Refractory Cohort Research Articles

Long-term efficacy and safety of tofacitinib in patients with ulcerative colitis: 3-year results from a real-world study.

The efficacy and safety of tofacitinib for the treatment of refractory ulcerative colitis (UC) has been demonstrated in clinical trials. Although, a series of reports with real-world evidence of its short-term efficacy and safety profiles have already been published, reports of long-term real-world data have been limited. We aimed to show our 3-year evidence on the clinical use of tofacitinib for the treatment of UC, focusing on its efficacy and safety profiles. A retrospective observational study was conducted on patients who started tofacitinib for active refractory UC at our hospital. The primary outcome was the retention rate until 156 weeks after initiating tofacitinib. The secondary outcomes were short-term efficacy at 4, 8, and 12 weeks; long-term efficacy at 52, 104, and 156 weeks; prognostic factors related to the cumulative retention rate; loss of response; and safety profile, including adverse events. Forty-six patients who were able to be monitored for up to 156 weeks after tofacitinib initiation, were enrolled in this study. Continuation of tofacitinib was possible until 156 weeks in 54.3%, with > 50% response rates and > 40% remission rates. Among patients in whom response or remission was achieved and tofacitinib was deescalated after 8 weeks of induction treatment, 54.3% experienced relapse but were successfully rescued by and retained on reinduction treatment, except for 1 patient. No serious AEs were observed in the study. Tofacitinib is effective and safe as long-term treatment in a refractory cohort of UC patients in real-world clinical practice.

Phase I Trial of Brentuximab Vedotin Plus Cyclosporine in Relapsed/Refractory Hodgkin Lymphoma

IntroductionBV is an antibody-drug conjugate directed against CD30 and is safe and effective in relapsed/refractory (R/R) Hodgkin lymphoma (HL). Most patients with r/r cHL respond well to BV monotherapy; however, the large of majority of them eventually progress on this drug, and BV-resistant HL remains an unmet need. Preclinical data suggest that BV resistance is mediated at least in part by increased drug efflux associated with increased expression of multidrug resistance pump 1 (MDR1) while CD30 expression appears to be preserved in BV resistant cell lines and patient samples. We conducted a phase 1 study evaluating BV + cyclosporine (CsA) in BV-refractory HL and previous reported results in the dose finding cohort. Here we report the final results from the phase 1 study. MethodsThis was a phase I trial of BV + CsA in patients with r/r HL with dose-finding and dose escalation cohorts. Eligibility criteria included age ≥ 18 years with r/r HL after at least 1 prior line of therapy. Treatment consisted of 1.8 mg/kg BV intravenously on day 1 and CsA 5 to 7.5 mg/kg PO twice daily on days 1 to 5; cycles were 21 days long. Patients in the expansion cohort had to have cHL refractory to BV. The primary objectives were to evaluate safety and tolerability and to determine MTD of BV + CsA; the secondary objective was to determine efficacy of this combination. Results29 patients were enrolled onto the study, 14 in the dose finding cohort and 15 in the dose expansion BV refractory cohort. Study accrual was terminated before target accrual due to unacceptable toxicity. 62% of patients were male, and the median age was 36 years (range: 20-69). The median number of prior therapies was 5 (range: 3-12); all patients had prior BV, and 93% had PD-1 directed therapy, and 93% were BV-refractory. Of 22 evaluable patients, CR rate was 27% and ORR 64%; median DOR 4.9 months. Treatment-related deaths occurred in 3 patients, and another patient died during cycle 1 due to cardiac arrest deemed unlikely related to be protocol therapy. All grade GI toxicity was seen in 90% of patients (G3+ in 24%); other common adverse events were nausea (90%), hypertension (90%), nausea (90%), hypertension (90%), anemia (86%), fatigue (76%), neutropenia (76%), leukopenia (76%), hypomagnesemia (76%), anorexia (66%), and hyponatremia (66%). DiscussionBV + CsA demonstrated modest activity in BV-refractory r/r HL; however, toxicity is substantial.

Efficacy and safety of combination therapy with binimetinib, encorafenib, and cetuximab for BRAF non-V600E mutated metastatic colorectal cancer: Results from a phase 2 BIG BANG trial (EPOC1703).

3585 Background: BRAF mutations which are found in 8-12% of metastatic colorectal cancer (mCRC) can be classified into three groups; Class 1 and 2 tumors do not respond to anti-EGFR antibody therapy because of the RAS independent activity, while previous studies suggested potential anti-tumor activity of anti-EGFR antibody for class 3 tumor. Combination therapy with binimetinib, encorafenib, and cetuximab showed the substantial efficacy for BRAF V600E mutated mCRC in the BEACON CRC trial, however, the clinical activity of these triplet therapy for BRAF non-V600E mutated mCRC is unknown. Here, we conducted a multicenter phase 2 trial to assess the efficacy and safety of combination therapy with binimetinib, encorafenib, and cetuximab in patients with BRAF non-V600E mutated mCRC. Methods: We enrolled patients with RAS wild-type and BRAF non-V600E mutated mCRC, refractory or intolerant to at least one fluoropyrimidine-based chemotherapy, and no prior history of anti-EGFR antibody (primary analysis cohort) or refractory to prior anti-EGFR antibody (anti-EGFR antibody refractory cohort). Enrolled patients receive binimetinib (45 mg BID), encorafenib (300 mg QD), and cetuximab (initially 400 mg/m2 and subsequently 250 mg/m2, weekly) until disease progression or unacceptable toxicity. The primary endpoint was investigator-assessed confirmed objective response rate (ORR) in the primary analysis cohort with sample size of 21 patients. Results: Between May 2018 and March 2023, 12 and 20 patients were enrolled in the primary analysis cohort and the anti-EGFR antibody refractory cohort, respectively (same order in the following abstract). 7 and 19 patients had a history of ≥ 2 lines of previous chemotherapy, respectively. The most frequent mutation overall was BRAF D594G (n=14, 43.8%). There were each 2 responders in both cohorts, resulting in 16.7% (95%CI, 2.1-48.4%) and 10.0% (95%CI, 1.2-31.7%) of confirmed ORR, respectively. Among 7 patients harboring class 1 or 2 tumors in both cohorts combined, there were 2 responders (ORR 28.6%). Median progression-free survival was 3.3 months and 3.0 months, respectively. Grade 3 or higher adverse events occurred in 4 and 10 patients, respectively, and no new safety signals were identified. Conclusions: The combination therapy with binimetinib, encorafenib, and cetuximab showed modest efficacy for BRAF non-V600E mutated mCRC, with a manageable safety profile, although there was not enough statistical power due to slow accrual. Circulating-tumor DNA analyses at the timepoint of before and after treatment are ongoing. Clinical trial information: UMIN000031857. [Table: see text]

