1. Is there anything new
for relapsed AML?
Steven M. Kornblau, M.D.
Department of Leukemia
Department of Stem Cell Transplantation and
Cellular Therapy
2. The Status Quo
• Most patients achieve remission
– 80% < age 60, no AHD
– 50% >60 or prior AHD
• Most relapse
– Cure rate 20-25% overall therefore 2/3rd relapse
• Cure after relapse without SCT very unlikely
– Exceptions: APL & those inadequately treated
• Conventional chemotherapy hasn’t advanced in a
long, long time.
• Strategy
– Get to SCT, Directly, or chemo to temporize
– No donor. Palliate, chemo or symptomatic care.
3. Allogeneic SCT
• Curative in
– ~35% subsequent CR
– 25% refractory relapse (IBMTR data)
• When to perform
– ASAP- but most can’t wait & will need something
– In CR2
• But most won’t achieve a second CR
• Toxicity and infections can close window of opportunity
4. CR1 duration < 1 year or 1o ref < 1 year or 1o ref 1-2 years >2 years
# prior salvage attempts >1 0 0 0
N 58 160 30 15
CR Rate <1% 14% 47% 73%
Model for Predicting 2nd Remission Attainment
CR1 duration < 1 year or 1o ref 1-2 years >2 years
Prior Salvage Therapy? Yes No Yes No No
Prior Salvage Response No CR CR No CR CR
# of Prior Salvage > 1 1 1 1
Cytogenetics/AHD Fav Unfav Fav
CR/N 1/ 90 1/ 10 5/62 16/87 2/11 5/9 14/30 10/15
CR rate 1% 10% 10% 20% 20% 40% 40% 66%
Therapy choice Phase I Phase II Combination Chemo
Estey & Kornblau Blood 1996;88 :756
Estey & Kornblau unpublished 1998As an aside, perhaps Phase I and II studies should be sure to
include patients form each category , or report what category they had
5. Models for Predicting Survival After Relapse
GOELAMS
CR1 Duration
EPI
> 12 Mo
< 12 Mo
0
1
> 18 Mo
7-18 Mo
< 6 Mo
0
3
5
Cytogenetics
Not High
High Risk
0
1
Inv16
T(8;21)
Other
FLT3 ITD
Neg
Positive
0
1
<35
36-45
>45
Age
0
3
5
0
1
2
Prior SCT? 2
Points % CR2 1 Yr OS 5 Yr OS
0-6 85% 70% 46%
7-9 60% 49% 18%
10-14 34% 16% 4%
Points 2 Yr
OS
2 Yr
EFS
0 58% 45%
1 37% 31%
2-3 12% 12%
Breems JCO 2005;23(9):1669-78
CR1 Duration
Cytogenetics
Chevallier Leukemia 2011;25(6);939-44
6. FLT3-ITD: Poor prognosis at relapse too
Overall Survival After Relapse 1
Overall
Survival
After CR#2
Ravandi LeukRes 2010:34;752-756
FLT3 -WT FLT3-ITD
N 69 34
CR (p= 0.09) 41% 24%
Med Surv (p= 0.001) 37 weeks 13 weeks
Diploid Cytogenteics
Not Tx with anti FLT3
agent
CR#2
Remission
Duration
8. Current Common Chemotherapy
Combinations: MEC
• Days 1-2-3: Mitoxantrone 12mg/m2/d & Ara-C 500 mg/m2 /d
• Days 8-9-10: Etoposide 200 mg/m2/d & Ara-C 500 mg/m2
• N=133
• Age 15-70 (22 >60)
• Cytogenetics ? but 7 M4Eos and 13 APL
• Median 1st CR 11 mo
• CR Overall 60%
– 1st salvage for CR1>6mo =76% for CR1 <6mo =46%
– >1st CR 45%
– Primary refractory 41%
• Overall survival, not receiving SCT = 7 mo
Archimbaud JCO 1995:13;11-18
9. Results of Randomized Trials In Patients With
Relapsed or Refractory AML:
Nothing Stands Out as Better
Study Treatment N
2nd CR
Rate, %
Median 2nd
CR Duration,
Months
ED, %
Median
OS,
Months
Kern W, et al.1 HDAraC + Mit vs
IDAC + Mit
186 52 vs 45 5.3 vs 3.3 32 vs 17 5 vs NA
Martiat P, et al.2 HDAraC + Amsa vs
HDAraC + Mit
52 53 vs 60 11 vs 12 15 vs 8 8 vs 11
Larson R, et al.3 HDAraC vs
HDAraC + Amsa
36 14 vs 53 NA 25 vs 25 2 vs 6
Vogler W, et al.4 HDAraC vs
HDAraC + Eto
131 40 vs 45 12 vs 25 NA 5 vs 5
Ohno R, et al.5 MAE vs
MAE + G-CSF
58 42 vs 54 14 vs 12 8 vs 0 NA
9
Abbreviations: CR = complete remission; OS = overall survival; HDAraC = high-dose cytarabine; Mit = mitoxantrone; IDAC = intermediate-dose AraC; NA = not available;
Amsa = amsacrine; Eto = etoposide; MAE = Mit + AraC + Eto; G-CSF = granulocyte-colony stimulating factor; EMA = Eto + Mito + AraC; GM-CSF = granulocyte,
macrophage–colony stimulating factor; ADE = AraC + daunorubicin + Eto; CSA = cyclosporine; seq ADE = sequential ADE; MEC = Mit + Eto + AraC.
