Azacitidine In Acute Myeloid Leukemia Research Articles

Abstract 4735: The histone deacetylase inhibitor pracinostat modulates the transcriptome of diffuse large B-cell lymphoma cells and is active in combination with several targeted agents

Abstract Background: Pracinostat (SB939) is a class I, II and IV histone deacetylase inhibitor (HDACi), in phase 3 in combination with azacitidine for acute myeloid leukemia (NCT03151408). We reported a strong preclinical activity as a single agent in lymphomas (Mensah et al, AACR 2018). Interestingly, anti-tumor activity differed between metabolically-defined subtypes of diffuse large B-cell lymphoma (DLBCL): lower in OxPhos than in B cell receptor (BCR) cell lines. Thus, we now report RNA-Seq on OxPhos and BCR DLBCL cell lines treated with pracinostat. We also present results of a combination screening with 9 anti-lymphoma drugs for future clinical development of this HDACi. Methods: For RNA-Seq, OxPhos (Toledo, Pfeiffer, WSU-DLCL2) and BCR (SU-DHL-4, SU-DHL-6, OCI-LY-1) cell lines were treated with pracinostat or DMSO for 6 hours (h) or 14 days (d). Absolute fold change > 2 with adjusted P <0.01 were used as thresholds. Combinations (72 h) with 5-azacytidine, ibrutinib, lenalidomide, bendamustine, everolimus, rituximab, idelalisib, bortezomib and copanlisib were evaluated on germinal center B-cell (GCB: SU-DHL-6, VAL) and activated B cell-like (ABC: OCI-LY-10, TMD8) DLBCL using the Chou-Talalay combination index (CI). Results: At transcriptome level, pracinostat determined a time-dependent modulation of proliferation and cell cycle genes with differences between OxPhos and BCR cell lines. The more sensitive BCR showed a higher number of modulated genes at both timepoints than the less sensitive OxPhos DLBCL. Moreover, while the upregulated transcripts increased with time in both metabolic clusters [doubled in BCR (1201 vs 591) and almost tripled in OxPhos (330 vs 120)], the opposite was true for downregulated genes in BCR (358 vs 600) but not in less sensitive OxPhos (186 vs 187). Combinations of pracinostat with ibrutinib [0.37 (0.01 - 0.73)] or lenalidomide [0.29 (0.11 - 0.46)] were synergistic in ABC. Idelalisib [0.67 (0.46 - 0.92)] and everolimus [0.78 (0.57 - 1.11)] were both effective in combination with pracinostat in all ABC and 1 GCB, while rituximab was synergistic in 1 ABC and all GCB [0.61 (0.32 - >1.1)]. Copanlisib [0.87 (0.45 - 0.94)] and 5-azacytidine [0.96 (0.64 - 1.14)] were additive with pracinostat in 3/4 cell lines and were synergistic in the remaining. Combination with bortezomib was beneficial in 3 cell lines [0.94 (0.5 - 1.53)] and bendamustine combined effectively with pracinostat in 2 of the 4 cell lines [1.1 (0.89 - 1.3)]. Conclusions: Modulation of the DLBCL transcriptome by pracinostat occurs already at 6 h, suggestive of a rapid effect of pracinostat on chromatin architecture, but it differs between OxPhos and BCR DLBCL. In terms of combinations, pracinostat addition to other targeted agents was largely beneficial. Citation Format: Afua A. Mensah, Filippo Spriano, Eugenio Gaudio, Chiara Chiara Tarantelli, Luciano Cascione, Andrea Rinaldi, Emanuela Lovati, Emanuele Zucca, Anastasios Stathis, Claudio Pietra, Francesco Bertoni. The histone deacetylase inhibitor pracinostat modulates the transcriptome of diffuse large B-cell lymphoma cells and is active in combination with several targeted agents [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4735.

Cost-effectiveness analysis for midostaurin versus standard of care in acute myeloid leukemia in the United Kingdom

AimsMidostaurin (MIDO) has been proposed for the treatment of newly-diagnosed adult patients with FMS-like tyrosine kinase 3 mutation-positive (FLT3+) acute myeloid leukemia (AML) in combination with standard chemotherapy. The cost-effectiveness of MIDO and standard of care (SOC) followed by MIDO monotherapy was compared to SOC alone for newly-diagnosed FLT3+ AML in the UK.MethodsA partitioned survival model was developed from a UK public healthcare system perspective to compare the cost-effectiveness of MIDO plus SOC and SOC over a lifetime horizon. The model included the following health states/partitions: induction, consolidation, monotherapy, complete remission (CR), relapse, stem cell transplantation (SCT), SCT recovery, and post-SCT recovery. Data on CR, overall survival, and adverse events were obtained from a Phase III clinical trial. Overall survival was extrapolated beyond the trial horizon using a ‘cure model’ approach and data from the Office for National Statistics. Utilities were identified via a systematic review. Routine care utilization was obtained from the National Institute for Health and Care Excellence single technology appraisal for azacitidine in AML (TA399). The costs of drugs and administration, adverse events, hospitalizations, physician visits, and end-of-life care were incorporated.ResultsIncremental life years (LYs) and quality-adjusted life years (QALYs) gained by patients on MIDO and SOC versus SOC were 1.67 and 1.47, respectively. At an incremental cost of £54,072 over a lifetime horizon, the ICER was £32,465 per LY and £36,826 per QALY. Sensitivity analyses were generally consistent with the base case findings.ConclusionsWith limited treatments in FLT3+ AML, MIDO represents a clinically significant advance in the management of newly-diagnosed AML. Using a threshold of £50,000 per QALY for end-of-life treatment, MIDO was shown to be a cost-effective option for newly-diagnosed FLT3+ AML.

Selective Inhibitors of Histone Deacetylases 1 and 2 Synergize with Azacitidine in Acute Myeloid Leukemia.