Oral decitabine and cedazuridine plus venetoclax for older or unfit patients with acute myeloid leukaemia: a phase 2 study

Hypomethylating agents combined with venetoclax are effective regimens in patients with acute myeloid leukaemia who are ineligible for intensive chemotherapy. Decitabine and cedazuridine (ASTX727) is an oral formulation of decitabine that achieves equivalent area-under-curve exposure to intravenous decitabine. We performed a single centre phase 2 study to evaluate the efficacy and safety of ASTX727 plus venetoclax. This study enrolled patients with newly diagnosed (frontline treatment group) acute myeloid leukaemia who were ineligible for intensive chemotherapy (aged ≥75 years, an Eastern Cooperative Oncology Group [ECOG] performance status of 2-3, or major comorbidities) or relapsed or refractory acute myeloid leukaemia. Being aged 18 years or older and having an ECOG performance status of 2 or less were requirements for the relapsed or refractory disease treatment cohort, without any limits in the number of previous lines of therapy. Treatment consisted of ASTX727 (cedazuridine 100 mg and decitabine 35 mg) orally for 5 days and venetoclax 400 mg orally for 21-28 days in 28-day cycles. The primary outcome was overall response rate of ASTX727 plus venetoclax. Living patients who have not completed cycle one were not evaluable for response. Safety was analysed in all patients who started treatment. This study was registered on ClinicalTrials.gov (NCT04746235) and is ongoing. The data cutoff date for this analysis was Sept 22, 2023. Between March 16, 2021, and Sept 18, 2023, 62 patients were enrolled (49 frontline and 13 relapsed or refractory) with a median age of 78 years (IQR 73-82). 36 (58%) were male; 53 (85%) were White, 4 (6%) Black, 2 (3%) Asian and 3 (5%) other or did not answer. 48 (77%) of 62 patients were European LeukemiaNet 2022 adverse risk, 24 (39%) had antecedent myelodysplastic syndromes, 12 (19%) had previously failed a hypomethylating agent, ten (16%) had therapy-related acute myeloid leukaemia, and 11 (18%) had TP53 mutations. The median follow-up time was 18·3 months (IQR 8·8-23·3). The overall response rate was 30 (64%) of 47 patients (95% CI 49-77) in frontline cohort and six (46%) of 13 patients (19-75) in relapsed or refractory cohort. The most common grade 3 or worse treatment-emergent adverse events were febrile neutropenia in 11 (18%) of 62 patients, pneumonia in eight (13%), respiratory failure in five (8%), bacteraemia in four (6%), and sepsis in four (6%). Three deaths occurred in patients in remission (one sepsis, one gastrointestinal haemorrhage, and one respiratory failure) and were potentially treatment related. ASTX727 plus venetoclax is an active fully oral regimen and safe in most older or unfit patients with acute myeloid leukaemia. Our findings should be confirmed in larger multicentric studies. MD Anderson Cancer Center Support Grant, Myelodysplastic Syndrome/Acute Myeloid Leukaemia Moon Shot, Leukemia SPORE, Taiho Oncology, and Astex Pharmaceuticals.

P716 Efficacy and safety of upadacitinib during induction in Crohn’s disease: Real-world experience

Abstract Background Upadacitinib is a selective JAK1 inhibitor that has recently been approved for treatment of moderate-severe Crohn’s disease, with Phase III clinical trials showing positive efficacy and safety profiles. Our aim was to evaluate the real-world experience of upadacitinib in a refractory cohort of Canadian patients with Crohn’s disease. Methods This was a two-centre retrospective study looking at 12-week induction data for patients with active Crohn’s disease from McGill University Health Centre and Hamilton Health Sciences. The primary outcome was clinical remission at 12 weeks, with secondary outcomes including clinical response, biochemical remission, and biochemical response. Clinical remission was defined as a Harvey-Bradshaw index (HBI) < 5. Clinical response was defined as an HBI reduction of ≥ 3. Biochemical remission was defined as a c-reactive protein (CRP) < 5 mg/L and/or fecal calprotectin (FCP) < 250 μg/g. Biochemical response was defined as a reduction of CRP or fecal calprotectin by 50% from baseline. These parameters were all evaluated at 8 and 12 weeks. Adverse events were summarized for patients who had follow up data available and included in the efficacy analysis. Results There were 28 patients who were treated in total, all of which had multiple biologic treatment failures. Baseline median age was 37, median HBI was 9, median CRP was 9.41 mg/L, and median FCP was 580 μg/g. The median disease duration was 13.5 years. Four patients discontinued upadacitinib due to no response or side effects. For all available data including patients who discontinued upadacitinib, clinical remission was achieved at 12 weeks in eight patients (8/11, 72.7%). Clinical response was achieved in eight patients (8/11, 72.7%), biochemical remission was achieved in four patients (4/11, 36.4%), and biochemical response was achieved in six patients (6/11, 54.6%). Of those that were initially on steroids (n=5), four patients (4/5, 80.0%) were able to wean off steroids and achieved a steroid-free clinical or biochemical response at 12 weeks. Of those who had previously been on off-label tofacitinib (n=5), clinical follow-up data was available for three patients at the end of the 12-week induction period. Two patients achieved clinical remission (2/3, 66.7%) and three patients had a clinical response (3/3, 100%). Among 13 patients with follow-up data, adverse events were observed in three patients (3/13, 23.1%), with two having non-serious infections (2/13, 15.4%) and one having fevers of unknown origin (1/13, 7.69%). Conclusion This real-world multicentre Canadian induction study shows favourable efficacy and tolerability of upadacitinib in refractory active Crohn’s disease.

