Leukemia, Myelodysplasia, Transplantation

CML cells

Credit: UC San Diego

In vitro experiments have revealed new insight into tyrosine kinase inhibitor (TKI) resistance among patients with chronic myeloid leukemia (CML).

Though it’s now possible to overcome TKI resistance resulting from single BCR-ABL1 mutants, targeting compound mutants remains a challenge.

So researchers tested several TKIs on various BCR-ABL1 compound mutants to determine which drug, if any, would be most effective for each combination.

The results appear in Cancer Cell.

Thomas O’Hare, PhD, of the Huntsman Cancer Institute at the University of Utah, and his colleagues first took an inventory of clinical BCR-ABL1 compound mutations associated with TKI resistance that had been reported in the literature.

The team identified 12 kinase domain positions that account for most clinical BCR-ABL1 TKI resistance—M244, G250, Q252, Y253, E255, V299, F311, T315, F317, M351, F359, and H396.

All of the clinically reported compound mutations include at least 1 of the 12 key positions, and most (65%) include 2. Each position has been implicated in resistance to 1 or more TKIs, including imatinib, nilotinib, dasatinib, bosutinib, rebastinib, and ponatinib.

The researchers found that some of the compound mutations they studied conferred resistance several-fold higher than that of either contributing mutation alone.

“We were able to sequence about 100 clinical samples, which gave us a very large body of data to shed light on the number of compound mutations and how they develop,” said Michael Deininger, MD, PhD, also of the Huntsman Cancer Institute.

“One key finding was that compound mutations containing an already known mutation called T315I tend to confer complete resistance to all available TKIs.”

The researchers had focused their testing on ponatinib, as the drug has proven effective against resistant CML, particularly cases with the T315I mutation. Unfortunately, ponatinib was often no match for compound mutations including T315I.

Tests did suggest that a 30 mg/day dose of ponatinib would maintain efficacy against 7 of the 8 non-T315I compound mutants tested, though the Y253H/E255V mutant proved resistant.

The researchers also found that a 15 mg/day dose of ponatinib could pre-empt outgrowth of 5 of the 8 non-T315I compound mutants, though Y253H/E255V, E255V/V299L, and F317L/F359V might be problematic.

But ponatinib proved substantially less effective against T315I-inclusive compound mutants. Nine of 10 T315I-inclusive compound mutants showed little or no sensitivity to ponatinib or any of the other TKIs tested. M244V/T315I was the only compound mutant not resistant to ponatinib.

The researchers noted that because ponatinib has proven effective against the T315I mutant in isolation, many patients treated with ponatinib are likely to have this mutation.

So it may be necessary to perform more sensitive screening on these patients to determine whether they might have T315I-inclusive compound mutants that could confer resistance.

“Fortunately, the problems we are studying affect a minority of CML patients,” Dr O’Hare said. “[S]till, this leaves some patients with no good treatment option at all. Our goal is to have a TKI option for every patient.”

According to Dr O’Hare, it’s only a matter of time until analogous compound mutations emerge in many other cancers, including acute myeloid leukemia and non-small cell lung cancer.

“Our findings in CML will provide a blueprint for contending with resistance in these highly aggressive diseases as well,” he concluded.

CML cells

Credit: UC San Diego

In vitro experiments have revealed new insight into tyrosine kinase inhibitor (TKI) resistance among patients with chronic myeloid leukemia (CML).

Though it’s now possible to overcome TKI resistance resulting from single BCR-ABL1 mutants, targeting compound mutants remains a challenge.

So researchers tested several TKIs on various BCR-ABL1 compound mutants to determine which drug, if any, would be most effective for each combination.

The results appear in Cancer Cell.

Thomas O’Hare, PhD, of the Huntsman Cancer Institute at the University of Utah, and his colleagues first took an inventory of clinical BCR-ABL1 compound mutations associated with TKI resistance that had been reported in the literature.

The team identified 12 kinase domain positions that account for most clinical BCR-ABL1 TKI resistance—M244, G250, Q252, Y253, E255, V299, F311, T315, F317, M351, F359, and H396.

All of the clinically reported compound mutations include at least 1 of the 12 key positions, and most (65%) include 2. Each position has been implicated in resistance to 1 or more TKIs, including imatinib, nilotinib, dasatinib, bosutinib, rebastinib, and ponatinib.

The researchers found that some of the compound mutations they studied conferred resistance several-fold higher than that of either contributing mutation alone.

“We were able to sequence about 100 clinical samples, which gave us a very large body of data to shed light on the number of compound mutations and how they develop,” said Michael Deininger, MD, PhD, also of the Huntsman Cancer Institute.