Acute myeloid leukemia (AML) is a heterogeneous group of hematopoietic stem cell disorders characterized by defects in myeloid differentiation and increased proliferation of neoplastic hematopoietic precursor cells. Outcomes for patients with AML remain poor, highlighting the need for novel treatment options. Aberrant epigenetic regulation plays an important role in the pathogenesis of AML, and inhibitors of DNA methyltransferase or histone deacetylase (HDAC) enzymes have exhibited activity in preclinical AML models. Combination studies with HDAC inhibitors plus DNA methyltransferase inhibitors have potential beneficial clinical activity in AML, however the toxicity profiles of non-selective HDAC inhibitors in the combination setting limit their clinical utility. In this work, we describe the preclinical development of selective inhibitors of HDAC1 and HDAC2, which are hypothesized to have improved safety profiles, for combination therapy in AML. We demonstrate that selective inhibition of HDAC1 and HDAC2 is sufficient to achieve efficacy both as a single agent and in combination with azacitidine in preclinical models of AML, including established AML cell lines, primary leukemia cells from AML patient bone marrow samples and in vivo xenograft models of human AML. Gene expression profiling of AML cells treated with either an HDAC1/2 inhibitor, azacitidine, or the combination of both have identified a list of genes involved in transcription and cell cycle regulation as potential mediators of the combinatorial effects of HDAC1/2 inhibition with azacitidine. Together, these findings support the clinical evaluation of selective HDAC1/2 inhibitors in combination with azacitidine in AML patients.

Clinical outcomes of AML patients treated with Azacitidine in Portugal: A retrospective multicenter study

Retrospective data was collected from 77 elderly acute myeloid leukemia (AML) patients treated with Azacitidine (AZA) and 50 elderly AML patients treated with intensive chemotherapy (IC) from 4 Portuguese Hospitals.Median OS was 10.6 months in those receiving AZA as 1st line. Response (overall response rate 44%) had a significant impact on overall survival (p=<0.0001). Median OS of the comparator IC cohort was significantly inferior to that observed in the cohort treated with AZA in first line (p=0.0104).These results support the efficacy of AZA in AML in the elderly in any line of treatment.

Gilteritinib (ASP2215), a Novel FLT3/AXL Inhibitor: Preclinical Evaluation in Combination with Azacitidine in Acute Myeloid Leukemia

Background FMS-like tyrosine kinase 3 (FLT3) is one of the most frequently mutated genes in acute myeloid leukemia (AML). Activating mutations in FLT3 such as internal tandem duplications (ITD) at the juxtamembrane domain are present in approximately 25-30% of newly diagnosed AML cases. Patients with AML harboring the FLT3-ITD mutation have poorer prognosis following the current induction chemotherapy treatment of cytarabine (AraC) and an anthracycline (daunorubicin [DNR] or idarubicin [IDR]). Azacitidine (Aza) is a treatment option for AML patients who are not eligible for intensive chemotherapy. Gilteritinib, a novel, small molecule inhibitor of the tyrosine kinases FLT3/AXL, is in Phase 3 development for treatment of FLT3 mutation-positive AML, including patients with FLT3-ITD mutations. In previous preclinical studies, gilteritinib has demonstrated superior antitumor effects when given in combination with AraC and either DNR or IDR compared with combination chemotherapy. Here, we report preclinical antileukemic activity of gilteritinib in combination with Aza against FLT3-ITD mutation-positive AML.Methods: The antitumor effects of gilteritinib alone and in combination with Aza were investigated in MV4-11 cells harboring the FLT3-ITD mutation. Apoptosis was detected using annexin V staining via flow cytometry; PARP cleavage was evaluated via Western blot analysis. Anti-apoptotic protein expression was evaluated by Western blot. Furthermore, the combination antitumor effects were evaluated in MV4-11-xenografted nude mice administered once-daily, oral gilteritinib at 3 mg/kg for 21 days alone and concomitantly with once-daily intravenous Aza at 3 mg/kg for 5 days. Pharmacokinetic parameters were also investigated in MV4-11 xenografted nude mice. Statistical differences in antitumor effects of combination therapy versus gilteritinib alone and combination therapy versus Aza alone were assessed on Day 21 using the Student's t-test.Results: Gilteritinib treatment for 48h resulted in an induction of apoptosis in MV4-11 cells as determined by an increase in annexin V-positive cells. When used in combination, gilteritinib augmented the Aza-induced increase in annexin V-positive cells. Gilteritinib also decreased the expression of anti-apoptotic proteins such as MCL-1, BCL2L10, and survivin, which are reported to be important in chemotherapy sensitivity, following 24h treatment. In combination with annexin results, an increase in PARP cleavage was also observed in MV4-11 cells following gilteritinib treatment; cells co-treated with gilteritinib and Aza showed a further increase in PARP cleavage. In mice xenografted with MV4-11 cells, oral gilteritinib (3 mg/kg/day) inhibited the tumor growth by 71%; Aza alone did not suppress tumor growth. The tumor volume in the doublet combination group (94% growth inhibition) was significantly smaller than in each single treatment group on Day 21 (Figure). No obvious influences on body weight, behavior, or diarrhea were noted in the combination group. Plasma concentrations for either gilteritinib or Aza were not considerably increased by their use in combination therapy when compared with the concentrations observed with single treatment.Conclusions: Gilteritinib treatment augmented Aza-induced apoptosis in part by reductions of anti-apoptotic protein expressions in vitro. In the non-clinical models used, gilteritinib, in combination with Aza, showed superior antitumor efficacy compared with each single agent alone. These findings support the development of gilteritinib in combination with Aza as a potential treatment of FLT3-ITD mutation-positive AML. [Display omitted] DisclosuresUeno:Astellas Pharma Inc: Employment. Mori:Astellas Pharma Inc: Employment. Kamiyama:Astellas Pharma Inc: Employment. Kaneko:Astellas Pharma Inc: Employment. Isshiki:Astellas Pharma Inc: Employment. Takeuchi:Astellas Pharma Inc: Employment.