The Combination of Nivolumab and CC-486 Is Active in Hodgkin Lymphoma Refractory to PD-1 Blockade

Introduction: PD1 blockade is highly active in patients (pts) with relapsed/refractory (RR) Hodgkin lymphoma (HL); however, most patients ultimately progress on therapy, and HL that is refractory to PD1 blockade remains an unmet need. Furthermore, as PD-1 directed therapies are being administered in earlier lines, it is anticipated that pts with RR HL will be increasingly refractory to PD-1 directed therapies. Hypomethylating agents (HMA) have been shown to increase T-cell infiltration and upregulate PD-1 and CTLA-4 expression in tumors, as well as suppress myeloid-derived suppressor cells. We hypothesized that HMA might restore the sentivity of HL to PD-1 directed therapies. Therefore, we conducted a phase I study evaluating the safety and efficacy of nivolumab and CC-486, an oral HMA, in pts with RR HL refractory to PD-1 blockade. Methods:Adult pts with RR HL who had progressed after at least 1 prior line of therapy and were refractory to PD-1 therapy were enrolled to receive oral CC-486 and nivolumab IV in 28-day cycles. PD-1 refractoriness was defined as progressive disease (PD) as best response, or PD while receiving or within 12 weeks of the last anti-PD-1 directed therapy. Pts were treated in a dose-finding cohort at 2 dose levels (DL) using a Rolling 6 design and then in a dose expansion cohort at the recommended phase 2 dose (RP2D). In DL1, CC-486 was administered at 200 mg PO daily on days 1-7, and in DL2 CC-486 was dosed at 300 mg PO daily on days 1-7; nivolumab 480 mg IV was given on day 8 in both DLs. Treatment could be continued for up to 2 years. Primary endpoints were determination of the RP2D and overall response rate (ORR) defined as the proportion of patients with a complete response (CR) or partial response (PR). Responses were assessed by investigators using PET-CT according to the 2014 Lugano Classification. Results: As of July 7, 2023, 21 pts have been enrolled including 3 at DL1 and 18 at DL2 (RP2D). At baseline, 57% were male with a median age of 40 years (range 25-71), 95% had stage III-IV disease, and 71% had primary refractory disease, defined as lack of a complete remission (CR) or relapse within 3 months of frontline treatment. The median number of prior therapies was 6 (range 2-14), and 90% had prior brentuximab vedotin (BV). 76% of pts had received pembrolizumab, 67% had received nivolumab, and 43% had received both agents previously. 52% had undergone autologous stem cell transplant and 5% had had prior allogeneic stem cell transplant. Baseline characteristics are shown in Table 1. The median number of cycles was 7 (range: 3-17). Among 19 pts evaluable for response (2 pending), ORR was 63% and CR rate was 10%. An additional 32% had SD as their best response; only one pt had PD as the best response. The median follow-up time was 9 months (range 2.8-16.3), and 71% of pts remain on treatment with an estimated median PFS of 11.3 months (95% CI: 7.1-N/A). 6 pts stopped therapy, including 4 for disease progression, 1 at treating physician's discretion and 1 due to patient preference. The most common adverse events (AEs), any grade (Gr), were nausea (86%), diarrhea (71%), vomiting (48%), headache (33%), fatigue (29%), neutropenia (19%), and anemia (19%). Only two Gr 3+ AEs were recorded: one patient experienced Gr 3 anemia and another Gr 4 hypercalcemia. Notably, the hypercalcemia fully resolved with supportive care and did not recur with subsequent cycles. The only immune-related AE was grade 1 hypophysitis in a single pt. Conclusions: Nivolumab combined with CC-486 is tolerable and elicits a high response rate in a PD-1 refractory cohort. At this time, the study has been amended to enroll 10 more patients at DL2 to provide a better estimation of the efficacy.

17th International Conference on Malignant Lymphoma, Palazzo dei Congressi, Lugano, Switzerland, 13 - 17 June, 2023.