“One key finding was that compound mutations containing an already known mutation called T315I tend to confer complete resistance to all available TKIs.”

The researchers had focused their testing on ponatinib, as the drug has proven effective against resistant CML, particularly cases with the T315I mutation. Unfortunately, ponatinib was often no match for compound mutations including T315I.

Tests did suggest that a 30 mg/day dose of ponatinib would maintain efficacy against 7 of the 8 non-T315I compound mutants tested, though the Y253H/E255V mutant proved resistant.

The researchers also found that a 15 mg/day dose of ponatinib could pre-empt outgrowth of 5 of the 8 non-T315I compound mutants, though Y253H/E255V, E255V/V299L, and F317L/F359V might be problematic.

But ponatinib proved substantially less effective against T315I-inclusive compound mutants. Nine of 10 T315I-inclusive compound mutants showed little or no sensitivity to ponatinib or any of the other TKIs tested. M244V/T315I was the only compound mutant not resistant to ponatinib.

The researchers noted that because ponatinib has proven effective against the T315I mutant in isolation, many patients treated with ponatinib are likely to have this mutation.

So it may be necessary to perform more sensitive screening on these patients to determine whether they might have T315I-inclusive compound mutants that could confer resistance.

“Fortunately, the problems we are studying affect a minority of CML patients,” Dr O’Hare said. “[S]till, this leaves some patients with no good treatment option at all. Our goal is to have a TKI option for every patient.”

According to Dr O’Hare, it’s only a matter of time until analogous compound mutations emerge in many other cancers, including acute myeloid leukemia and non-small cell lung cancer.

“Our findings in CML will provide a blueprint for contending with resistance in these highly aggressive diseases as well,” he concluded.

CML cells

Credit: UC San Diego

In vitro experiments have revealed new insight into tyrosine kinase inhibitor (TKI) resistance among patients with chronic myeloid leukemia (CML).

Though it’s now possible to overcome TKI resistance resulting from single BCR-ABL1 mutants, targeting compound mutants remains a challenge.

So researchers tested several TKIs on various BCR-ABL1 compound mutants to determine which drug, if any, would be most effective for each combination.

The results appear in Cancer Cell.

Thomas O’Hare, PhD, of the Huntsman Cancer Institute at the University of Utah, and his colleagues first took an inventory of clinical BCR-ABL1 compound mutations associated with TKI resistance that had been reported in the literature.

The team identified 12 kinase domain positions that account for most clinical BCR-ABL1 TKI resistance—M244, G250, Q252, Y253, E255, V299, F311, T315, F317, M351, F359, and H396.

All of the clinically reported compound mutations include at least 1 of the 12 key positions, and most (65%) include 2. Each position has been implicated in resistance to 1 or more TKIs, including imatinib, nilotinib, dasatinib, bosutinib, rebastinib, and ponatinib.

The researchers found that some of the compound mutations they studied conferred resistance several-fold higher than that of either contributing mutation alone.

“We were able to sequence about 100 clinical samples, which gave us a very large body of data to shed light on the number of compound mutations and how they develop,” said Michael Deininger, MD, PhD, also of the Huntsman Cancer Institute.

“One key finding was that compound mutations containing an already known mutation called T315I tend to confer complete resistance to all available TKIs.”

The researchers had focused their testing on ponatinib, as the drug has proven effective against resistant CML, particularly cases with the T315I mutation. Unfortunately, ponatinib was often no match for compound mutations including T315I.

Tests did suggest that a 30 mg/day dose of ponatinib would maintain efficacy against 7 of the 8 non-T315I compound mutants tested, though the Y253H/E255V mutant proved resistant.

The researchers also found that a 15 mg/day dose of ponatinib could pre-empt outgrowth of 5 of the 8 non-T315I compound mutants, though Y253H/E255V, E255V/V299L, and F317L/F359V might be problematic.

But ponatinib proved substantially less effective against T315I-inclusive compound mutants. Nine of 10 T315I-inclusive compound mutants showed little or no sensitivity to ponatinib or any of the other TKIs tested. M244V/T315I was the only compound mutant not resistant to ponatinib.

The researchers noted that because ponatinib has proven effective against the T315I mutant in isolation, many patients treated with ponatinib are likely to have this mutation.

So it may be necessary to perform more sensitive screening on these patients to determine whether they might have T315I-inclusive compound mutants that could confer resistance.

“Fortunately, the problems we are studying affect a minority of CML patients,” Dr O’Hare said. “[S]till, this leaves some patients with no good treatment option at all. Our goal is to have a TKI option for every patient.”

According to Dr O’Hare, it’s only a matter of time until analogous compound mutations emerge in many other cancers, including acute myeloid leukemia and non-small cell lung cancer.