Mechanisms of Resistance to Volasertib and Its Combination Effect with Azacitidine Inacute Myeloid Leukemia (AML)

Mechanisms of Resistance to Volasertib and Its Combination Effect with Azacitidine Inacute Myeloid Leukemia (AML)

Abstract 4724: Novel and selective inhibitors of histone deacetylases (HDAC) 1 and 2 synergize with DNA methyltransferase inhibitor azacitidine in acute myeloid leukemia (AML)

Abstract AML is a heterogeneous group of hematopoietic stem cell disorders characterized by defects in myeloid differentiation and increased proliferation of neoplastic hematopoietic precursor cells. Outcomes for patients with AML remain generally poor, highlighting the need for novel treatment options. Aberrant epigenetic regulation plays an important role in the pathogenesis of AML, and the DNA methyltransferase inhibitor VIDAZA™ (azacitidine) is approved by European Medicines Agency for the treatment of elderly patients with AML. Numerous clinical studies are ongoing to investigate the benefit of combining azacitidine with other investigational agents in AML. HDAC inhibitors are promising agents for the treatment of AML. Combination studies with HDAC inhibitors plus DNA methyltransferase inhibitors have suggested beneficial clinical activity in AML. However, the toxicity profiles of non-selective HDAC inhibitors in the combination settings limit the clinical benefit. In this work, we describe the preclinical development of highly selective HDAC inhibitors, which are hypothesized to have improved safety profiles than non-selective HDAC inhibitors, for combination therapy in AML. We demonstrate that selective HDAC1/2 inhibitors are highly effective and efficacious both as single agents and in combination with azacitidine in preclinical models of AML, including established AML cell lines, bone marrow samples freshly derived from AML patients and in vivo xenograft models of human AML. At the molecular level, gene expression profiling, DNA methylation mapping and chromatin immunoprecipitation analysis were performed on AML cells treated with either an HDAC1/2 inhibitor, azacitidine, or the drug combination. Molecular signatures and genes involved in myeloid cell differentiation, apoptosis and cell cycle arrest were identified as potential mediators of the combinatorial effects of HDAC1/2 inhibition with azacitidine. Together, these findings support the clinical evaluation of selective HDAC1/2 inhibitors in combination with azacitidine in AML patients. Citation Format: Chengyin Min, Steven N. Quayle, Pengyu Huang, Jeffrey R. Shearstone, Simon S. Jones, Min Yang. Novel and selective inhibitors of histone deacetylases (HDAC) 1 and 2 synergize with DNA methyltransferase inhibitor azacitidine in acute myeloid leukemia (AML). [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 4724.

Azacitidine in Acute Myeloid Leukemia with >30% Bone Marrow Blasts and

BackgroundIn the Phase III trial (AML-001; NCT01074047) that assessed azacitidine (AZA) vs conventional care regimens (CCR; intensive chemotherapy, low-dose cytarabine or best supportive care as preselected by the treating physician) in older patients (≥65 years) with newly diagnosed acute myeloid leukemia (AML) and >30% bone marrow (BM) blasts, AZA was associated with a clinically meaningful improvement in overall survival (OS) vs CCR.1Patient registry data, if performed with adequate quality control, can complement and be of additional value to data generated in clinical trials. The Austrian Azacitidine Registry (AAR; NCT01595295) was initiated to gain a comprehensive view of the use, safety and efficacy of AZA in patients with AML in a 'real world' clinical practice setting.2,3 No formal exclusion criteria existed, as the aim was to include all AML patients treated with AZA, irrespective of age, comorbidities, and/or previous lines of treatment.2,3Aims and methodsThe aim of this analysis was to assess the efficacy and safety of 1st -line AZA in patients with AML who were included in the AAR and who fulfilled the BM blast percentage and white blood cell (WBC) count entry criteria of the AML-001 trial (BM blasts >30% and WBC <15G/L). Outcomes of the subgroups of patients with poor-risk cytogenetics and with AML and myelodysplasia-related changes (AML-MRC) who received 1st -line AZA were also evaluated.ResultsA total of 95 patients were identified that fulfilled the BM blast percentage and WBC count entry criteria of the AML-001 trial (data cut-off June 19 2015). Apart from a higher proportion of AML-MRC and a lower proportion of AML-not otherwise specified (AML-NOS) within the AAR, baseline characteristics were comparable to those observed in AML-001 (i.e. age, BM blast percentage, gender, therapy-related AML, prior myelodysplastic syndrome (MDS), Eastern Cooperative Oncology Group Performance Status (ECOG PS), cytogenetic risk, transfusion dependence, hemoglobin level, WBC count, absolute neutrophil count, and platelet (PLT) count; Figure 1). Patient status at data cut-off, reasons for AZA discontinuation and treatment characteristics were also similar: median number of AZA cycles was 5 (1-51) and 6 (1-28) for the AAR and AML-001 trial, respectively (Figure 1). Patient outcome in terms of overall response according to International Working Group criteria4 (31.5 vs 29.0%), red blood cell (42.1 vs 38.5%) and PLT transfusion independence (34.5 vs 40.6%) did not differ significantly between the AAR and the AML-001 trial. Furthermore, median OS was highly concordant between the AAR and AML-001 overall (10.8 vs 10.4 months; Figure 2A) as well as for various patient subgroups: 12.2 vs 12.7 months for patients with AML-MRC (Figure 2B); 14.6 vs 14.1 months for patients with normal cytogenetics; 13.1 vs 13.0 months for patients with intermediate-risk cytogenetics; and 7.2 vs 6.4 months for patients with high-risk cytogenetics (Figure 2C). After 1 year, 47.4% of patients were still alive in the AAR cohort compared with 46.5% in the AML-001 trial (p=0.924). Event-free survival was 5.5 (range: 0-35.3) vs 6.7 (range: 5-8.8) months in the AAR and AML-001 trial, respectively. The 30-day (8.4 vs 6.6%; p=0.642) and 60-day (15.5 vs 16.2%; p=0.903) mortality rates were comparable. The incidence of febrile neutropenia (24.2 vs 28.0%) and Grade 3-4 treatment-emergent (TE) neutropenia were similar between the AAR and AML-001; however, higher rates of TE thrombocytopenia (47.4 vs 15.7%; p=0.023) and anemia (31.6 vs 26.3%; p<0.001) were observed in the AAR.ConclusionThese data confirm the safety and efficacy of AZA in a patient-population for whom this drug has not yet been approved, i.e. AML with more than 30% BM blasts and without leukocytosis. These data therefore complement prospective clinical trial data and support the role of well-designed and in-depth clinical registries.