Introduction: The prognosis of patients (pts) with diffuse large B-cell lymphoma (DLBCL) and involvement of the central nervous system (CNS) remains dismal. Anti-CD19 chimeric antigen receptor T-cells (CART) are considered standard treatment for pts with refractory or relapsed (r/r) DLBCL. Pts with involvement of the CNS were excluded from most CART trials; however, anecdotal reports suggest that CART might be an effective treatment option for such pts. This EBMT registry study aimed at compiling data of a larger cohort of pts with primary (PCNSL) or secondary CNS lymphoma (SCNCL) to better define the role of CART in these settings. Methods: All centres contributing to the EBMT database were asked for consecutive cases of PCNSL and SCNSL, which had been treated with any type of CART between January 2018 and December 2021. Reported pts were identified in the database and analysed for major patient characteristics, pre-treatment aspects, and major clinical endpoints. Kaplan Meier estimates were used to calculate overall survival (OS) and progression-free survival (PFS), whereas cumulative incidence was used for relapse incidence (RI), and non-relapse mortality (NRM). Results: 74 pts with PCNSL (n = 10) or SCNSL (n = 64) and complete information on major endpoints after CART and a median follow-up of 20.2 months [CI: 13.25–23.5] were analysed. Median age was 61.6 years (range 31–80), 31 pts were female. 37 of 57 pts (64.9%) had three or more prior treatment lines, 36.5% of pts had undergone autologous hematopoietic cell transplantation. 14 of 70 pts (20%) had ECOG ≥2. Disease-status at CART was complete (CR) or partial remission (PR) for 31.5% (6.8% and 24.7%, respectively) of pts, 68.5% of pts were in relapse, refractory, or had progressive disease. For one patient information on disease status was missing. 40 pts received axicabtagene ciloleucel (Yescarta®), 34 pts were treated with tisagenlecleucel (Kymriah®). OS- and PFS-rates at 12 months were 51.1% [CI: 40.2–64.8] and 33.7% [CI: 24.3–46.7] for the whole cohort. RI at 12 months was 59.4% [CI: 46.9–69.8]. NRM was 7% [CI: 2.5–14.5]. OS and PFS for pts in CR/PR were 53.0% [CI: 35.5–79.3] and 42.1% [CI: 25.9–68.7]. For the refractory cohort OS and PFS were 51.7% [CI: 38.7–69.0] and 30.6% [CI: 19.9–46.9], respectively. Conclusion: With a 51% OS-rate at 12 months CART seem to be a very effective therapeutic option in heavily pre-treated r/r PCNSL or SCNSL, particularly for pts being refractory to prior therapy. These results compare favourably with those of conventional treatment (including a minority of pts treated with autoSCT) in SCNSL with a median overall survival of 3.5 months (Schmitz et al., 2016) and 12-months OS-rate of 20% (Thieblemont et al., 2023). Pts with CNS involvement and r/r LBCL should be considered for treatment with CART. The research was funded by: Lymphoma Working Party of the EBMT GoCART coalition Keywords: Aggressive B-cell non-Hodgkin lymphoma, Cellular therapies Conflicts of interests pertinent to the abstract. S. Fuhrmann Consultant or advisory role: KiteGilead, BMS Celgene, Janssen D. Beauvais Honoraria: Merck & Co N. Kröger Consultant or advisory role: Takeda Honoraria: Takeda, Sanofi, Kite, Neovii, Amgen, BMS, Novartis, Jazz Research funding: Neovii, Riemser, DKMS, BMS, Novartis M. Stelljes Consultant or advisory role: MSD, Amgen, Novartis, Pfizer, Jazz, BMS, Kite Honoraria: MSD, Medac, Novartis, Pfizer, Jazz, BMS, Kite Research funding: Pfizer B. von Tresckow Consultant or advisory role: Allogene, BMS/Celgene, Cerus, Incyte, IQVIA, Gilead Kite, Miltenyi, Novartis, Noscendo, Pentixapharm, Roche, Amgen, Pfizer, Takeda, Merck Sharp & Dohme, Gilead Kite Honoraria: AstraZeneca, BMS, Incyte, Novartis, Roche Pharma AG, Takeda, Merck Sharp & Dohme Research funding: Novartis, Merck Sharp & Dohme, Takeda Educational grants: AbbVie, AstraZeneca, Gilead Kite, Merck Sharp & Dohme, Roche, Takeda, and Novartis P. Dreger Honoraria: Novartis, Kite, BMS, Miltenyi A. Sureda Consultant or advisory role: Takeda, BMS/Celgene, Novartis, Janssen, Gilead, Sanofi Honoraria: Takeda, BMS/Celgene, MSD, Janssen, Amgen, Novartis, Gilead, Kite, Sanofi, Roche, Alexion Research funding: Takeda, BMS/Celgene Other remuneration: Speaker’s bureau: Takeda, Non-profit organisations: Presidency of the GETH-TC, Presidency of the EBMT N. Schmitz Stock ownership: BMS Honoraria: Allogene Research funding: Astra Zeneca, Janssen, Roche Educational grants: Allogene, Miltenyi B. Glaß Honoraria: Novartis, JAZZ, Gilead, BMS, Roche, Abbvie, Miltenyi Research funding: Riemser, Roche

Multiomic Analysis of CD38 Expression Levels in 209 Untreated and Daratumumab-Resistant Patients

The anti-CD38 antibody Daratumumab (Dara) is widely used in first-line as well as in relapsed/refractory multiple myeloma (MM). Primary or secondary resistance eventually occurs in all treated patients but the underlying mechanisms are poorly understood: Genetic alterations that lead to loss of function affecting epitopes on CD38, low baseline expression of CD38 or the selection of CD38dim cells were associated with suboptimal response to treatment. Interestingly, drugs such as all-trans retinoic acid, panobinostat or DNMT inhibitors increase Dara efficiency through reversible upregulation of CD38. Overall, three cohorts with overall 209 patients were examined for this dataset. We conducted flow cytometry in 21 therapy naïve and 19 Dara-refractory patients using a Dara epitope-specific antibody. All untreated and 11 of the resistant patients stained positive for CD38 MM, suggesting CD38 independent resistance mechanisms. In eight patients, CD38 expression was not detected; however, in five of them, additional staining with a CD38 multiepitope antibody confirmed CD38 persistence, reflecting epitope blockade through Dara or epitope mutation that interferes with the binding of the antibody. Finally, in three out of 19 refractory patients, CD38 could not be detected with both antibodies. To quantify CD38 receptor density on a molecular level, we established super-resolution imaging by direct stochastic optical reconstruction microscopy (dSTORM) in the same patients. dSTORM uses fluorophore-conjugated antibodies and provides an unprecedented molecular 20 nm resolution for individual cells. We observed intra-patient heterogeneity of the CD38 receptor density with a mean expression of 35.15 ± 13.42 receptors/µm² (range 3.61-67.24) in the Dara naïve patients. Notably, in the refractory group, we found a significant decline (p=0.03) with a mean of 22.7 ± 18.26 receptors/µm² (range 17.07-63.77). In two of the three patients with no CD38 detectable, CD38 persistence could be assessed by dSTORM below the detection rate of flow cytometry. One patient remained negative for CD38, suggesting true loss of the receptor, causing Dara resistance in this patient. Next, we confirmed downregulation of CD38 gene expression using qPCR, and significantly reduced expression in the Dara refractory cohort (p=0.01). Of note, correlation between gene and receptor expression was moderate (p=0.49, r=0.57), leaving room for epigenetic regulation or posttranscriptional modification. To interrogate whether epigenetic regulation of CD38 via DNA methylation may underlie differential CD38 receptor expression, we performed deep bisulfite sequencing of MM cells and PBMCs obtained from 41 patients from our institution. CD38 on chromosome 4 contains several regulatory regions: One promoter, two adjacent promoter flanking regions and 11 enhancer regions described in ENSEMBL genome browser (GRCh38.13). The CD38 promoter was fully unmethylated (mean methylation: 0.31% ± 0.2%, range 0.2%-0.9%), but variable methylation of a CD38 promoter flanking region upstream of the promoter was detectable with 30.08% ± 17.8% (range 0.9%-61.5%) in the MM cells compared to 59.6% ± 3.9% (range 49.0%-66.7%) in the PBMCs from the same patients (p <0.001). This highlights phenotypic plasticity and suggests that DNA methylation may play a regulatory role in CD38 expression. We are currently investigating the methylome of all 14 regulatory regions in 38 Dara resistant patients (18 of them with longitudinal sampling before and after Dara therapy), 33 Dara responsive patients and 52 plasma cells obtained from healthy donors. Finally, in a cohort of 127 patients from our institution with WGS data available we screened for genetic alterations with potential impact on the CD38 receptor expression. We found monoallelic CD38 deletions in 18 patients, with one patient having an additional 11kb deletion conferring to an exon 3 loss. Exon-6 skipping, as recently described, was not detectable in the cohort. In conclusion, genetic alterations affecting the CD38 locus and true loss of the CD38 receptor are rare events and do not explain Dara resistance in most affected patients. dSTORM imaging provides additional insights in the CD38 receptor downregulation in MM patients treated with anti-CD38 moAb therapy. Regulatory mechanisms such as epigenetic regulation need to be further explored.