“Our findings in CML will provide a blueprint for contending with resistance in these highly aggressive diseases as well,” he concluded.

Recently, Federal Practitioner talked with Sanjai Sharma, MD, about how signaling pathways in chronic lymphocytic leukemia (CLL) is critical to the development of therapeutic agents to treat this disease. Ibrutinib and idelalisib are therapeutic agents that block signaling pathways and, therefore, inhibit the growth of CLL cells.

For more information about CLL, read "Signaling Pathways and Novel Inhibitors in Chronic Lymphocytic Leukemia," in our August 2014 issue.

Dr. Sharma is a physician at the West Los Angeles VA Medical Center and associate professor in the Department of Medicine, Hematology/Oncology at UCLA, both in California.

Recently, Federal Practitioner talked with Sanjai Sharma, MD, about how signaling pathways in chronic lymphocytic leukemia (CLL) is critical to the development of therapeutic agents to treat this disease. Ibrutinib and idelalisib are therapeutic agents that block signaling pathways and, therefore, inhibit the growth of CLL cells.

For more information about CLL, read "Signaling Pathways and Novel Inhibitors in Chronic Lymphocytic Leukemia," in our August 2014 issue.

Dr. Sharma is a physician at the West Los Angeles VA Medical Center and associate professor in the Department of Medicine, Hematology/Oncology at UCLA, both in California.

Recently, Federal Practitioner talked with Sanjai Sharma, MD, about how signaling pathways in chronic lymphocytic leukemia (CLL) is critical to the development of therapeutic agents to treat this disease. Ibrutinib and idelalisib are therapeutic agents that block signaling pathways and, therefore, inhibit the growth of CLL cells.

For more information about CLL, read "Signaling Pathways and Novel Inhibitors in Chronic Lymphocytic Leukemia," in our August 2014 issue.

Dr. Sharma is a physician at the West Los Angeles VA Medical Center and associate professor in the Department of Medicine, Hematology/Oncology at UCLA, both in California.

Blood smear showing MDS

The UK’s National Institute for Health and Care Excellence (NICE) has issued a final draft guidance recommending lenalidomide (Revlimid) as an option for treating myelodysplastic syndromes (MDS) characterized by 5q deletion.

Lenalidomide is approved in the European Union to treat transfusion-dependent anemia caused by low- or intermediate-1 risk MDS characterized by 5q deletion when other therapeutic options are insufficient or inadequate.

However, the main treatment option for this patient population in the UK is best supportive care, which involves regular red blood cell transfusions.

In earlier draft guidances, NICE did not support lenalidomide use in MDS patients with 5q deletion. Although data suggested the drug is effective for these patients, a NICE advisory committee was not convinced the drug provided a survival benefit.

But now, the committee has concluded that lenalidomide is a clinically effective treatment for these patients because it is associated with a statistically significant improvement in transfusion independence and health-related quality of life compared with placebo.

Furthermore, the committee said it is plausible that lenalidomide can indirectly improve overall survival by improving transfusion independence.

“The committee heard from clinical experts that lenalidomide is an effective therapy,” said Sir Andrew Dillon, NICE chief executive.

“Celgene–who market lenalidomide–worked with us to provide enough evidence to make it possible for us to recommend it for this group of people. Celgene provided a revised analysis and further information on their proposal for a reduction in the cost of the drug to the NHS [National Health Service].”

This patient access scheme involves the NHS paying for lenalidomide treatment for up to 26 monthly cycles. And Celgene will provide the drug free of charge for those people who receive more than 26 monthly cycles.

Lenalidomide is available in 21-day packs of 10 mg and 5 mg capsules at net prices of £3780 and £3570, respectively. The cost of a 28-day cycle of treatment with 10 mg of lenalidomide (excluding value-added tax) is £3780.

The committee noted that the incremental cost-effectiveness ratio for lenalidomide compared with best supportive care is uncertain because the proportion of people who might need treatment beyond 26 cycles is uncertain.

However, the committee accepted that a commitment from Celgene to publish data on the proportion of people receiving treatment beyond 26 cycles would provide reassurance that lenalidomide is a cost-effective use of NHS resources in MDS patients with 5q deletion.

NICE’s final draft guidance is now with consultees, who have the opportunity to appeal against it. Until NICE issues a final guidance, NHS bodies should make decisions locally on the funding of specific treatments.

Blood smear showing MDS

The UK’s National Institute for Health and Care Excellence (NICE) has issued a final draft guidance recommending lenalidomide (Revlimid) as an option for treating myelodysplastic syndromes (MDS) characterized by 5q deletion.