Intensive Treatment Versus Azacitidine for Acute Myeloid Leukemia in Elderly: Retrospective Evaluation

Backround: Most of patients with acute myeloid leukaemia (AML) are elderly and older age is an negative prognostic factor for AML. There is no consensus about treatment of elderly patients with AML. In this study, we evaluated intensive treatment with cytosine arabinoside and idarubicine versus azacitidine treatment. Primary objectives were evaluation of disease free (DFS) and overall survival (OS), the rate of complete remission and the remission duration. Methods: 45 patients with AML were evaluated retrospectively. We examined peripheral blood smear, bone marrow aspirate and trephine, immunophenotyping and cytogenetic analysis, biochemical evaluation of renal and liver function and coagulation profile in pre-treatment period. Intensive treatment consisted of cytosine arabinoside 200 mg/m2/day for 7 days and idarubicin 12 mg/m2/ for 3 days. Bone marrow examination was done between 14-28 days for intensive treatment and 2-6 cyclus for azacitidine treatment. Consolidation treatment (1-3) was done after intensive treatment if the patients were remission. All patients were ≤ECOG 2. Growth factors were not routinely administered before, during or after chemotherapy. Statistical analyses, differences in baseline characteristics between groups were analyzed using the Student's t-test for continuous variables and differences in OS between groups were then analyzed using the likelihood ratio or log-rank tests. Table 1. The main properties of patients with elderly AML Treatment arm Mean age Sex M/F Leucocyte mean Hb gr/dl FAB (n) MDS history(n) LDH Complete remission Total 73±9 26/19 34.029 ±6870 8.53±1,2 M0:15, M1:6, M2:15,M4:4,M5:2 Yes:21 No:24 276±151 15 Intensive 72±7 18/10 44.176±12390 6.91±2 M0:6, M1:4, M2:12, M4:3, M5:1 yes: 14 299±101 13 Azacitidine 74±8 8/9 31.289±4013 8,95±1.6 M0:9, M1:2, M2:3, M4:1, M5:1 yes:7 256±72 2 Results: Total patient number were 45 and they were ≥ 65 years (yrs). Male/female ratio was 29/16. Two patients rejected leukemia treatment. One patient were not evaluated for treatment response. Intensive arm consisted of 26 patients and azacitidine arm 16 patients. Disease free survival and overall survival for intensive arm and azacitidine arm were 12,1±9,4, 16,7±22,4, respectively. The most importance factors were leucocyte counts, hb level. Picture 1-2: Disease free survival and overall survival for intensive arm and azacitidine arm Conclusions: These results showed that intensive treatment is more effective than azacitidine in elderly AML patients with ECOC≤2. There is need for large studies which include higher number of patients with AML in order to evaluate efficiency of intensive treatment. Figure 1. Figure 1. Figure 2. Figure 2. Disclosures No relevant conflicts of interest to declare.

Abstract B84: Novel and selective inhibitors of histone deacetylases (HDAC) 1 and 2 significantly enhance the activity of the DNA methyltransferase inhibitor azacitidine in acute myeloid leukemia (AML)

Abstract AML is a heterogeneous group of hematopoietic stem cell disorders characterized by defects in myeloid differentiation and increased proliferation of neoplastic hematopoietic precursor cells. There is a great need for novel approaches to treat AML due to limited improvements in the treatment of patients over the past several decades. Aberrant epigenetic regulation plays an important role in the pathogenesis of AML, and the DNA methyltransferase inhibitor azacitidine is approved for the treatment of myelodysplastic (MDS), which frequently progresses to AML, and is commonly used in AML patients. Numerous clinical studies are ongoing to investigate the benefit of combining azacitidine with other investigational agents in AML. HDAC inhibitors are promising agents for the treatment of AML. Selective HDAC inhibitors are predicted to reduce combination drug toxicity and other side effects observed with pan-HDAC inhibitors, while still enabling therapeutic benefits. In this work, we demonstrate that potent and selective inhibitors of HDAC1/2 are highly efficacious both as single agents and in combination with azacitidine in preclinical models of AML, including established AML cell lines and bone marrow samples freshly derived from AML patients. Combination treatment in vivo demonstrated good tolerability, and ongoing efficacy studies in AML xenograft models will be discussed. At the molecular level, gene expression profiling and DNA methylation mapping were performed on MV4-11 cells treated with an HDAC1/2 inhibitor, azacitidine, or the combination. Molecular signatures were analyzed by GSEA. Significantly more genes and signatures were upregulated than downregulated by the single agent and combination treatments, consistent with the transcription activation mechanism of these compounds. Signatures and genes involved in myeloid cell differentiation, apoptosis and cell cycle arrest were identified as potential mediators of the combinatorial effects of HDAC1/2 inhibition with azacitidine. Together, these findings support the clinical evaluation of selective HDAC1/2 inhibitors in combination with azacitidine in AML and potentially MDS patients. Citation Format: Chengyin Min, Steven N. Quayle, Pengyu Huang, Jeffrey R. Shearstone, Simon S. Jones, Min Yang. Novel and selective inhibitors of histone deacetylases (HDAC) 1 and 2 significantly enhance the activity of the DNA methyltransferase inhibitor azacitidine in acute myeloid leukemia (AML). [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2015 Nov 5-9; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl 2):Abstract nr B84.