The Real-World Effectiveness and Safety of Ustekinumab in the Treatment of Crohn's Disease: Results From the SUCCESS Consortium.

We evaluated the real-world effectiveness and safety of ustekinumab (UST) in patients with Crohn's disease (CD). This study used a retrospective, multicenter, multinational consortium of UST-treated CD patients. Data included patient demographics, disease phenotype, disease activity, treatment history, and concomitant medications. Cumulative rates of clinical, steroid-free, endoscopic, and radiographic remissions were assessed using time-to-event analysis, and clinical predictors were assessed by using multivariate Cox proportional hazard analyses. Serious infections and adverse events were defined as those requiring hospitalization or treatment discontinuation. A total of 1,113 patients (51.8% female, 90% prior antitumor necrosis factor exposure) were included, with a median follow-up of 386 days. Cumulative rates of clinical, steroid-free, endoscopic, and radiographic remissions at 12 months were 40%, 32%, 39%, and 30%, respectively. Biologic-naive patients achieved significantly higher rates of clinical and endoscopic remissions at 63% and 55%, respectively. On multivariable analyses, prior antitumor necrosis factor (hazard ratio, 0.72; 95% confidence interval, 0.49-0.99) and vedolizumab exposure (hazard ratio, 0.65; 95% confidence interval, 0.48-0.88) were independently associated with lower likelihoods of achieving endoscopic remission. In patients who experienced loss of remission, 77 of 102 (75%) underwent dose optimization, and 44 of 77 (57%) achieved clinical response. An additional 152 of 681 patients (22.3%) were dose-optimized because of primary nonresponse incomplete response to UST, of whom 40.1% (61 of 152) responded. Serious infections occurred in 3.4% of patients while other noninfectious adverse events (lymphoma [n = 1], arthralgia [n = 6], rash [n = 6], headache [n = 3], hepatitis [n = 3], hair loss [n = 3], neuropathy [n = 1], and vasculitis [n = 1]) occurred in 2.4% of patients. UST represents a safe and effective treatment option for CD, with 40% of patients from a highly refractory cohort achieving clinical remission by 12 months. The greatest treatment effect of UST was seen in biologic-naive patients, and dose escalation may recapture clinical response.

Brigatinib in Japanese patients (pts) with ALK+ NSCLC: Final results from the phase 2 J-ALTA trial.

9075 Background: In previous J-ALTA (NCT03410108) analyses, brigatinib demonstrated substantial efficacy and manageable safety in pts with TKI-refractory and TKI-naive ALK+ NSCLC. We report the final J-ALTA results. Methods: J-ALTA was a single arm, multicenter, open-label study that included ALK TKI-naive and -refractory NSCLC expansion parts. The main cohort within the refractory part was a group with alectinib-refractory NSCLC. Primary endpoints: IRC-assessed confirmed ORR in the alectinib-refractory cohort; IRC-assessed 12-month PFS in the TKI-naive cohort. Secondary endpoints included confirmed ORR (IRC-assessed in the total refractory cohort; investigator-assessed in all cohorts); DoR, PFS, DCR, and iPFS by IRC; and safety. Final analyses were performed following last pt last contact. Results: A total of 104 pts were enrolled; 72 had TKI-refractory (56% female; median age, 53.0 y) and 32 had TKI-naive (53% female; median age, 60.5 y) NSCLC. As of 28 July, 2021 (last pt last contact), median follow-up was 24.2 mo in the refractory cohort (alectinib-refractory subgroup [n = 47], 23.0 mo) and 22.1 mo in the TKI-naive cohort. Confirmed ORR was 34% (95% CI: 21–49) by IRC with 16 partial responses (PR) in the alectinib-refractory cohort and 32% (21–44; 22 PR) in the total refractory cohort. In the TKI-naive cohort, IRC-assessed 24-mo PFS was 73% (90% CI: 55–85); median PFS was not mature. Additional efficacy analyses are reported in Table. TEAEs were reported in all 104 pts (most common: increased CPK, 79%; hypertension, 48%; diarrhea, 47%). Grade ≥3 TEAEs were reported in 68% and 91% of pts in the TKI-refractory and -naive cohorts, respectively; most commonly (TKI-refractory/naive) elevated CPK, 24%/50%; elevated lipase, 15%/19%; hypertension, 11%/34%. Pneumonitis was mandated to be reported as an SAE regardless of severity and was the only SAE reported in &gt; 5% of pts (refractory, n = 5 [7%; early onset, 1]; naive, n = 4 [13%; early onset, 0]). TEAEs led to dose interruption/reduction/discontinuation in 63%/31%/7% of pts in the TKI-refractory cohort and 94%/69%/0% in the TKI-naive cohort. Conclusions: Final efficacy and safety results in pts with TKI-refractory and -naive NSCLC were consistent with previous J-ALTA analyses. No new safety signals were observed in either cohort. Brigatinib demonstrated a favorable benefit-risk profile and is an important option for Japanese pts with ALK+ NSCLC regardless of TKI treatment history. Clinical trial information: NCT03410108. [Table: see text]

Phase I dose escalation and expansion study of defactinib, pembrolizumab, and gemcitabine in patients with advanced treatment-refractory pancreatic cancer.