1Kern W, et al. Leukemia. 2000;14: 226–231; 2Martiat P, et al. Eur J Haematol. 1990;45:164–167; 3Larson RA, et al. Br J Haematol. 1992;82:337–346;
4Vogler WR, Leukemia. 1994;8:1847–1853; 5Ohno R, et al. Blood. 1994;83:2086–2092.
Slide Courtesy of Stefan Faderl
10. Current Common Chemotherapy
Combinations: FLAG
Fludarabine 30m g/m2/d , Ara-C 2 g/m2 /d 1-5, G-CSF 300 day 1-6
Jackson Br J Haem 2001:112; 127
Group1 N=21 Group 2 N=44
Since stopping TX >6 Mo < 6 mo or 1oRef
Age median 48 (18-69) 47 (21-74)
Cytogenetics F/I/U % 19 /24 /10 48%? 2 / 61 / 18 19%?
CR 81% 30%
Median Survival 16 mo 3 ml
11. Combinations of Purine Nucleotide Analogs With ARA-C
in Patients With Relapsed/Refractory AML
Study N
Salvage
Regimen
Overall
CR Rate, %
OS and Time ED, %
Wierzbowska A, et al.1 118 CLAG-M 58 14% at 4 yrs 8
Steinmetz HT, et al.2 36 FLAG-IDA 52 15% at 1 yrs 14
Jackson G, et al.3 83 FLAG 81 50% at 2 yrs 18
de la Rubia J, et al.4 32 FLAG-IDA 53 40% at 1 yrs 9
Clavio M, et al.5 59 FLAG/FLANG 59 NA 10
Carella A, et al.6 41 FLAG 56 20% at 2 yrs 7
Wrzesień-Kuśet A et al.7 58 CLAG 50 42% at 1 yrs 17
Pastore D, et al.8 46 FLAG-IDA 52 NA 7
Hänel M, et al.9 29 Mit-FLAG 59 34% at 1 yrs 14
Huhmann I, et al.10 22 FLAG 50 58% at 1 yrs 5
Camera A, et al.11 61 FLAD 52 5.8 months 12
1Wierzbowska A, et al. Eur J Haematol. 2008;80:115–126; 2Steinmetz HT, et al. Ann Hematol. 1999;78: 418–425; 3Jackson G, et al. Br J Haematol.
2001;112:127–137; 4de la Rubia J, et al. Leuk Res. 2002;26:725–730; 5Clavio M, et al. Haematologica. 1996;81:513–520; 6Carella AM, et al. Leuk Lymphoma.
2001;40:295–303; 7Wrzesieo-Kuśet A, et al. Eur J Haematol. 2003;71:155–162; 8Pastore D, et al. Ann Hematol. 2003;82:231–235; 9Hänel M, et al. Onkologie.
2001; 24:356–360; 10Huhmann IM, et al. Ann Hematol. 1996;73:265–271; 11Camera A, et al. Ann Hematol. 2009;88:151–158.
Slide Courtesy of Stefan Faderl
12. Fludarabine + Ara-C Effective After
Mitoxantrone + Etoposide Failure
• N = 18 Fav = 1, Int = 15 Unfav = 1 (Flt3 ?)