Abstract 5372: Novel and selective inhibitors of histone deacetylases (HDAC) 1 and 2 significantly enhance the activity of the DNA methyltransferase inhibitor azacitidine in acute myeloid leukemia (AML)

Abstract AML is a heterogeneous group of hematopoietic stem cell disorders characterized by defects in myeloid differentiation and increased proliferation of neoplastic hematopoietic precursor cells. There is a great need for novel approaches to treat AML due to limited improvements in the treatment of patients over the past several decades since the development of cytarabine and daunorubicin combination therapy. Aberrant epigenetic regulation plays an important role in the pathogenesis of AML, and the DNA methyltransferase inhibitor azacitidine is approved for the treatment of myelodysplastic (MDS) which frequently progresses to AML. Numerous clinical studies are ongoing to investigate the benefit of combining azacitidine with other investigational agents in AML. HDAC inhibitors are emerging as promising agents for the treatment of AML. Selective HDAC inhibitors are predicted to reduce the combination drug toxicity and other side effects observed with non-selective HDAC inhibitors, while also realizing beneficial therapeutic effects. One example is ricolinostat (ACY-1215), a first-in-class orally available HDAC inhibitor that is 11-fold selective for HDAC6, synergizes with proteasome inhibitors (Santo, et al, Blood, 2012) and immunomodulatory agents (Quayle, et al, ASH, 2013) in preclinical models of B-cell malignancies, which has thus far demonstrated an improved safety and tolerability profile in Phase I trials in multiple myeloma (Raje, Haematological, 2014, Suppl 1). In this work, we evaluated the efficacy of azacitidine in combination with selective inhibitors of either HDAC1/2, HDAC3 or HDAC6 on AML cells. Comparison of the panel of selective HDAC inhibitors demonstrated that HDAC1/2 inhibition is sufficient to reduce cell viability, induce differentiation, arrest cell cycle progression and initiate apoptosis in multiple AML cell lines. Selective inhibition of HDAC3 induced differentiation yet had no effect on cell cycle progression or apoptosis, while selective inhibition of HDAC6 had no effect on differentiation, cell cycle arrest or apoptosis in these cells. Furthermore, combining HDAC1/2 inhibition with azacitidine led to significantly enhanced induction of differentiation and apoptosis, and decreases in AML cell viability compared to either agent alone. Ongoing studies exploring the molecular mechanism underlying the activity of selective HDAC1/2 inhibitors, as well as the activity of combination treatment with azacitidine in primary AML cells and animal models of AML, will be discussed. Together, these findings provide support for the clinical evaluation of selective HDAC1/2 inhibitors in combination with azacitidine in AML and potentially MDS patients. Citation Format: Chengyin Min, Steven N. Quayle, David Tamang, Simon S. Jones, Min Yang. Novel and selective inhibitors of histone deacetylases (HDAC) 1 and 2 significantly enhance the activity of the DNA methyltransferase inhibitor azacitidine in acute myeloid leukemia (AML). [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 5372. doi:10.1158/1538-7445.AM2015-5372

Azacitidine in Older Patients with Acute Myeloid Leukemia (AML) and Adverse Karyotype. Subanalisis from the Alma Study

BackgroundAdverse karyotype and age are associated with poor prognosis in older AML patients (pts). Although complete remission (CR) can be achieved with intensive chemotherapy (IC) in pts with adverse cytogenetics, overall survival (OS) and leukemia free-survival (LFS) are poor (Knipp S, et al. Cancer 2007). In addition, low doses of ARA-C (LDAC) did not offer survival benefit in older pts with poor cytogenetics as compared to hydroxyurea and best supportive care (BSC) (Burnett A, et al. Cancer 2007). Azacitidine has shown a survival advantage in older pts with newly diagnosed AML in a recent phase 3 trial, as compared to conventional care regimens (BSC/LDAC/IC)(Dombret H, et al. EHA 2014).AimTo evaluate the role of azacitidine and factors associated with OS in pts with newly diagnosed AML and adverse karyotype from the ALMA study (Ramos F, et al. Blood 2012;120:abstract 3593).MethodsRetrospective, multicenter study, of pts with newly diagnosed AML and adverse karyotype who received front-line azacitidine in Spain. Response to azacitidine was evaluated by ELN-2010 criteria. Overall survival was evaluated by Kaplan-Meier method and log-rank test.ResultsThirty-nine pts were identified. Median age: 71y (52-83). Baseline characteristics are shown in table 1. All pts received azacitidine (75 mg/m2 sc x7 days) as first line treatment. Median time from AML diagnosis to therapy was 16 days (1-88). 56% of pts had bone marrow (BM) blasts >30% at diagnosis (median: 32%; range: 20-90). Five out of 39 (13%) pts had leucocyte count (WBC) >15x109/L and 20/39 (51%) had ECOG performance status >1. Complex karyotype (CK) and monosomal karyotype (MK) was present in 18/39 pts each (46%). Within the subset showing CK, 14/18 (78%) had MK. Complete remission (CR) and CRi was 23.1% and 5.1% respectively (ORR=28.2%). Median courses of therapy to best response: 3 (1-11). After 17m median follow-up, median OS (95% CI) was 7m (3.1-8.8). Estimated 1-year survival was 29.8%. There were no differences in median OS in pts with MK vs. rest of pts with CK (median OS 9m [95% CI: 5.3-12.6] vs. 6.5m [3.1-8.8], respectively; p=0.854). Monosomal karyotype, CK with >5 abnormalities, BM blasts >30% and ECOG status >1 did not achieve statistically significance in multivariate analysis. Only WBC at baseline (>10x109/L or >15x109/L; threshold not relevant) had an impact on OS in both univariate (3m [95% CI: 4.9-13] vs. 9m [4.9-13] if WBC <10x10e /L; p=0.014) and multivariate analysis (HR=3.3, [95% CI 1.1-9.5], p=0.025; Table 2). Most frequent causes of death were disease progression and infection (82%).Table 2Multivariate analysis for survivalParameterHR95% CIp-valueWBC >10x109/L3.341.17-9.580.025BM blast >30%1.080.46-2.540.855MK0.950.33-2.740.919CK1.610.58-4.510.361ECOG >11.840.81-4.170.144ConclusionAlbeit retrospective and non-comparative, azacitidine seems to improve median and 1y survival as compared to historic AML data in pts with adverse cytogenetics. An elevated WBC >10x109/L at diagnosis was the only parameter associated to adverse outcome in this set of pts.Table 1Baseline characteristicsAge, median (range)71 (52-83)ECOG performance status 0-1 2-319 (48.7%) 20 (51.3%)WBC (x109/L), median (range) WBC >10x109/L, N (%)2.2 (0.9-89.2) 5 (12.8%)BM blasts, median; (range) BM blasts >30%, N (%)32 (20-90) 22(56.4%)Complex karyotype (CK), N (%)18 (46.2)Monosomal karyotype (MK), N (%)18 (46.2%)Both CK and MK, N (%)14/18 (77.8%)Prior MDS, N (%)11 (28.2%)Karyotype, N (%) Complex >3 Complex >5 Chrom 7 abn Chrom 3 abn -7 only Chrom 5 and 7 abn Chrom 5 abn Other6 (15.4%) 11 (28.2%) 4 (10.3%) 4 (10.3%) 8 (20.5%) 2 (5.1%) 2 (5.1%) 2 (5.1%)*Excludes pts with chromosome 5 and 7 abnormality DisclosuresFalantes:Celgene: Consultancy. Off Label Use: Use of azacitidine in AML with blast count >30% This paper deals with both on-label and off-label use of azacitidine in AML. Xicoy:Celgene: Honoraria. Ramos:Celgene: Honoraria, Membership on an entity’s Board of Directors or advisory committees.