4146 Background: Targeting focal adhesion kinase (FAK) renders checkpoint immunotherapy effective in pancreatic ductal adenocarcinoma (PDAC) mouse models. Defactinib is a highly potent oral FAK inhibitor shown to have a tolerable safety profile. We evaluated the safety and recommended phase 2 dose (RP2D) of defactinib in combination with pembrolizumab and gemcitabine for PDAC patients. Methods: We conducted a multicenter, open-label, phase I study with dose escalation and expansion phases. In 3x3 dose escalation, patients with refractory solid tumors were treated at five escalating dose levels of defactinib and gemcitabine to identify a RP2D. In expansion phase, patients with metastatic PDAC who progressed on frontline treatment (refractory cohort) or had treatment response or stable disease (SD) on standard gemcitabine/nab-paclitaxel (maintenance cohort) were treated at RP2D. Pre- and post-treatment tumor biopsies were performed to evaluate changes in tumor immunity. Results: The triple drug combination was well-tolerated with no dose-limiting toxicities. Among 17 treated patients with refractory PDAC, the disease control rate (DCR) was 58.8% with one partial response (PR) and nine SDs and the median progression-free survival (PFS) and overall survival (OS) were 4.2 months and 9.1 months, respectively. Among the evaluable patients in the maintenance cohort, DCR was 63.6% with one PR and six SD. Three patients with SD came off study due to treatment- or disease-related complications. The median PFS and OS were 5.0 months and 8.3 months, respectively. Conclusions: The combination of defactinib, pembrolizumab, and gemcitabine was well-tolerated, had promising preliminary efficacy, and showed increased infiltrative T lymphocytes in post-treatment tumor biopsies. Incorporation of a more potent chemotherapy backbone should be considered to achieve better clinical response in future trial design. Clinical trial information: NCT02546531.

Ustekinumab for the treatment of moderate to severe ulcerative colitis: a multicentre UK cohort study

ObjectiveUstekinumab is an interleukin-12/interleukin-23 receptor antagonist licensed for the treatment of ulcerative colitis (UC). Clinical trial data were promising; however, real-world data are limited. We assessed the safety and effectiveness...

Safety and efficacy of pressurized intraperitoneal aerosolized chemotherapy in appendiceal and colorectal cancer patients with peritoneal carcinomatosis: A first-in-US phase I study.

125 Background: Pressurized intraperitoneal aerosolized chemotherapy (PIPAC) is being evaluated as a novel minimally invasive palliative treatment of peritoneal metastases (PM). Prior studies have established the feasibility and safety of repeated PIPAC treatments in gastrointestinal and gynecologic cancers. The goal of the present phase 1 trial was to establish the safety and feasibility of PIPAC oxaliplatin in a highly chemotherapy refractory colorectal and appendiceal cancer patient population. Methods: Patients with biopsy-proven peritoneal metastases from colorectal or appendiceal cancer underwent up to three PIPAC treatments using oxaliplatin (92 mg/m2) with a six-week interval at two academic centers. Patients with bowel obstruction, extra-peritoneal metastases, or poor performance status (ECOG&gt;2) were excluded. PIPAC was nebulized over 5 min with a 30 min aerosol dwell time. Apart from the first PIPAC cycle, the patients also received a sensitizing dose of 5FU/LV (400mg/m2) within 24 hours of the procedure. Primary end point was safety as assessed by dose limiting toxicities within 6 weeks of the first PIPAC. Secondary endpoints included safety with the addition of 5FU/LV, efficacy, surgical morbidity, technical failure rate, progression-free and overall survival, pharmacokinetics (PK), and quality of life assessment. Results: A total of 8 patients were included: 5 colorectal; and 3 appendiceal. Median number of prior chemotherapy cycles was 2 (Interquartile range – IQR; 1.5-3.5). All patients were refractory to systemic oxaliplatin-based chemotherapy. Median time from diagnosis to PIPAC was 16 months (IQR; 5.6, 17.5) and Peritoneal Carcinomatosis Index was 29 (IQR; 20.5, 31.5). Five (62.5%) patients completed 3 PIPAC cycles while in 3 (37.5%) patients PIPAC was discontinued due to disease progression within the peritoneal cavity. No surgical complication or dose limiting toxicity was observed. Only one patient developed grade 3 treatment-related toxicity after first PIPAC (anemia), and another patient after second PIPAC (abdominal pain and anemia). At the completion of PIPAC treatment 5 patients had stable disease and 3 had disease progression. Pharmacokinetic, histologic response and preliminary survival data will be presented at the meeting. Conclusions: PIPAC with oxaliplatin is safe and feasible in a highly chemotherapy refractory cohort of appendiceal and colorectal carcinomatosis patients with or without sensitizing 5-FU/ LV. Clinical trial information: NCT04329494.

REAL WORLD EFFECTIVENESS AND SAFETY OF OZANIMOD: INITIAL RESULTS FROM A LARGE TERTIARY CENTER

Abstract BACKGROUND In May 2021 the United Stated Food and Drug Administration (FDA) approved the use of ozanimod for moderate to severe ulcerative colitis (UC) based on the results of the pivotal phase 3 TRUE NORTH trials. We present the first report of real world data describing the use of ozanimod in clinical practice. METHODS This prospective, observational cohort study includes consecutive patients with active UC who initiated ozanimod at our center following FDA approval. We collected demographic, clinical, and laboratory data. Clinical disease activity was assessed using the Simple Clinical Colitis Activity Index (SCCAI). Clinical response was defined as a decrease in ≥3 points in SCCAI from baseline, and clinical remission was defined as an SCCAI score of ≤ 2. Adverse events were extracted from the electronic medical records (EMR) and regular clinical pharmacist follow up. RESULTS 18 patients have initiated ozanimod therapy at our center. We observed 15 patients with UC, 1 patient with indeterminate colitis (IC), 1 patient with Crohn’s colitis, and 1 patient with lymphocytic colitis. All patients were included in the safety analysis and only patients with UC or IC were included in the effectiveness analysis. The mean age was 44.7 ± 18.5 with a mean age at disease duration of 9.6 ± 10.4. Ten (62%) patients were male, most patients 11 (69) had left sided colitis; 12 (75%) had previous biologic exposure. Additional demographics are described in Table 1. At week 4, follow up was available for 11 patients. Among these, 7 (64%) patients demonstrated clinical response, 2 (18%) were in clinical remission, and 1 patient achieved corticosteroid (CS) free remission. At week 8, follow up data was available for 7 patients; 3 (43%) patients had a clinical response and 1 (14%) patient achieved CS free remission (Figure 1A). 7 patients had complete blood counts at weeks 0 and 4, and all of these patients had a reduction in absolute lymphocyte counts (mean ± SD 1.46±0.47 109 cells/liter) (Figure 1B). There were 5 adverse events during the follow up period, none of which required treatment cessation. 1 patient had self-limited gastroenteritis, 1 patient had transient fatigue and another transient nausea. 1 patient developed mild liver enzyme derangement. 1 patient had non-specific chest pain and therapy was paused for a day until investigations returned negative. CONCLUSION This is the first real world data from a relatively treatment refractory cohort of UC patients and shows promising effectiveness and safety of ozanimod. Longer follow-up in larger patient cohorts is required to assess ozanimod’s role in clinical practice.

