ALBERT

Description: CAM307 is a phase III, open-label, multinational, randomized controlled trial comparing alemtuzumab (CAM) with chlorambucil (CHLO) for previously untreated BCLL requiring therapy. Eligible patients with Rai Stages I–IV were randomized 1:1 to either CAM 30 mg IV tiw for up to 12 weeks or CHLO 40 mg/m2 po q 28 days up to 12 cycles. CAM patients received prophylactic trimethoprim/sulfamethoxazole DS and famciclovir treatment during therapy and until CD4+ counts were ≥200 cells/μL. The primary endpoint was PFS; secondary endpoints were response rate, overall survival, and safety. A total of 297 patients were enrolled (CAM n=149 and CHLO n=148); median age: 60 years; performance status 0–1: 96%; maximum lymph node size ≥5 cm: 22%; and Rai Stage I–II: 63%, Rai Stage III–IV: 33%. Diagnosis, Rai Stage, response and disease progression were confirmed by an independent response review panel (IRRP). CAM has a significantly prolonged PFS compared to CHLO (p=0.0001; see KM survival curve).PFS in CAM vs CHLO patients with adverse cytogenetic findings of del 17p (n=21) was 10.7 mo vs 2.2 mo and for trisomy 12 (n=39) was 18.3 mo vs 12.9 mo. Results were similar for patients with del 11q (n=54, 8.5 mo vs 8.6 mo). Common (≥15%) CAM reported adverse events (AEs) (n=147), likely infusion-related, included pyrexia (70%), chills (53%), nausea (18%), hypotension (16%) and urticaria (16%). Common AEs (≥15%) in the CHLO arm (n=147) were nausea (37%) and vomiting (18%). Frequency of asymptomatic CMV viremia on the CAM arm was 52%; CMV infection occurred in only 16%, none grade 4. CAM treatment was interrupted in 56% of CMV viremic patients, and resumed in 92% with ORR 92% (31% CR). Ganciclovir was administered to 41% of CAM patients with CMV viremia. Infections, including CMV, were reported in 76% of CAM and 50% of CHLO patients while on study. Relevant grade 3/4 treatment-emergent events included (CAM vs CHLO): lymphopenia (97% vs 3%), pyrexia (8% vs 0%), CMV events (8% vs 0%) and chills (3% vs 0%). Treatment emergent grade 3/4 thrombocytopenia (16% vs 13%) and anemia (14% vs 19%) were similar, and although grade 3/4 neutropenia was more common with CAM, (45% vs. 26%), AEs of CAM vs CHLO bacteremia/sepsis (3% vs 2%) and febrile neutropenia (5% vs 3%) were comparable. Serious AEs were reported for 44% of CAM (20% for IV Ganciclovir only in CMV viremic patients) and 20% of CHLO patients while on study treatment. CONCLUSIONS: CAM307 demonstrates that therapy-naïve BCLL patients treated with CAM have significantly longer PFS and higher ORR than those treated with CHLO, with manageable toxicities. Although CMV reactivation was reported in the CAM arm, prompt intervention maintained efficacy. The activity seen here supports ongoing investigations of CAM in first line combination therapy, high risk patients and consolidation. Figure Figure

Description: Abstract 919 Background: Patients (pts) with Rai Stage III/IV CLL have a shorter median survival compared to Rai Stage I/II pts. We previously reported significant improvement in progression-free survival (PFS) with FluCam compared to single-agent fludarabine (Flu) in pts with previously treated CLL (Engert ASH 2009; EHA 2010). Here we report the efficacy and safety of FluCam and Flu in a subset of these pts with advanced stage CLL. Methods: In a Phase 3, multi-center, controlled trial, pts with relapsed/refractory CLL were randomized to receive either IV Flu 25 mg/m2 on days 1–5 every 28 days or IV alemtuzumab (Cam) in combination with IV Flu (FluCam). Prior to cycle 1, FluCam pts were required to undergo Cam escalation (3 mg, 10 mg, 30 mg); once the 30 mg dose was tolerated, pts began cyclic administration of Flu 30 mg/m2 IV and Cam 30 mg IV on days 1–3 every 28 days. Pts could receive up to 6 cycles of either therapy depending on response and toxicity. Randomization was accomplished utilizing the minimization method to ensure balance between treatment arms with