Overall Survival in Older Patients with Newly Diagnosed Acute Myeloid Leukemia (AML) with >30% Bone Marrow Blasts Treated with Azacitidine By Cytogenetic Risk Status: Results of the AZA-AML-001 Study

Overall Survival in Older Patients with Newly Diagnosed Acute Myeloid Leukemia (AML) with >30% Bone Marrow Blasts Treated with Azacitidine By Cytogenetic Risk Status: Results of the AZA-AML-001 Study

Azacitidine in Acute Myeloid Leukemia: Comparison of Patients with AML-MRF Vs AML-NOS Enrolled in the Austrian Azacitidine Registry

Azacitidine in Acute Myeloid Leukemia: Comparison of Patients with AML-MRF Vs AML-NOS Enrolled in the Austrian Azacitidine Registry

Dual epigenetic targeting with panobinostat and azacitidine in acute myeloid leukemia and high-risk myelodysplastic syndrome

Therapeutic options are limited for elderly patients with acute myeloid leukemia (AML). A phase Ib/II study was undertaken to evaluate the maximum-tolerated dose (MTD) and preliminary efficacy of the pan-histone deacetylase inhibitor panobinostat (LBH589) in combination with azacitidine in patients with AML or high-risk myelodysplastic syndrome (MDS) naïve to intensive chemotherapy. Thirty-nine patients (AML=29, MDS=10) received azacitidine 75 mg/m2 subcutaneously (days 1–5) and oral panobinostat (starting on day 5, thrice weekly for seven doses) in 28-day cycles until toxicity or disease progression. Dose-limiting toxicities during the phase Ib stage were observed in 0/4 patients receiving 10 mg panobinostat, in 1/7 patients (fatigue) receiving 20 mg, in 1/6 patients (fatigue) receiving 30 mg and in 4/5 patients (fatigue, syncope, hyponatremia and somnolence) receiving 40 mg. In phase II, an additional 17 patients received panobinostat at a MTD of 30 mg. The overall response rate (ORR=CR+CRi+PR) in patients with AML was 31% (9/29) and that in patients with MDS was 50% (5/10). After a median follow-up of 13 months, the median overall survival was 8 and 16 months in patients with AML and MDS, respectively. Increased histone H3 and H4 acetylation was a useful early biomarker of clinical response. Combining panobinostat with azacitidine was tolerable and clinically active in high-risk MDS/AML patients, warranting further exploration.

Azacitidine Treatment For Patients With Myelodysplastic Syndromes and Acute Myeloid Leukemia Harboring Chromosome 3q Abnormalities

BackgroundKaryotype is one of the key prognosis factors in myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). Chromosome 3q abnormalities, including aberrant expression of EVI-1, represent a small subset of patients and are associated with a poor outcome in both MDS and AML patients treated with conventional treatment. Azacitidine is the current standard of care for high-risk MDS and is also active in AML. Given that AZA may provide responses in patients with poor chances of response to conventional treatment as patients with monosomy 7 and given the strong epigenetic modifications related to EVI-1 dysregulation, AZA may represent an interesting option for patients with 3q abnormalities. Therefore, we analyzed the outcome of patients with Chromosome 3q abnormalities treated with Azacitidine. Patients and methodsThis is a retrospective multicenter study. Patients were included if 1/ Diagnosis of MDS, CMML, or AML, including therapy related neoplasms 2/ harbored chromosome 3q abnormalities and/or EVI-1 overexpression by PCR 3/ received at least one cycle of azacitidine for either frontline or relapse treatment. Response was evaluated according IWG 2006 criteria. This cohort of patients was compared to 406 high risk MDS and AML patients without 3q abnormalities included in the French AZA compassional program. ResultsA total of 184 patients were analyzed. Median age was 64 years. According to WHO classification, patients presented RA/RCMD/RAEB-1 28% of cases, RAEB-2/CMML-2 31% of cases, and AML 41% of cases. Median bone marrow blast count was 15%. Cytogenetics were inv(3)/t(3;3) 22%, del(3q)/monosomy 3 26%, t(3q26;x) 20%, EVI-1 overexpression without 3q abnormality 14%, t(3q21;x) 4% and other 3q abnormalities 14%. 58% of patients had complex karyotype. Azacitidine was used frontline for 67% of patients, 33% being previously treated with intensive chemotherapy. Median number of cycle of azacitidine was 5 (1-33). Overall response rate was 47% (Complete or Partial response 27%). 31 patients (25% of patients younger than 70y) bridged to allogeneic transplantation. With a median follow-up of 16 months, median overall survival was 10.5 months. Younger age (below 65y, 13m vs 10m, p=0.052), low bone marrow blast count (below 20%, 13m vs 8m, p=0.001), presence of t(3q21;x) (74 vs 10 months, p=0.008), few cytogenetic abnormalities (below 3, 14m vs 9m, p=0.003), and use of Azacitidine frontline (13m vs 8 m, p=0.029) were associated with a better survival. Long term survival remains limited with a 3 years survival probability below 10%. Interestingly, baseline characteristics and prognosis of patients with EVI-1 overexpression without 3q cytogenetic abnormality were comparable with patients with 3q26 cytogenetic abberation. Then, we compared our cohort with MDS/AML patients without 3q abnormalities, their overall response rate was 30% (41% for HR MDS, 15% for AML, including 11% CR/PR), and median OS was 10.5 months (15 months for HR MDS and 7 months for AML). When we merged the 2 cohorts and performed multivariate analyses, presence of 3q abnormality had no prognosis impact on either response or survival. ConclusionAzacitidine seems to limit the dismal outcome associated with 3q abnormalities and thus represents a good alternative to conventional chemotherapy including for patients eligible for allogeneic transplantation. Moreover, our data showed that 3q group is heterogeneous with a favorable outcome for the small subset of patients with 3q21 abnormalities. Disclosures:Prebet:CELGENE: Honoraria. Off Label Use: Use of azacitidine in acute myeloid leukemia.