• Prior CR with 3+7 alone (n=11) or with ME (n=7)
• Standard HDAC consolidation (most 4 cycles)
• Treated with
– Mitoxantrone 10mg/m2 &
– Etoposide 100mg/m2 x 5 days
• CR in 7 (39%)
• Median survival 4.5 mo, 2 still alive ~ 1 yr
•
McLaughlin Int J Hema 2012:96;743-747
15. • 10 of 37 Allo SCT relapses from 2007-2009
– BU-Cy/Flu Cy +TBI in 4
– 4 sib 2 haplo sib, 4 MUD
• AML = 4 MDS = 6 Age 25-71
• Time from SCT to relapse: 0 0 5 6 14 18 18 36 36 132 months
• Relapse = loss of donor chimerism + morphology/cytogenetics
• Azacitidine 75mg/m2/d x 5 d (n=9) 40mg (n=1)
• Best BM response = CR in 6, 3 progressed, 1 revert to MDS
– 2 CR got DLI, 1 developed cGVHD
– 4 CR lost all host chimerism 2 with MRD
– 1 relapsed
• Median survival = 422 Days Median FU of CR = 624 Days
• 5 of 27 relapses not TX with aza from same period are alive.
Hypomethylating agents after HSCT
Bolanos-Meade Biol Blood Marrow Transplant 2011;17(5) 754-758
17. Clofarabine – Combinations
Day
Ara-C 1000 mg/m2 over 2hr
4 hrs after Clof
1 5432
Clofarabine 40 mg/m2 over 1 hr
Placebo over 1 hr
1 5432
1 5432
Ara-C Clof+ara-C P Ara-C + Clofarabine + G-CSF
N 163 163 46
Age 67 (55-82) 67 (55-86) 53 19-69
Cyto F/I/P % 6/53/39 4/40/49 6% 54% 40%
30 D Mortality 5% 16% <0.01
Disease Status 1oRef Rel 1oRef Rel 1oRef Rel
% 44 56 46 54 N = 18 N =32
CR 18 18 33 38 0.04 66% >6 mo 60%, < 6 mo 26%
ORR 23 23 46* 49* <0.01 61%
Median Survival
(Mo)
5.5 7.2 5.1 8.7 9 mo
Faderl JCO 2012:28;2492-2499
Day
Ara-C 2g/m2
4 hrs after Clof
1 5432
Clof 15-25 mg/m2
GCSF 5μ /kg
1 5432
1 5432
Becker Br J Haem 2011:155;182-9
or
18. Clofarabine in the Elderly & Infirm
• Newly DX AML
• UWCM-001 >70, >60 & poor PS (WHO >2) or with
cardiac comorbidity
• BIOV-121 >64 & unsuitable for intensive
• Dose: 30mg/m2/d over 1 hour days 1-5
• Conclusion: Its better than LDAC
Burnett JCO 2010:282389-2395
N Age
median
CR CRi
UWCM-001 40 71 50% 5%
BIOV-121 66 71 21% 24%
Total 106 71 32% 16%
Fate of
CR/CRi
Relapse =27
Toxicity =10
Unknown = 5
Median
Survival
CR= 47 wks
CRi = 30
All =19 wks
19. Lenalinomide
• AML N= 31 ALL = 4 , Median age 63 (22-80)
– Primary refractory 8
– Relapsed & Refractory to last therapy = 23
– Post SCT n= 8 7 Allo, 1 Auto
• Unfavorable cytogenetics = 17
• Median # prior therapies = 2 (1-4)
– First therapy for this relapse n=12
• Response
– MTD = 50 mg per day
– DLT: fatigue
– AML
• CR = 5 (16%) at 25 35 50 50 50 mg/d
• Duration 5.6-14 mo
• all with WBC <3500
• Cyto complex, -7, tri13
• Post Allo, 4 as initial tx, 2 got GVHD and achieved CR.
– ALL CR = 0 Blum JCO 2010:28; 4919-4925
20. Can you spice up an old
recipe by adding a new
ingredient?