P340 Risankizumab in Inflammatory Bowel Disease: Real World Experience from a Pre-Approval Access Program

Abstract Background Risankizumab is a new generation monoclonal antibody which inhibits interleukin-23A. It has applications in several immune mediated inflammatory diseases including moderate-to-severe CD. Pre-approval access was granted for a cohort of patients who had active disease and prior use of all European licenced biologic therapies for CD. We aimed to define the effectiveness and tolerability of risankizumab in this real-world, treatment refractory cohort. Methods We performed a retrospective cohort analysis of prospectively maintained data for patients starting risankizumab between January and September, 2021. All patients received doses at four weekly intervals (IV, 600mg doses for CD and SC, 300mg doses for IBD-U). Clinical disease activity, biochemical activity and quality of life were measured using HBI, CRP and IBD-C scores, respectively. Study evaluations were made at baseline, weeks, 4 and, 12. Data were analysed in GraphPad prism and are described as median (range). Results Since January, 2021, 16 patients have started risankizumab. We included, 13 patients who had completed the, 12 week induction period at the time of submission;, 12 with CD and, 1 with IBD-U. Demographics are shown in Table, 1. The characteristics are consistent with a more aggressive phenotype with the majority of patients (9 (75%)) having perianal involvement as well as having either stricturing (5(42%)) or internal penetrating disease (3(25%)). Nine (75%) patients had undergone prior luminal surgery, 7 of whom still had stomas, therefore were not included in the analysis for HBI. Median HBI at baseline was, 5 (0–10) vs, 2 (0–8) at week, 4 and, 1.5 (0–2) at week, 12 and due to small patient numbers was not statistically significant. There was an improvement in IBD-C scores. Median IBD-C score at baseline was, 5 (0–14) vs, 11 (4–16) at week, 4 (p=0.034) and, 12 (2–16) at week, 12 (p=0.067). CRP decreased from, 12 mg/L (1–48) at baseline to, 8 mg/L (1–20) at week, 4 (p=0.23) and to, 6 mg/L (1–34) at week, 12 (p=0.022). Results are represented in Figure, 1. Two patients experienced mild headaches, no other side effects were reported. At initiation two patients were being treated with steroids; one has since discontinued and one has remained on steroids. No other patients initiated steroids. No patients discontinued risankizumab during the study period. Conclusion We present a heterogeneous cohort of patients with refractory CD despite multiple biologic mechanisms. Overall, there was a positive impact of risankizumab induction over a, 12 week period with respect to symptoms, quality of life and CRP, showing the effectiveness of risankizumab in this refractory cohort. We will follow up, and at week, 24 will objectively assess disease activity with cross sectional imaging and/or endoscopy.

OP05 Outcome of induction therapy with vedolizumab in children: Results from the prospective, multi-centre VEDOKIDS study

Abstract Background Limited data are available on the use of Vedolizumab (VDZ) in paediatric Crohn’s Disease (CD) and Ulcerative Colitis (UC). We evaluated the effectiveness and safety of VDZ to induce remission at week 14 in the prospective, multicenter VEDOKIDS study. Methods We enrolled children (age 0–18 years) with CD or UC commenced on VDZ with a standardized dosing of 177mg/BSA up to 300mg at 0, 2, 6 and q8 weeks thereafter. Non-responders had their dose escalated to q4wks at the discretion of the local physician. Explicit demographic, clinical and safety data were prospectively recorded via REDcap. Clinical remission was defined as steroid- and EEN-free remission (i.e. wPCDAI&amp;lt;12.5 or PUCAI&amp;lt;10) without the need for new medications. Complete remission was defined as clinical remission with normal CRP and ESR. Predictors of response were explored by Logistic regression. Results 128 children were enrolled, 60 (47%) with CD, and 68 (53%) with UC (58 (45%) males, mean age 13.8±3.6, 93 (73%) failed previous anti-TNF, median disease duration 2.3 years (IQR 0.9–4.7)). Using the ITT principle, clinical and complete remission rates for CD at week 14 were 30% and 20%, respectively, and for UC 50% and 38%, respectively (Fig 1). Clinical remission rates of those receiving VDZ as first line biologics versus second line were 57% and 34%, respectively (p=0.019; Fig 2); the corresponding complete remission rates were 49% and 23% (p=0.004). In the UC group, disease activity at baseline measured by the PUCAI predicted clinical remission at week 14 (OR=0.95, 95%CI 0.93–0.98; median baseline PUCAI 15 (IQR 0–30) in those achieving remission and 45 (20–55) in those who did not; p=0.002). ESR (OR=0.94, 95%CI 0.89–0.98; p=0.009) and a trend towards extensive disease (L3 vs. L1 and L2; OR 0.14, 95%CI 0.18–1.036, p=0.054) predicted clinical remission in CD. During the 14 weeks, 113 adverse events (AE) were recorded in 58 children: 28 AEs were possibly related to VDZ, all of which were mild-moderate and only 3 (11%) led to discontinuation of VDZ (leukocytoclastic vasculitis, myalgia and dyspnea). There were 18 serious AEs, only one was graded as possibly related to VDZ (headache). There were 18 non-serious cases (19%) of upper respiratory infections (pharyngitis, tonsilitis, parotitis, and otitis media) and one Campylobacter jejuni which was graded as serious. Conclusion In this prospective multicenter study, VDZ was safe and effective for inducing remission in a refractory cohort of paediatric IBD, more so in UC. Disease severity and extent at baseline may predict clinical response.