Lenalidomide is approved in the European Union to treat transfusion-dependent anemia caused by low- or intermediate-1 risk MDS characterized by 5q deletion when other therapeutic options are insufficient or inadequate.

However, the main treatment option for this patient population in the UK is best supportive care, which involves regular red blood cell transfusions.

In earlier draft guidances, NICE did not support lenalidomide use in MDS patients with 5q deletion. Although data suggested the drug is effective for these patients, a NICE advisory committee was not convinced the drug provided a survival benefit.

But now, the committee has concluded that lenalidomide is a clinically effective treatment for these patients because it is associated with a statistically significant improvement in transfusion independence and health-related quality of life compared with placebo.

Furthermore, the committee said it is plausible that lenalidomide can indirectly improve overall survival by improving transfusion independence.

“The committee heard from clinical experts that lenalidomide is an effective therapy,” said Sir Andrew Dillon, NICE chief executive.

“Celgene–who market lenalidomide–worked with us to provide enough evidence to make it possible for us to recommend it for this group of people. Celgene provided a revised analysis and further information on their proposal for a reduction in the cost of the drug to the NHS [National Health Service].”

This patient access scheme involves the NHS paying for lenalidomide treatment for up to 26 monthly cycles. And Celgene will provide the drug free of charge for those people who receive more than 26 monthly cycles.

Lenalidomide is available in 21-day packs of 10 mg and 5 mg capsules at net prices of £3780 and £3570, respectively. The cost of a 28-day cycle of treatment with 10 mg of lenalidomide (excluding value-added tax) is £3780.

The committee noted that the incremental cost-effectiveness ratio for lenalidomide compared with best supportive care is uncertain because the proportion of people who might need treatment beyond 26 cycles is uncertain.

However, the committee accepted that a commitment from Celgene to publish data on the proportion of people receiving treatment beyond 26 cycles would provide reassurance that lenalidomide is a cost-effective use of NHS resources in MDS patients with 5q deletion.

NICE’s final draft guidance is now with consultees, who have the opportunity to appeal against it. Until NICE issues a final guidance, NHS bodies should make decisions locally on the funding of specific treatments.

Blood smear showing MDS

The UK’s National Institute for Health and Care Excellence (NICE) has issued a final draft guidance recommending lenalidomide (Revlimid) as an option for treating myelodysplastic syndromes (MDS) characterized by 5q deletion.

Lenalidomide is approved in the European Union to treat transfusion-dependent anemia caused by low- or intermediate-1 risk MDS characterized by 5q deletion when other therapeutic options are insufficient or inadequate.

However, the main treatment option for this patient population in the UK is best supportive care, which involves regular red blood cell transfusions.

In earlier draft guidances, NICE did not support lenalidomide use in MDS patients with 5q deletion. Although data suggested the drug is effective for these patients, a NICE advisory committee was not convinced the drug provided a survival benefit.

But now, the committee has concluded that lenalidomide is a clinically effective treatment for these patients because it is associated with a statistically significant improvement in transfusion independence and health-related quality of life compared with placebo.

Furthermore, the committee said it is plausible that lenalidomide can indirectly improve overall survival by improving transfusion independence.

“The committee heard from clinical experts that lenalidomide is an effective therapy,” said Sir Andrew Dillon, NICE chief executive.

“Celgene–who market lenalidomide–worked with us to provide enough evidence to make it possible for us to recommend it for this group of people. Celgene provided a revised analysis and further information on their proposal for a reduction in the cost of the drug to the NHS [National Health Service].”

This patient access scheme involves the NHS paying for lenalidomide treatment for up to 26 monthly cycles. And Celgene will provide the drug free of charge for those people who receive more than 26 monthly cycles.

Lenalidomide is available in 21-day packs of 10 mg and 5 mg capsules at net prices of £3780 and £3570, respectively. The cost of a 28-day cycle of treatment with 10 mg of lenalidomide (excluding value-added tax) is £3780.

The committee noted that the incremental cost-effectiveness ratio for lenalidomide compared with best supportive care is uncertain because the proportion of people who might need treatment beyond 26 cycles is uncertain.

However, the committee accepted that a commitment from Celgene to publish data on the proportion of people receiving treatment beyond 26 cycles would provide reassurance that lenalidomide is a cost-effective use of NHS resources in MDS patients with 5q deletion.

NICE’s final draft guidance is now with consultees, who have the opportunity to appeal against it. Until NICE issues a final guidance, NHS bodies should make decisions locally on the funding of specific treatments.

An NK cell in action

Credit: Bjorn Onfelt/Dan Davis

In vitro experiments suggest a patient’s own natural killer (NK) cells can be expanded and modified to fight acute lymphoblastic leukemia (ALL).