21. Adding Imatinib to MEC
• MTD = 400 mg, N = 39, 21 @ MTD
• Primary refractory 32, 14 @ MTD
• CR1 duration
– <12 mo = 10, 3 @ MTD
– 12-24mo 12, 4 @ MTD
• Cytogenetics Fav:1 Int: 27 UnFav;21 ? = 4
• Response at MTD : 1oRef 43% Relapse 7/7
– Fav & Int 8/9 Unfav 33%
• Response correlated with inhibition of AKT but not ERK
phosphorylation
Day
Imatinib 200/300/400
Mitoxantrone 10 mg/m2
Etoposide 100 mg/m2
1 98765432 10
87654
87654
Brandwein Leukemia 2011:25;945-952
22. Pravastatin + IA
• AML Blast make or eat a lot of cholesterol resistance
• Blocking this with a statin reverses chemoresistance in vitro
• N=37 1oRef=7 Relapse #1=11, Rel #2=4
• Age Median 55 Cyto Fav = 3% Int = 27% Unfav =70%
Day
Idarubicin 12 mg/m2/d
Pravastatin 654321 7 8
654
Ara-C 1.5g/m2/d CI 654 7
Doses:
40 …1680 mg/day
MTD =1280
DLT= too many
pills!
New
11/15 73%
Cytogenetics Exp Obs Ratio
Intermediate 2.88 3 1.04
Unfavorable 4 8 2.0
Salvage
9/22 41%
Status Exp Obs Ratio
R1 3.96 7 1.77
R2 .4 1 2.5
All relapsed/Prim ref 4.96 9 1.81
SWOG Phase III trial stopped early in Nov 2012 for POSITIVE result
Kornblau JCO 2007:109;2999-3006
23. DAC + Gemtuzumab + Ozogamicin
Chowdhur y Am J Hema 2009:84;599-600
Day
Gemtuzumab Ozo 3 mg/m2
Decitabine20 mg/m2 129654321
• N = 12 A retrospective study?
• Age 29-66
• All relapsed with a median 3 prior Tx (1-6)
• Prior SCT Allo = 6, Auto = 1
• CR in 5 (42%) all SCT, 2 relapsed @ 2, 15 mo
– Ages 41 44 44 48 66,
– Cyto : Diploid, Diploid, Tri8, Diploid, T9:11
– # PriorSalvage 1 2 2 1 2
– CR1 duration?
• Mild Grade 1 & 2 tansaminitis
• Survival 4 still alive , median FU 1 yr.
24. Chemo + Gemtuzumab + Ozogamicin
Middeldorf Am J Hema 2010:85;477-481
• N = 23 with CD33+ CR1 duration?
• Drs choice of chemo, then if CD33+ Drs choice whether to give
it a “GO”.
• CR after chemo & before GO ?
GO single GO Chemo Chemo GO
N 3 5 16
Age 76 (70-82) 62 (43-74) 65 (43-76)
1oRef /R1 /R>1 2/1/0 1 /2 / 2 9 /5 /2
GO 9 mg/m2 D 1, 20 9 mg/m2 D 1 9 mg/m2 x1 D5-17
CR 0 0 13 81%
Inc 8/9 1oRef
25. Vorinostat + IA
• Does adding Histone deacetylase inhibitor add?
– Vorinostat 600 mg t.i.d. Days 1 2 3
– Ida 12mg/m2 /d x 3 Days 4 5 6
– ara-C 1.5 g/m2 /d x 3 or 4 Days 4 5 6 (7)
• N= 75 newly diagnosed
• median age 52 (19-65)
• Cytogenetics
– 29 diploid
– FLT3-ITD =11
• Mortality 4%
• CR = 76% (n=56) including 100% in FLT3 53% in -5 -7
• Relapse in 27
• OS median all patients =82 weeks FLT3-ITD 91 weeks
• Toxicity “ no excess” w.r.t. standard IA, Skin 38%
Garcia-Manero JCO 2012;30:2204-10
27. Tosedostat
• Aminopeptidase inhibitor
• Synergizes with Bortezomib
• MTD 120 mg 130 mg D x 28 D
• DLT – Thrombocytopenia & ALT elevation
• 51 AML, 41 at MTD, all >60yrs, 7 CR, 7 PR
• CR duration short 28 36 62 85 175 176 449 days
NH3-AA1-AAn….AAy-AAz-COOH
NH3-AA1-AAn….AAy-COOH + AAz
Proteosome Amino Acid depravation
Inc Small peptides
UPR ?