respect to study center, disease status, prior therapy, Rai Stage, age, gender, and lymph node size. All pts received prophylaxis with cotrimoxazole and famciclovir until CD4+ counts were 〉200 cells/mcL. The primary endpoint of the study was PFS with FluCam compared to Flu. A pre-specified subgroup analysis in Rai Stage III/IV pts compared PFS, overall response rate (ORR=CR + PR), complete response rate (CR), overall survival (OS) and safety in FluCam vs Flu treated pts. Differences in PFS between the 2 treatment arms were tested using the log-rank test. Results: Of the 335 pts enrolled in this study, 123 (37%) were Rai Stage III or IV (61 FluCam pts, 62 Flu pts). For the overall study population, FluCam significantly prolonged PFS compared with Flu (24.1 months (mos) vs 15.4 mos, respectively; p = 0.002; HR: 0.618; 95% CI 0.46–0.83). Data presented herein focus on the subgroup of CLL pts with Rai Stage III/IV disease. Demographics for this subset of FluCam vs Flu treated pts include: median age (65 yrs [36-80] vs 64 yrs [46-80]); gender (70% male vs 61% male); and prior Flu exposure (10% vs 8%) respectively. Pts received a median of 6 cycles in the FluCam arm and a median of 5 cycles in the Flu arm. FluCam significantly prolonged PFS compared with Flu (24.5 mos vs 11.8 mos, respectively; p 〈 0.001; HR 0.46; 95% CI 0.29–0.73). Similarly, the ORR (77% vs 56%; p = 0.016) and CR (16% vs 3%; p = 0.014) improved significantly with FluCam compared to Flu. With a median follow-up of 21 mos, pts treated with FluCam had significantly improved median OS compared with those treated with Flu (not reached vs 23.5 mos, respectively, p = 0.005 HR 0.44; 95% CI 0.24–0.79), representing a 56% reduction in the risk of death (Figure 1). Treatment-related adverse events (AE) occurred in 97% and 88% of Rai Stage III/IV pts receiving FluCam (n=59) and Flu (n=60) arms, respectively. There were no clinically relevant differences in the AE profile in pts with Rai Stage III/IV between arms. In the Rai Stage III/IV subgroup, the AEs that occurred ≥10% and more frequently in the FluCam arm relative to the Flu arm included infusion-related events and leukopenia. Reported all-cause grade 3/4 hematologic AEs in the FluCam vs Flu arms were neutropenia (47% vs 48%), leukopenia (29% vs 8%), thrombocytopenia (15% vs 20%), and anemia (7% vs 23%), respectively. The total frequency of treatment-emergent infections was 42% in the FluCam arm vs 52% in the Flu arm. No CMV infections were reported in either arm in this subset of pts. All-cause serious AEs (SAE) occurred in 37% and 45% in the FluCam and Flu arms, respectively. The most commonly reported all-cause SAEs in ≥5% of pts in either arm were pyrexia (5% vs 2%), neutropenia (3% vs 5%), febrile neutropenia (2% vs 8%) and anemia (0% vs 8%) for FluCam vs Flu respectively. Deaths occurring on therapy or within 30 days after last dose were 3% on the FluCam arm vs 8% on the Flu arm. Conclusion: Data presented in this subset analysis of Rai Stage III/IV CLL pts demonstrate a survival advantage, longer PFS and improved ORR/CR in pts treated with FluCam compared to Flu. The safety profile of FluCam in pts with advanced stage was acceptable and in most respects, comparable to the Flu alone arm. Overall, FluCam is a compelling treatment option in pts with previously treated advanced CLL. Disclosures: Engert: Genzyme: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Off Label Use: Alemtuzumab (Campath, MabCampath) is indicated for the treatment of CLL. This trial examined the use of alemtuzumab in combination with fludarabine monophospate. Gercheva:Genzyme: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Pilipenko:Genzyme: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Robak:Genzyme: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Wu:Genzyme: Employment, Equity Ownership. Sirard:Genzyme: Employment, Equity Ownership. Elter:Genzyme: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.