Researchers successfully expanded CD56+ cells isolated from the bone marrow and peripheral blood of ALL patients.

And these cells exhibited cytotoxicity against the patients’ own ALL cells. The effect was enhanced by the addition of IL-15 and a monoclonal antibody (mAb) targeting BAFF-R.

Hisham Abdel-Azim, MD, of Children’s Hospital Los Angeles, and his colleagues reported these results in Leukemia.

The researchers first used flow cytometry to detect CD56+ cells in bone marrow and peripheral blood samples from ALL patients. The team discovered these cells were detectable at diagnosis, post-induction, and relapse.

To expand the cells, the researchers cocultured them with artificial antigen-presenting K562 clone 9.mbIL-21 cells. The expanded CD56+ cells demonstrated allogeneic cytotoxicity against ALL cells, even in the absence of antibody.

The addition of a mAb targeting BAFF-R enhanced CD56+ cells’ cytotoxicity against ALL cells. The activity of these CD56+ cells was comparable to that of NK cells derived from healthy patients.

The researchers also compared CD56+CD3- cells to CD56+CD3+ cells and found the CD3- cells exhibited increased levels of activation in antibody-mediated cellular cytotoxicity reactions. The CD56+CD3+ cells were not stimulated by BAFF-R mAbs.

The team then tested the NK cells’ autologous cytotoxicity. And, as in previous experiments, the CD56+ cells from ALL samples demonstrated nonantibody-dependent cytotoxicity and enhanced cytotoxicity in the presence of BAFF-R mAbs.

Finally, the researchers decided to investigate whether the addition of IL-2 or IL-15 could further stimulate CD56+ cells’ cytotoxicity. And while they found that both cytokines did the job, IL-15 proved more successful.

“These results are very promising, with potential as a part of first-line therapy and also as a treatment for eliminating any remaining cancer cells . . . following standard chemotherapy,” Dr Abdel-Azim said. “We anticipate additional preclinical testing and then a clinical trial to evaluate the therapy in children with leukemia.”

An NK cell in action

Credit: Bjorn Onfelt/Dan Davis

In vitro experiments suggest a patient’s own natural killer (NK) cells can be expanded and modified to fight acute lymphoblastic leukemia (ALL).

Researchers successfully expanded CD56+ cells isolated from the bone marrow and peripheral blood of ALL patients.

And these cells exhibited cytotoxicity against the patients’ own ALL cells. The effect was enhanced by the addition of IL-15 and a monoclonal antibody (mAb) targeting BAFF-R.

Hisham Abdel-Azim, MD, of Children’s Hospital Los Angeles, and his colleagues reported these results in Leukemia.

The researchers first used flow cytometry to detect CD56+ cells in bone marrow and peripheral blood samples from ALL patients. The team discovered these cells were detectable at diagnosis, post-induction, and relapse.

To expand the cells, the researchers cocultured them with artificial antigen-presenting K562 clone 9.mbIL-21 cells. The expanded CD56+ cells demonstrated allogeneic cytotoxicity against ALL cells, even in the absence of antibody.

The addition of a mAb targeting BAFF-R enhanced CD56+ cells’ cytotoxicity against ALL cells. The activity of these CD56+ cells was comparable to that of NK cells derived from healthy patients.

The researchers also compared CD56+CD3- cells to CD56+CD3+ cells and found the CD3- cells exhibited increased levels of activation in antibody-mediated cellular cytotoxicity reactions. The CD56+CD3+ cells were not stimulated by BAFF-R mAbs.

The team then tested the NK cells’ autologous cytotoxicity. And, as in previous experiments, the CD56+ cells from ALL samples demonstrated nonantibody-dependent cytotoxicity and enhanced cytotoxicity in the presence of BAFF-R mAbs.

Finally, the researchers decided to investigate whether the addition of IL-2 or IL-15 could further stimulate CD56+ cells’ cytotoxicity. And while they found that both cytokines did the job, IL-15 proved more successful.

“These results are very promising, with potential as a part of first-line therapy and also as a treatment for eliminating any remaining cancer cells . . . following standard chemotherapy,” Dr Abdel-Azim said. “We anticipate additional preclinical testing and then a clinical trial to evaluate the therapy in children with leukemia.”

An NK cell in action

Credit: Bjorn Onfelt/Dan Davis

In vitro experiments suggest a patient’s own natural killer (NK) cells can be expanded and modified to fight acute lymphoblastic leukemia (ALL).

Researchers successfully expanded CD56+ cells isolated from the bone marrow and peripheral blood of ALL patients.

And these cells exhibited cytotoxicity against the patients’ own ALL cells. The effect was enhanced by the addition of IL-15 and a monoclonal antibody (mAb) targeting BAFF-R.