Apoptosis
Lowenberg JCO 2010;28:4333-38
28. PI3K/AKT/mTOR Pathway
• Promotes growth and proliferation
• Constitutively activated in the majority of
AML but not in normal CD34+ cells
• Important for the survival of AML cells,
particularly after genotoxic stress
• May be required by leukemic stem cells
for survival
• mTOR inhibition causes cell cycle arrest
of AML cells and increases the pro-
apoptotic effect of chemotherapy
HGF, Cytokines
PI3K/AKT
mTOR
4E-BP1 P70S6K
Translation
Cell cycle progression
Proliferation & Survival
RAPALOGS
FLT3
mTOR inhibition
Slide courtesy of Stefan Faderl
29. Trials with AKT/mTOR inhibitors
Study N Regimen Response
Recher
Blood 2005
9
(AML)
Phase 1 (Sirolimus)
S: 6 mg/d1, 2 mg/d2-28
PR 4/9
Perl
Clin Cancer
Res 2009
27
(AML)
Phase 1 (MEC+Sirolimus) *
S: MTD 12 mg/d1, 4 mg/d2-7
CR (n=4) =15%
+PR (N=2) ORR= 22%
Yee
ASH 2004
7
(AML/ALL)
Phase 2 (Temsirolimus)
T: 25 mg weekly
Modest activity (PB)
Yee
Clin Cancer
Res 2006
27
various
Phase 1/2 (Everolimus)
E: 5-10 mg daily
Modest activity (PB)
Ravandi
ASH 2008
39
(AML/MDS)
Phase 1 (Triciribine)
T: MTD 55 mg/m2 d 1,8,15
Modest activity (PB)
Table courtesy of Stefan Faderl
* Evidence of synergy with MEC not observed
30. Vosaroxin nee Voreloxin nee SNS-595
• Quinolone derivative, intercalates DNA and poisons Topo II
• Not a P-gp substrate, active in anthra-resistant settings
• Non cardiotoxic
• N=67; median age 65y (21-81) 84% AML (78% refract)
– Weekly D 1 8 15. N=42 18-90 mg/m2/wk iv bolus (max 4 cycles)
– Twice Weekly D 1, 4, 8, 11 N=31 9-50 mg/m2 iv bolus (max 4 cycles)
• DLT: stomatitis (grade 3-4)
• MTD: Weekly 72 mg/m2; Twice Weekly 40 mg/m2
• Complete remission CR or CRp
– Weekly N=4 1) 1° Relapse, 3 refractory Duration 1.7 2.4 3.1 9.1 mo
– Twice Weekly 1 CR refractory suartion 19.2 mo
• Phase II trial «VALOR» of ara-C +/- V in untreated elderly AML
Lancet Leukemia 2011:25;1808-14
31. Targeting Tumor Hypoxia: Hypoxia-Selective Cytotoxins
• Normal marrow is hypoxic 6%, Leukemic Marrow is 1%
• Agents are converted to toxic moieties only under hypoxia
• PR104 doses: 1100 (MTD in solid tumors), 1600, 2200, 3000 mg/m2
• Highly refractory population
• BM Blasts cleared in many
• CRp =4 CRi=2
• Relapse 2
• SCT 2, 2 pending
Brown Nat Rev
Ca
2004;4;437-447
0
10
20
30
40
50
60
70
80
90
100
0 20 40 60 80 100
Study Day
Blasts(%)
183-1009
183-1010
183-1011
182-1014
182-1020
182-1023
Information Courtesy Marina Konopleva
Patterson., Clin Can Res 2007
32. Sapacitabine (CS-682)
PHASE 1
• N=47; median age 65y; 42 R/R
AML
• 75-375 mg BID x 7d q3-4 wks (N=35)
375-475 mg BID d1-3, d8-10 q3-4 wks
(N=12)
• DLT: GI
• MTD 375 mg BID x 7 days; 425
mg BID d1-3, d8-10
• ORR: 13/47 (28%): 4 CRs, 2
CRp, 7 CRi
– 30-d mortality (4%)
Kantarjian et al, JCO 2010
• Orally bioavailable (fatty-acid
modified) cyanocytosine analog with
a unique mechanism of action
• Converts in vivo to CNDAC,
incorporates into DNA, causes SS-
DNA breaks, G2 arrest and apoptosis
PHASE 2
• N= 51 Untreated
• Median age 77y, 35% ≥80y
• Median 3 cycles
• ORR: A 45% (CR 10%); B 25%
(CR/CRp 10%); C 35% (CR/CRp
25%)
• 30-d mortality 8/60 (13%)
• 400 Mg BID D1-3 8-10 q 3-4 wk
selected for further testing
Kantarjian et al, ASH 2009
34. FLT3 inhibitors
• As single agents very few CRs
– Better at reducing PB than BM blasts
• Will addition to Chemotherapy improve results ?