Outcome with Hypomethylating Agent and Venetoclax Combination in Patients with Chronic Myelomonocytic Leukemia

Outcome with Hypomethylating Agent and Venetoclax Combination in Patients with Chronic Myelomonocytic Leukemia

Next Generation Sequencing Highlights the Role of Cell Cycle and Apoptosis Dysregulation and Hepatitis B Infection in Refractory Diffuse Large B Cell Lymphoma

About 10-15% DLBCL are primary refractory, the underlying biology aggressiveness contributed to refractoriness remain to be defined. To date, whole-exome (WES) or whole-genome sequences (WGS) obtained from primary or refractory/relapse DLBCL tumors have been published, while the biology study conduct on patients of mixed prognosis failed to characterizing the 10-15% primary refractory cases, and WES or WGS are not applicable in clinical routine practice. To address this issue, we performed target next generation sequencing in 11 primary refractory DLBCL cases. Through pathway enrichment analysis, as expected, the cell cycle/apoptosis and P53 signaling (FDR 10-11~10-9), NF-kB (FDR ~10-9), BCR signaling(FDR ~10-9), PI3K/Akt (FDR ~10-8), MAPK(FDR ~10-10), Wnt (FDR ~10-12), Jak/STAT (FDR ~10-14) signaling were significant mutated. Furthermore, some pathogen infection pathways were also significantly affected, which was not identified as significantly mutated in previous DLBCL WGS studies, including hepatitis B virus infection(HBV) signaling pathway involving BCL-2, MYC, MYD88, CREBBP, FAS, STAT3, TP53, and 4 of the 11 (36.4%) patients were HBsAg-positive. Overall, somatic mutations or copy number aberrations of CD79B (5/11, 45.5%), TP53(4/11, 36.3%), PIM1 (4/11, 36.3%) , MYD88 (3/11, 27.2%), KMT2D (3/11, 27.2%), CREBBP(3/11, 27.2%) and IRF4 (3/11, 27.2%) were the most prevalent aberrations. We separately compared the prevalence of target gene variants in our refractory (ref)-DLBCLs to published cohorts of responsive or de novo or relapse(rel) or relapse/refractory(r/r)-DLBCLs, the profile and frequency was highly concordant to those of relapse ones, while CD79B and cell cycle regulation or apoptosis related genes were more prevalent affected in our refractory cohort than those of responsive or de novo ones(table 2). [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

P476 Effectiveness and safety of ustekinumab in ulcerative colitis: Real-world evidence from the ENEIDA registry

BackgroundThe development program (UNIFI) has shown promising results of ustekinumab in ulcerative colitis (UC) treatment that should be confirmed in clinical practice.AimsPrimary: to evaluate the durability of ustekinumab treatment in UC patients in clinical practice. Secondary: to assess the short-term response (at week 16) and the long-term effectiveness (at maximum follow-up) and to assess the safety of ustekinumab in clinical practice.MethodsPatients included in the prospectively maintained ENEIDA registry who received at least one intravenous dose of ustekinumab due to active UC [Partial Mayo Score (PMS) >2] were included. Clinical activity and effectiveness were defined based on PMS.Results95 patients were included (table 1). At week 16, 53% of patients had clinical response (including 35% of patients in remission) (figure 1). In the multivariate analysis, elevated serum C-reactive protein was the only variable significantly associated with clinical remission. Long-term remission is represented in figure 2. 36% of patients discontinued the treatment with ustekinumab during a median follow-up of 31 weeks. The probability of maintaining ustekinumab treatment was 87% at week 16, 63% at week 56, and 59% at week 72 (figure 3); primary failure was the main reason for ustekinumab discontinuation. No variable was associated with risk of discontinuation. Three patients reported adverse events; one of them had a fatal severe SARS-CoV-2 infection. ConclusionUstekinumab is effective both in the short and the long-term in real-life, even in a highly refractory cohort. Higher inflammatory burden at baseline correlated with lower probability of achieving remission. Safety was consistent with the known profile of ustekinumab.

P284 Drug survival and remission rates in ustekinumab treated ulcerative colitis: Results from the Swedish Inflammatory Bowel Disease register (SWIBREG)

Abstract Background Randomised controlled trials may not correctly reflect clinical practice. We aimed to assess the clinical effectiveness of ustekinumab in a real-world cohort of patients with ulcerative colitis (UC). Methods This observational, multi-centre cohort study explored ustekinumab treated patients with UC from the Swedish inflammatory bowel disease register (SWIBREG), a nationwide quality register. Prospectively collected clinical data were extracted December 2020. The primary outcome was the 16-week ustekinumab continuation rate. Secondary outcomes included A) drug continuation rate at the end of follow-up, B) corticosteroid-free biochemical remission, defined as f-Calprotectin&amp;lt;250µg/g, and C) corticosteroid-free clinical remission per patient-reported Mayo score, i.e. a rectal bleeding subscore &amp;lt;1 and a stool frequency subscore ≤1 and not greater than baseline. Continuous data are presented as median and (interquartile range). Differences between baseline and follow-up visits were assessed by the Wilcoxon signed-rank test. Results In total, 145 patients were included and followed for a median period of 32 (19-56) weeks. Baseline characteristics are presented in Table 1. The drug continuation rate was 87% (126/145) at 16 weeks and 69% (100/145) at end of follow-up (Figure 1-2). Corticosteroid-free clinical and biochemical remission rates at follow-up visits are shown in Figure 3. The 6-point Mayo score decreased from 5 (3-6) at baseline to 2 (2-4) at 16 weeks (p&amp;lt;0.01) and to 3 (2-4) at last follow-up (p&amp;lt;0.01). F-calprotectin levels decreased from 779 (252-1530) µg/g to 246 (56-844) µg/g at week 16 (p=0.02) and to 142 (36-935) µg/g at last follow-up (p&amp;lt;0.01). Conclusion Ustekinumab was associated with clinical effectiveness in this nationwide real-world treatment refractory cohort.