Hisham Abdel-Azim, MD, of Children’s Hospital Los Angeles, and his colleagues reported these results in Leukemia.

The researchers first used flow cytometry to detect CD56+ cells in bone marrow and peripheral blood samples from ALL patients. The team discovered these cells were detectable at diagnosis, post-induction, and relapse.

To expand the cells, the researchers cocultured them with artificial antigen-presenting K562 clone 9.mbIL-21 cells. The expanded CD56+ cells demonstrated allogeneic cytotoxicity against ALL cells, even in the absence of antibody.

The addition of a mAb targeting BAFF-R enhanced CD56+ cells’ cytotoxicity against ALL cells. The activity of these CD56+ cells was comparable to that of NK cells derived from healthy patients.

The researchers also compared CD56+CD3- cells to CD56+CD3+ cells and found the CD3- cells exhibited increased levels of activation in antibody-mediated cellular cytotoxicity reactions. The CD56+CD3+ cells were not stimulated by BAFF-R mAbs.

The team then tested the NK cells’ autologous cytotoxicity. And, as in previous experiments, the CD56+ cells from ALL samples demonstrated nonantibody-dependent cytotoxicity and enhanced cytotoxicity in the presence of BAFF-R mAbs.

Finally, the researchers decided to investigate whether the addition of IL-2 or IL-15 could further stimulate CD56+ cells’ cytotoxicity. And while they found that both cytokines did the job, IL-15 proved more successful.

“These results are very promising, with potential as a part of first-line therapy and also as a treatment for eliminating any remaining cancer cells . . . following standard chemotherapy,” Dr Abdel-Azim said. “We anticipate additional preclinical testing and then a clinical trial to evaluate the therapy in children with leukemia.”

Doctor consults with cancer

patient and her father

Credit: Rhoda Baer

Guidelines developed almost 20 years ago can accurately predict infertility in girls with cancer, according to research published in The Lancet Oncology.

Researchers found the criteria in these guidelines can help healthcare professionals select which girls should be given the option of ovarian tissue cryopreservation.

The team noted that taking the initial samples of ovarian tissue involves a surgical technique that is still relatively experimental.

So it is crucial to accurately predict which patients are most likely to benefit from the procedure and when it can be safely performed.

The guidelines, known as the Edinburgh selection criteria, were instituted in 1996 to help healthcare professionals decide which girls should be given the option of cryopreservation, based on their age, type of cancer treatment, and their chance of cure.

Specifically, patients were required to meet the following criteria:

• Age younger than 35 years
• No previous chemotherapy or radiotherapy if 15 years or older at diagnosis, but mild, non-gonadotoxic chemotherapy was acceptable if a patient was younger than 15
• A realistic chance of surviving for 5 years
• A high risk of premature ovarian insufficiency (>50%)
• Informed consent (from parents and the patient, if possible)
• Negative serology results for HIV, syphilis, and hepatitis B
• Not pregnant and no existing children.

Testing the guidelines

To validate the selection criteria, W. Hamish B. Wallace, MD, of the Royal Hospital for Sick Children in Edinburgh, UK, and his colleagues analyzed 410 female cancer patients who were younger than 18 years at their time of diagnosis.

The patients were treated between January 1, 1996, and June 30, 2012, at the Edinburgh Children’s Cancer Centre, which serves the southeast region of Scotland.

In all, 34 patients (8%) met the Edinburgh selection criteria and were given the option of ovarian tissue cryopreservation before starting cancer treatment. Thirteen patients declined, 21 consented, and 20 had a successful procedure.

The researchers were able to assess ovarian function in 14 of the 20 patients with successful cryopreservation and 6 of the 13 patients who declined the procedure.

Of the 14 evaluable patients who underwent cryopreservation, 6 developed premature ovarian insufficiency at a median age of 13.4 years (range, 12.5–14.6), but 1 of these patients also had a natural pregnancy.

One patient each among the 6 evaluable patients who declined cryopreservation and the 141 evaluable patients who were not offered cryopreservation developed premature ovarian insufficiency.

So, overall, the probability of ovarian insufficiency was significantly higher for patients who met the Edinburgh selection criteria than for those who did not. The 15-year probability was 35% and 1%, respectively (P<0.0001).

The researchers said these results validate the use of the selection criteria, as they can accurately identify patients who will likely develop premature ovarian insufficiency.

“Advances in life-saving treatments mean that more and more young people with cancer are surviving the disease,” Dr Wallace said. “Here, we have an opportunity to help young women to have families of their own when they grow up, if they so choose.”