ALL FLT3 mut Chemo Chemo + L
N 112 112
Age 54 (21-79) 59 (20-81)
CR 12% 17%
CRp 9% 9%
CR1 <6 11% 19%
CR1 >6 29% 32%
Survival 160D 160D
CR1 <6mo MEC + Lestaurtinib 80mg
CR1 >6 mo HiDAC + Lestaurtinib 80mg
Response correlates with target level inhibition
Only 58% got inhibited at D 15
Levis Blood 2011:117;3294-3301
FLT3 Mut FLT3 WT
Dose 50 100 50 100
N 18 17 31 29
Age>64 39% 53% 77% 72%
CR 0 0 0 0
PR 0 1 0 0
Heme
improvement
50% 41% 43% 26%
Midostaurin 50 or 100 mg twice daily
Fischer JCO 2010:28;4239-45
35. AC220-002 : Phase II in AML salvage
Cohort >60, CR1 < 1 yr or 1oRef >18 Rel/Ref to 2nd line or HSCT
Mutation Status ITD+ FLT3-WT ITD+ FLT3-WT
N 92 41 99 38
Age 70 (54-85) 69 (60-78) 50 (19-77) 55 (30-73)
CR composite 54% 32% 44% (4% CR) 34% (3% CR)
PR 18% 9% 24% 13%
Median CRc
duration
12.7 wks 22.1 wks 11.3 5
Median Survival 25 19 23.1 25.6
Cortes ASH 2012 Abstract # 48
Dose: Females 90 mg Males 135 mg continuously
QTc 25 % Grade 3-4 13% 26% Gr 3-4 10%
Levis ASH 2012 Abstract # 673
36. Alphabet Soup Trials for Relapsed AML at MDACC
Agent MOA Phase Combo? Group
Lintuzumab AntiCD33 Ab 1 + LD araC > 60yrs
Omacetaxine Protein Syn, histoneDAC 1 + LD araC > 60yrs
Pf-04449913 Hedgehog 1B + LD araC or DAC > 60yrs
SGI-110 Super DAC 1 > 60yrs
Tosedostat Aminopeptidase inhibitor I/II araC or Aza Post hypomethylating
Vosaroxin Anthracycline III Ara-C +/- V Relapse1
Plerixifor +G-CSF CXCR4 inhibitor I /II +MEC Relapse1
BP-100-1.01 L-GRB2 AS I Salvage
ABT348 Aurora Kinase I + ara-C Salvage
AMG 900 Aurora Kinase I Salvage
KB004 Anti EphrinA3 I Salvage
BKM120 PI3K inhibitor I Salvage
Lurbinectedin Ds-DNA breaks I Salvage
CWP232291 WNT inhibitor I Salvage
PRI-724 B-Catenin inhibitor I /II Salvage
AZD1208 PIM Kinase inhibitor 1A/!B Salvage
DFP-10917 Purine analog-Sapacitabine I /II
MK-8242 HDM2 inhibitor I + Chemo Salvage
37. Conclusions
• Thus far nothing is better than old fashioned combo
chemo
– Clofarabine single agent has utility
• Many fascinating ideas :
– Hypoxia, cholesterol blockade, Imatinib
– Results of follow up studies required
• Lots of new agents
• FLT3 – Many drugs, unimpressive results
•
There is great chaos under (the relapsed AML ) heaven
– the situation is excellent (for new ideas and new
agents) - Mao Zedong
38.
