%) in the control DA arm versus 110/137 (80%) in the DAGO arm (P=0.31). There were 5/134 (4%) induction deaths in DA arm and 9/137 (6%) in DAGO arm (P=0.41). Primary resistant AML rate was 29/134 (22%) after DA versus 18/137 (13%) after DAGO (P=0.08). At 2 years, EFS was estimated at 15.6% in DA arm versus 41.4% in the DAGO arm (P=0.0018), while DFS was 18.1% in DA arm and 48.5% in the DAGO arm (P=0.0009). This significant benefit in EFS (primary objective) was observed in pts aged

Description: Background: More than 50% of newly-diagnosed patients with AML are older than 60 years of age. In this age group, the benefits of intensive chemotherapy are debated, due to excessive toxicity and short duration of response. Negative impacts of unfavorable cytogenetics and associated comorbidities are assumed to explain these results. Prolonged survival may, however, be observed in some patients even there is no well-established post-remission therapy at the present time. Methods: In the randomized ALFA-9803 trial in AML patients aged 65 years or more, we randomly compared idarubicin or daunorubicin throughout the study (R1) and two different post-remission strategies (R2): one single intensive consolidation course similar to induction versus six ambulatory cycles with one dose of idarubicin/daunorubicin (day 1) and 2x60 mg/m2/d cytarabine SC (day 1 to 5) delivered in out-patients on a monthly basis. Primary endpoint was 2-year overall survival (OS). From Nov 1999 to Apr 2006, 416 patients with de novo (#353) or post-MDS AML (#63) were included (median actuarial follow-up, 34 months). Median age was 72 years. High-risk cytogenetics was defined as complex (5 abns or more), monosomy 7, chromosome 5 and 7 abns, or 3q abn. Associated comorbidities were scored prospectively. Results: Complete remission (CR) rate was 57%, with 4% CRi and 10% induction deaths (ID), after a 4+7 induction with either 45 mg/m2/d daunorubicin or 9 mg/m2/d idarubicin (day 1 to 4) and cytarabine 200 mg/m2/d CIV (day 1 to 7), followed by lenograstim G-CSF until myeloid recovery. Salvage with intermediate-dose cytarabine and mitoxantrone was used in 54 patients. By multivariate analyses, only high comorbidity score (p=0.001) and advanced age (p=0.02) predicted ID. High-risk cytogenetics (p