Doctor consults with cancer

patient and her father

Credit: Rhoda Baer

Guidelines developed almost 20 years ago can accurately predict infertility in girls with cancer, according to research published in The Lancet Oncology.

Researchers found the criteria in these guidelines can help healthcare professionals select which girls should be given the option of ovarian tissue cryopreservation.

The team noted that taking the initial samples of ovarian tissue involves a surgical technique that is still relatively experimental.

So it is crucial to accurately predict which patients are most likely to benefit from the procedure and when it can be safely performed.

The guidelines, known as the Edinburgh selection criteria, were instituted in 1996 to help healthcare professionals decide which girls should be given the option of cryopreservation, based on their age, type of cancer treatment, and their chance of cure.

Specifically, patients were required to meet the following criteria:

• Age younger than 35 years
• No previous chemotherapy or radiotherapy if 15 years or older at diagnosis, but mild, non-gonadotoxic chemotherapy was acceptable if a patient was younger than 15
• A realistic chance of surviving for 5 years
• A high risk of premature ovarian insufficiency (>50%)
• Informed consent (from parents and the patient, if possible)
• Negative serology results for HIV, syphilis, and hepatitis B
• Not pregnant and no existing children.

Testing the guidelines

To validate the selection criteria, W. Hamish B. Wallace, MD, of the Royal Hospital for Sick Children in Edinburgh, UK, and his colleagues analyzed 410 female cancer patients who were younger than 18 years at their time of diagnosis.

The patients were treated between January 1, 1996, and June 30, 2012, at the Edinburgh Children’s Cancer Centre, which serves the southeast region of Scotland.

In all, 34 patients (8%) met the Edinburgh selection criteria and were given the option of ovarian tissue cryopreservation before starting cancer treatment. Thirteen patients declined, 21 consented, and 20 had a successful procedure.

The researchers were able to assess ovarian function in 14 of the 20 patients with successful cryopreservation and 6 of the 13 patients who declined the procedure.

Of the 14 evaluable patients who underwent cryopreservation, 6 developed premature ovarian insufficiency at a median age of 13.4 years (range, 12.5–14.6), but 1 of these patients also had a natural pregnancy.

One patient each among the 6 evaluable patients who declined cryopreservation and the 141 evaluable patients who were not offered cryopreservation developed premature ovarian insufficiency.

So, overall, the probability of ovarian insufficiency was significantly higher for patients who met the Edinburgh selection criteria than for those who did not. The 15-year probability was 35% and 1%, respectively (P<0.0001).

The researchers said these results validate the use of the selection criteria, as they can accurately identify patients who will likely develop premature ovarian insufficiency.

“Advances in life-saving treatments mean that more and more young people with cancer are surviving the disease,” Dr Wallace said. “Here, we have an opportunity to help young women to have families of their own when they grow up, if they so choose.”

Doctor consults with cancer

patient and her father

Credit: Rhoda Baer

Guidelines developed almost 20 years ago can accurately predict infertility in girls with cancer, according to research published in The Lancet Oncology.

Researchers found the criteria in these guidelines can help healthcare professionals select which girls should be given the option of ovarian tissue cryopreservation.

The team noted that taking the initial samples of ovarian tissue involves a surgical technique that is still relatively experimental.

So it is crucial to accurately predict which patients are most likely to benefit from the procedure and when it can be safely performed.

The guidelines, known as the Edinburgh selection criteria, were instituted in 1996 to help healthcare professionals decide which girls should be given the option of cryopreservation, based on their age, type of cancer treatment, and their chance of cure.

Specifically, patients were required to meet the following criteria:

• Age younger than 35 years
• No previous chemotherapy or radiotherapy if 15 years or older at diagnosis, but mild, non-gonadotoxic chemotherapy was acceptable if a patient was younger than 15
• A realistic chance of surviving for 5 years
• A high risk of premature ovarian insufficiency (>50%)
• Informed consent (from parents and the patient, if possible)
• Negative serology results for HIV, syphilis, and hepatitis B
• Not pregnant and no existing children.

Testing the guidelines

To validate the selection criteria, W. Hamish B. Wallace, MD, of the Royal Hospital for Sick Children in Edinburgh, UK, and his colleagues analyzed 410 female cancer patients who were younger than 18 years at their time of diagnosis.

The patients were treated between January 1, 1996, and June 30, 2012, at the Edinburgh Children’s Cancer Centre, which serves the southeast region of Scotland.

In all, 34 patients (8%) met the Edinburgh selection criteria and were given the option of ovarian tissue cryopreservation before starting cancer treatment. Thirteen patients declined, 21 consented, and 20 had a successful procedure.