39. Overall Survival Using European Prognostic
Index & GOELAMS
Breems JCO 2005;23(9):1669-78 Giles Br J Haem 2006 ;134(1):58-61
They are superimposable
GOELAMS
40. Results of Randomized Trials In Patients With
Relapsed or Refractory AML
Study Treatment N
2nd CR
Rate, %
Median 2nd
CR Duration, Mo
ED, %
Median
OS, Mo
Karanes C, et al.1 HDAraC vs
HDAraC + Mit
162 32 vs 44 9 vs 5 10 vs 16 8 vs 6
Thomas X, et al.2 EMA vs
EMA + GM-CSF
72 81 vs 89 4 vs 5 8 vs 5 9 vs 10
Liu Yin J, et al.3 ADE +/-CSA vs
Seq ADE +/- CSA
235 57 vs 38 NA 16 vs 24 NA
List A, et al.4 MEC vs
MEC + PSC-833
226 33 vs 39 NA 15 vs 18 NA
Greenberg P, et al.5
MAE vs
MAE + G-CSF
129 25 vs 17 9 vs 10 10 vs 16 5 vs 4
Feldmen E, et al.6
MEC vs
MEC + lintuzumab
191 23 vs 29 NA NA 8 vs 6
Giles FJ, et al.7 HDAraC vs
HDAraC + laromustine
178 19 vs 35 332 vs 275 2 vs 11
177 vs
128
40
1Karanes C,et al. Leuk Res.1999;23:787–794; 2Thomas X,, et al. Leukemia. 1999;13:1214–1220; 3Liu Yin JA,, et al. Br J Haematol. 2001;113:713–726; 4List AF, et al. Blood. 2001;98:3212–3220;
5Greenberg PL, et al. J Clin Oncol. 2004;22:1078–1086; 6Feldman EJ, et al. J Clin Oncol. 2005;23:4110–4116; 7Giles FJ, et al. Blood (ASH Annual Meeting Abstracts). 2006;108:Abstract 1970.
Slide Courtesy of Stefan Faderl
41. Current Common Chemotherapy
Combinations: Clofarabine +AraC
• N = 30, 18 Relapsed 13 with >1 prior salvage
• CR1 duration?
• Age <60 30% > 60 70%
• Cytogenetics Fav:1 Int: 13 Unfav 14 ? = 2
• Many comorbidities
– CV history 43%
– Karnofsky PS 80 or less in 53%
• Early death rate = 28% in relapsed/refractory
• CR=47% Relapsed 5 (27%) 60% first 23% >1
• Fav & Int Cyto 5/7 =70%, Unfav 2/9 = 22%
•
Agura The Oncologist 2011;16:197-206
Day
Clofarabine 40 mg/m2 over 1 hr
Ara-C 1000 mg/m2 over 2hr
4 hrs after Clof
1 5432
1 5432
42. AC220-002 : Phase II in AML salvage
Cohort 1 2 3
Features >60 ITD+
R1
>18 ITD+ R2
or Post SCT
>18 ITD-
R1 R2
Planned N 120 120 60
Analyzed 25 37
CR 0 0
CRp or CRi 9 (41%) 15 (48%)
PR 7 (32%) 6 (19% )
Median Survival Not Reached 24 wks
Dose 200 mg
If QTc 135 males
90 females
Opened 11/09
100 Sites
Planned Interim Analysis
N=62 2/22/2011
QTc 34%
Females > Males
http://www.ambitbio.com/pdf/AC220-002_EHA%202011_06_08_11.pdf
43. AC220 = Quizartinib: Phase 1 in AML salvage
• N=76; median age 60y; 24% FLT3/ITD+
• Dosing (oral solution)
– 12-450 mg once daily x 14d, q4wks (ID regimen)
– 200 and 300 mg/d x 28d (CD regimen)
• MTD 200 mg CD
– DLT at 300 mg CD (QTc prolongation)
• ORR 30%: CR+CRp+CRi 13%, PR 17%
– Most responses @1 cycle; median DOR 14 wks
• Higher ORR in FLT3/ITD+ (56% vs 20%)
• Phase 2 study in FLT3/ITD+ AML (advanced) ongoing
• Phase 1 combo trials planned
Cortes et al, ASH 2009
44. Nucleolin targeting Aptamer AS1411 +
HDAC
• Aptamers are “chemical antibodies” bind with specificity.
• AS1411 binds Nucleolin on cell surface apoptosis
• Phase II trial N =71 Relapsed/refractory up to 3 prior TX
– HDAC 1.5g/m2 q 12 hr x 8 doses Days 4-7 Alone N=23
– With AS1411 10mg CI Days 1-7 N= 22
– or with AS1411 40mg/kg.d CI Days 1-7 N=26
Stuart ASCO Proceedings 2009 #7019
HDAC HDAC +10 HDAC+40
Evaluable 14 21 9
Early Death 2 1 1
“Response” 0/13 3/19 4/7
Why no update in 3 years?