Description: CAM307 is a randomized Phase III trial comparing the efficacy and safety of alemtuzumab (CAM) with chlorambucil (CHLO). The trial enrolled 297 previously untreated patients (pts) requiring therapy according to NCI-WG criteria. Pts were randomized 1:1 to CAM (n=149) vs CHLO (n=148) using standard dosing regimens. Fluorescence in situ hybridization (FISH) on interphase nuclei of lymphocytes isolated from blood was analyzed for cytogenetic abnormalities prior to the start of therapy. FISH analysis was performed using 13 DNA probes to detect chromosomal aberrations in 17p13.1 (P53), 13q14 (RB1, D13S319 and D13S25), 11q22.3-11q23 (ATM and MLL), 6q27 (subtelomere), 6q21 (chromosome 6q21/alphasatellite 6 cocktail probe), trisomy 8q24 (c-myc), trisomy 12 (CEP12) and translocations involving the locus of immunoglobulin heavy chain gene (IGH, 14q32.33). Samples were analyzed in 282 pts (95%); chromosomal aberrations were detected in 231 pts (82%) while 51 pts (18%) exhibited a normal interphase FISH pattern. The most frequent abnormalities were deletions (del) at loci 13q (49%), sole del 13q (24%), 11q (19%), 17p (7 %), 6q (4 %), and trisomies 12 (14%) and 8q (5%). Translocations IGH, 14q32.33 were detected in 10 pts (4%). An exploratory analysis was performed to correlate time to event variables (assessed by an independent response review panel) with cytogenetics. Overall 165 pts (59%) revealed combination abnormalities. The most frequently observed chromosomal associations were: del 13q + del 14q (N=20, 12%), del 11q + del 13q (N=17, 10%), del 11q + del 13q + del 14q (N=11, 7%), del 11q + del 14q (N=7, 4%), trisomy 12 + del 13q (N=5, 3%), del 13q + del 17p (N=4, 2%), del 11q + trisomy 12 (N=3, 2%) and del 17p + del 6q (N=3, 2%). Coexistence of del 17p and del 11q was not observed. Although del 13q was observed with all chromosome abnormalities, nearly half of the cases del 13q14.3 (D13S25 and D13S319) coincided with an ATM deletion (11q22.3). FISH analysis has allowed the detection of uncommon abnormalities: tetraploidy (n=1), hyperdiploidy (n=1), trisomy 18 (n=1) and c-myc oncogene amplification (〉15 copies per nuclei) (n=2). The latter is a well known abnormality in solid tumors but rarely seen in leukemia. In addition, del of the IGH variable region was detected in 70 pts. The biological and clinical significance of this abnormality is to be investigated. Conclusions: Overall, 82% of treatment naïve BCLL pts revealed cytogenetic aberrations and 59% were combination abnormalities. CAM307 demonstrates a significant improvement in PFS in pts treated with CAM vs CHLO who present with del 13q as the sole abnormality; no difference in pts with del 11q. However, a trend towards improved PFS was observed in pts with trisomy 12 and del 17p, which did not reach significance due to small sample size. Further investigation of CAM therapy in high risk cytogenetic subgroups is warranted.