Possible Biomarkers To Predict Response In Patients With Myelodysplastic Syndromes (MDS) Or Acute Myeloid Leukemia (AML) Treated With 5-Azacitidine

IntroductionAzacitidine (aza) was the first drug to demonstrate a survival benefit for MDS patients (pts) in a randomized trial [Fenaux, Lancet Oncol 2009]. However, only about half of the pts respond and even after achieving complete remission (CR) and with sustained treatment, pts usually relapse. To date, limited data is available on prognostic factors influencing response. Therefore, until now we have analyzed 71 pts with MDS or AML, treated with at least 3 cycles of aza, to identify prognostic indicators that might help to improve treatment decisions. Patients and Methods71 cases were included and characterized by cytogenetics and various molecular assays including sensitive next-generation sequencing for mutations in ASXL1, DNMT3A, EZH2, FLT3-LM, IDH1, IDH2, KRAS, MLL-PTD, NRAS, RUNX1, SF3B1, SRSF2, TET2, and TP53. Median age was 71 (50-84) years. 38 pts had MDS (8 RAEB I, 26 RAEB II, 4 RCMD), 28 had AML (6 dysplastic, 16 sAML/MDS, and 6 tAML/MDS), and 5 pts had MDS/MPD. The IPSS [Greenberg, Blood 1997] was low in one, intermediate (int) 1 in 4, int 2 in 26, and high in 14 pts. Regarding cytogenetic risk groups we found 39 low, 11 int and 20 high risk pts according to IPSS and 49 int vs 21 high risk pts according to AML criteria [Grimwade, Blood 2010].Median time from diagnosis to treatment was 122 days (0-2348). With a median follow up of 1091 days from start of treatment median survival was 530 days (95% CI 412-874). Pts received a median number of 6 cycles (3-43). 12 pts have received allogeneic transplantation after aza treatment and were censored at that date. To assess the impact of biomarkers, Kaplan-Meier curves and Cox models were estimated from the first day of treatment. Variables were considered for multivariate analysis if the univariate p value was <0.1. ResultsRegarding cytogenetics, 47% of pts exhibited a normal karyotype, 17% had chromosome 7 abnormalities, 13% of karyotypes included del5q, 13% +8, 7% del20q, and 13% were complex. All except one case showed molecular aberrations. The most frequently mutated gene was ASXL1 (42%), followed by RUNX1 (38%), SRSF2 (38%), TET2 (30%), TP53 (18%), DNMT3A (16%), IDH2 (13%), NRAS (13%), EZH2 (12%), SF3B1 (11%), IDH1 (9%), FLT3-ITD (8%), MLL-PTD (7%), and KRAS (6%).Responses were observed in 33 pts (46%; 4 CR, 3 marrow CR with hematological improvement, 8 partial remission, and 18 HI). When cytogenetic abnormalities were examined, responses were seen in 45% of pts with normal karyotype, in 50% of pts with chromosome 7 aberrations, in 33% with del5q, in 67% with +8, in 56% with complex karyotype, and in all 5 cases with del20q (p=0.02).Regarding molecular abnormalities response rate was highest in pts with mutations in NRAS (67%) and IDH2 (63%), followed by RUNX1 (56%), ASXL1 (54%), SF3B1 (43%), TP53 (42%), SRSF2 (36%), TET2 (30%), DNMT3A (30%), MLL-PTD (25%), KRAS (25%), FLT3-ITD (20%), IDH1 (17%), and EZH2 (13%). However none of these mutations had a significant impact on response rate, possibly due to limited statistical power. The only p-value <0.1 was seen for EZH2 (p=0.08).Finally we analyzed the influence of prognostic markers on survival in aza treated pts. In univariate analysis potential candidate variables were: TP53 (p=<0.01, HR: 3.63), cytogenetic group according to AML (p=0.02, HR 2.02) or IPSS (p=0.07, HR (high-low) 1.92, (int-low) 0.86), complex karyotype (p<0.01, HR: 3.17), age [yrs] (p=0.01, HR: 1.08), Hb [g/dl] (p=0.078, HR: 0.836), time to start of aza [yrs] (p=0.01, HR: 0.753), MLL-PTD (p=0.07, HR: 2.87), and AML vs MDS (p=0.01, HR: 2.13).In multivariate analysis TP53 retained a significant influence on survival (HR: 4.99 [CI: 2.20-11.31], p<0.01), accompanied by age (HR:1.10 [CI: 1.03-1.16], p<0.01), Hb (HR: 0.69 [CI: 0.52-0.93], p=0.01), AML vs. MDS (HR: 2.42 [CI: 1.21-4.84], p=0.01), and time to start of aza (HR: 0.70 [CI: 0.52-0.94], p=0.02).TP53 mutations negatively influenced survival, although response rates were comparable to other pts. Response duration was often short. However, pts might still benefit from aza treatment, if combination therapy (e.g. lenalidomide in del5q and TP53 positive pts) or allogeneic transplantation consolidate and prolong treatment results ConclusionAfter the analysis of 71 pts, TP53 mutations represent the only somatic mutations with a significant negative impact on survival in aza treated pts. The small group of pts with del20q might have higher response rates. The analysis of further pts is ongoing. Disclosures:Kuendgen:Celgene: Honoraria, Research Funding. Off Label Use: Azacitidine in AML >30% marrow blasts. Lauseker:Celgene: Honoraria. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Alpermann:MLL Munich Leukemia Laboratory: Employment. Albuquerque:MLL Munich Leukemia Laboratory: Employment. Kohlmann:MLL Munich Leukemia Laboratory: Employment. Schnittger:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Gattermann:Novartis: Honoraria, Research Funding; Celgene: Honoraria, Research Funding. Germing:Celgene: Honoraria, Research Funding. Götze:Celgene Corp: Honoraria.

Azacitidine With Or Without Entinostat For The Treatment Of Therapy-Related Myeloid Neoplasm: Further Results Of The E1905 North American Leukemia Intergroup Study

▪ BackgroundTherapy-related myeloid neoplasm (tMN) includes t-myelodysplasia (tMDS) and t-acute myeloid leukemia (tAML) and are serious late effects of the treatment of cancer. Prognosis of tMN is poor, related to the increased frequency of adverse cytogenetics and other clinical features which predict poor response to conventional treatment. Over the last years, azacitidine (AZA) has become the standard of treatment for high risk MDS (Silverman, JCO 2002; Fenaux, Lancet Oncol 2009) and has shown efficacy in AML. AZA represents an interesting option for patients with tMN considering its safety profile and its efficacy in poor prognosis subgroups of apparently de novo MDS patients including those with monosomy 7. Most prospective trials of AZA have excluded patients with tMN. Most tMN data are retrospective or registry studies (Bally, Leuk Res 2013). This abstract presents the results of 47 t-MN patients prospectively enrolled as a specific cohort in the E1905 study. MethodsE1905 study is a randomized phase 2 study from the North American Leukemia Intergroup (NCT00313586, Prebet , ASH 2010) testing 10 days of AZA (50mg/m2/d s.c.) vs. 10 days of AZA + the histone deacetylase inhibitor entinostat (4 mg/m2/d PO days 3 and day 10). 6 cycles of treatment were planned; responding patients could receive up to 24 cycles. MDS, CMML, and AML with myelodysplasia-related changes were included. Patients with tMN were subsequently accrued as a separate cohort after amendment of the protocol. Response was assessed using IWG 2000 criteria (Cheson et al, Blood 2000); the primary endpoint of the overall trial was achievement of a normal hemogram in 25% of treated patients in either treatment arm. ResultsA total of 47 patients were included. Median age was 70 years (39y-83y), 45% male, and 94% of patients had ECOG PS 0-1. 29 patients could be subclassified as t-MDS and 18 as t-AML. At inclusion, median peripheral blood counts were: neutrophils 1.0 G/l, Platelets 35 G/L, Hemoglobin 9.2 g/l, peripheral blood blasts 0%, marrow blasts 14.0%. 68% of patients were RBC transfusion dependent and 40% platelet transfusion dependent. As expected, the cytogenetic evaluation showed a high frequency of unfavorable risk cytogenetics (74%) as compared to normal or intermediate risk cytogenetics (26%). Baseline characteristics were not statistically different between the 2 arms. 24 patients were treated with AZA monotherapy and 23 with AZA+entinostat. The median number of administered cycles was 4 and was significantly higher in patients treated with AZA monotherapy (6 cycles vs.3 cycles, p=0.008). 8 patients in the combination arm and 1 patient in the AZA monotherapy arm died of infection or hemorrhage before cycle 3. In an intent to treat analysis, overall response rates (CR, PR, or trilineage Hematologic improvement) were 11/24 (46%) in AZA monotherapy (95% CI 26 – 67%) and 4/23 (17%) in the combination arm (95% CI 5 – 39%, p=0.06 comparing the two arms). Median overall survival in the two arms were 12.8 months and 5.7 months (p=0.008). ConclusionsIn this group of very high risk patients with therapy-related myeloid neoplasms, the use of the novel 50 * 10 schedule of azacitidine monotherapy appears effective, with response rates comparable to those for patients with de novo MDS/AML treated on the same protocol (74 pts, 40% with unfavorable cytogenetics, ORR=32%, median OS=18 months). Because there are no prospective data examining the approved dose schedule of AZA (75 mg/m2/day * 7 days), it is not clear if this surprisingly high response rate derives from the current extended schedule of lower dose AZA, or would be true with standard dose AZA as well. This high response may enable many of these patients to proceed to allogeneic stem cell transplant. Entinostat combined with azacitidine at the dose and schedule applied in E1905 does not appear to be effective and tolerable as compared to azacitidine alone. Disclosures:Prebet: CELGENE: Honoraria. Off Label Use: Use of azacitidine in acute myeloid leukemia. Gore:CELGENE: Equity Ownership, Research Funding.

P-192 Efficacy of azacitidine in acute myeloid leukemia: A retrospective study

P-192 Efficacy of azacitidine in acute myeloid leukemia: A retrospective study

Komplete Remission einer relapsierten akuten myeloischen Leukämie nach einem einzigen Therapiezyklus Azacytidin

A 75-year-old female patient presented with late relapse of acute myeloid leukemia (AML). She received a single cycle of azacitidine before refusing further treatment. Around 6 weeks after this single azacitidine cycle, complete remission-according to international working group criteria-was observed with continuous improvement in peripheral blood counts to normal values, transfusion-independence, normal blast count (< 5 %) with normal morphology and flow cytometry, as well as a normal bone marrow karyotype and no dysplastic stigmata suggestive of a coexisting myelodysplastic syndrome. The patient also showed a pronounced improvement in performance status. Seven months later a second relapse occurred, followed by one additional azacitidine cycle that showed only a transient and a minor increase in thrombocytes and granulocytes, corresponding to an international working group nonresponse. As azacitidine treatment was interrupted after a single cycle, this case gives insight into the kinetics of response. The lack of response to azacitidine in AML after the second relapse suggests that azacitidine administration should be maintained after response.