Description: Abstract 537 Introduction: Single-arm pilot and Phase II trial data suggested that the combination of fludarabine and alemtuzumab (FluCam) may improve outcome for patients (pts) with relapsed or refractory chronic lymphocytic leukemia (CLL). To validate these observations, a Phase III, multicenter, open-label, randomized study was conducted to compare the efficacy and safety of FluCam vs. fludarabine (Flu) alone as second-line therapy for pts with relapsed or refractory CLL. Methods: Patients with Rai Stages I-IV were randomized to FluCam or Flu using the minimization method to ensure a balance between treatment arms by study center, Rai stage, disease status, age, sex, prior Flu therapy, and maximum lymph node (LN) size. FluCam was administered in Phases A and B. Patients received escalating doses of intravenous (IV) alemtuzumab alone (Phase A). Once alemtuzumab 30 mg IV was tolerated, pts received FluCam as Flu 30 mg/m2 IV followed immediately by alemtuzumab 30 mg IV on days 1-3 of a 28 day cycle (Phase B). In the Flu arm, pts received 25 mg/m2IV on days 1-5 of a 28 day cycle. For both arms, all pts could receive up to six cycles depending on response and toxicity. All pts received prophylaxis with trimethoprim/sulfamethoxazole DS and famciclovir until CD4+ counts were ≥200 cells/μL. The primary endpoint was progression-free survival (PFS). Secondary endpoints were overall response (OR), complete response (CR), overall and 3 year survival, and safety. The primary analysis was based on the independent response review panel's (IRRP) assessment of response and date of progression for each patient. Two interim analyses were prospectively planned and conducted by the data and safety monitoring board (DSMB) with the final analysis planned after a total of 190 events. The 2nd interim analysis included 139 PFS events and met the pre-specified criteria; the DSMB recommended early study termination. Results: 335 pts were randomized (FluCam n=168 and Flu n=167); Rai Stage III-IV: 37%; median age: 60 years; prior Flu therapy: 20% and maximum LN size ≥5 cm: 14%. The median treatment cycles received were 6 for both arms. 60% of FluCam and 64% of Flu pts received 6 cycles of treatment. The median IRRP determined PFS for FluCam was significantly prolonged compared to Flu (29.6 months vs. 20.7 months, respectively; p=0.005; HR 1.63 [95% CI: 1.16, 2.28]; Figure 1). Median PFS by Rai Stage was: Stage I-II - 27.4 months for FluCam (n = 105) vs. 21.3 months for Flu (n = 103), p=0.215; Stage III-IV - 26.1 months for FluCam (n = 61) vs. 12.1 months for Flu (n = 62), p=0.003. Per investigator response assessment, FluCam resulted in significantly higher OR and CR rates (OR: FluCam 84.8% vs. Flu 67.9%, p10% of the pts included pyrexia, neutropenia, leukopenia, thrombocytopenia, anemia, chills, lymphopenia, rash, infusion related reactions, nausea and urticaria in the FluCam arm; and, neutropenia, thrombocytopenia, anemia and leukopenia in the Flu arm. Treatment-emergent grade 3/4 thrombocytopenia (18% vs. 22%), neutropenia (60% vs. 66%) and anemia (13% vs. 22%) were comparable in FluCam vs. Flu arms. Overall, 33% (n=54) of pts in the FluCam arm experienced a SAE vs. 26% (n=42) in the Flu arm. Reported SAEs for neutropenia were 4.9% in the FluCam arm and 1.8% in the Flu arm; however, febrile neutropenia was similarly reported in the two arms 3.7% vs 3.6% of pts, respectively. Infections including CMV occurred in 47% and 35% of the FluCam and Flu pts, respectively. Symptomatic CMV infection occurred only in the FluCam arm in 8% of pts, of which 1% were SAEs and 0% classified as grade 4 or higher. Deaths occurring on therapy or within 30 days after last dose were 2% on the FluCam arm vs. 5% on the Flu arm. Conclusions: The 2ndinterim analysis indicates that the combination of FluCam is superior to Flu as second-line therapy for pts with relapsed or refractory CLL, including those with advanced disease stage. With significantly longer PFS, higher OR and CR rates, an acceptable safety profile and a convenient administration regimen, FluCam may be an additional second-line treatment option for pts with relapsed or refractory CLL. Disclosures: Engert: Genzyme Corporation: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Off Label Use: Alemtuzumab (Campath, MabCampath) is indicated for the treatment of CLL. This trial examined the use of alemtuzumab in combination with fludarabine monophospate.. Gercheva:Genzyme Corporation: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Robak:Genzyme Corporation: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Galina:Genzyme Corporation: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Wu:Genzyme Corporation: Employment. Sirard:Genzyme Corporation: Employment. Elter:Genzyme Corporation: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.