The researchers were able to assess ovarian function in 14 of the 20 patients with successful cryopreservation and 6 of the 13 patients who declined the procedure.

Of the 14 evaluable patients who underwent cryopreservation, 6 developed premature ovarian insufficiency at a median age of 13.4 years (range, 12.5–14.6), but 1 of these patients also had a natural pregnancy.

One patient each among the 6 evaluable patients who declined cryopreservation and the 141 evaluable patients who were not offered cryopreservation developed premature ovarian insufficiency.

So, overall, the probability of ovarian insufficiency was significantly higher for patients who met the Edinburgh selection criteria than for those who did not. The 15-year probability was 35% and 1%, respectively (P<0.0001).

The researchers said these results validate the use of the selection criteria, as they can accurately identify patients who will likely develop premature ovarian insufficiency.

“Advances in life-saving treatments mean that more and more young people with cancer are surviving the disease,” Dr Wallace said. “Here, we have an opportunity to help young women to have families of their own when they grow up, if they so choose.”

Nude mouse

Credit: Armin Kübelbeck

Preclinical experiments may have revealed why some cancer patients do not respond to retinoic acid.

Investigators found that a protein known as AEG-1 blocks the effects of retinoic acid in acute myeloid leukemia (AML) and liver cancer.

They also noted that AEG-1 is overexpressed in nearly every cancer type, so these findings could impact the care of countless cancer patients.

The team reported their findings in Cancer Research.

The group’s experiments revealed that AEG-1 binds to retinoid X receptors (RXR), which help regulate cell growth and development. RXR is typically activated by retinoic acid, but the overexpressed AEG-1 proteins found in cancer cells block these signals and help promote tumor growth.

“Our findings are the first to show that AEG-1 interacts with the retinoid X receptor,” said study author Devanand Sarkar, MBBS, PhD, of Virginia Commonwealth University Massey Cancer Center in Richmond.

Specifically, he and his colleagues found that AEG-1 protected hepatocellular carcinoma cells and AML cells from retinoid- and rexinoid-induced cell death.

But in nude mouse models, blocking the production of AEG-1 allowed all-trans retinoic acid to kill hepatocellular carcinoma cells.

The investigators therefore believe that targeting AEG-1 could sensitize AML patients and those with hepatocellular carcinoma to retinoid- and rexinoid-based therapies.

“This research has immediate clinical relevance, such that physicians could begin screening cancer patients for AEG-1 expression levels in order to determine whether retinoic acid should be prescribed,” Dr Sarkar added.

He and his colleagues have been studying AEG-1 for years. They were the first to create a mouse model demonstrating the role of AEG-1 in liver cancer, and they have been working to develop targeted therapies that block AEG-1 production.

The present study expanded their knowledge of the molecular interactions of AEG-1.

“We are continuing to test combination therapies involving AEG-1 inhibition and retinoic acid in animal models, and the initial results are promising,” Dr Sarkar said. “If we continue to see these results in more complex experiments, we hope to eventually propose a phase 1 clinical trial in patients with liver cancer.”

Nude mouse

Credit: Armin Kübelbeck

Preclinical experiments may have revealed why some cancer patients do not respond to retinoic acid.

Investigators found that a protein known as AEG-1 blocks the effects of retinoic acid in acute myeloid leukemia (AML) and liver cancer.

They also noted that AEG-1 is overexpressed in nearly every cancer type, so these findings could impact the care of countless cancer patients.

The team reported their findings in Cancer Research.

The group’s experiments revealed that AEG-1 binds to retinoid X receptors (RXR), which help regulate cell growth and development. RXR is typically activated by retinoic acid, but the overexpressed AEG-1 proteins found in cancer cells block these signals and help promote tumor growth.

“Our findings are the first to show that AEG-1 interacts with the retinoid X receptor,” said study author Devanand Sarkar, MBBS, PhD, of Virginia Commonwealth University Massey Cancer Center in Richmond.

Specifically, he and his colleagues found that AEG-1 protected hepatocellular carcinoma cells and AML cells from retinoid- and rexinoid-induced cell death.

But in nude mouse models, blocking the production of AEG-1 allowed all-trans retinoic acid to kill hepatocellular carcinoma cells.

The investigators therefore believe that targeting AEG-1 could sensitize AML patients and those with hepatocellular carcinoma to retinoid- and rexinoid-based therapies.

“This research has immediate clinical relevance, such that physicians could begin screening cancer patients for AEG-1 expression levels in order to determine whether retinoic acid should be prescribed,” Dr Sarkar added.

He and his colleagues have been studying AEG-1 for years. They were the first to create a mouse model demonstrating the role of AEG-1 in liver cancer, and they have been working to develop targeted therapies that block AEG-1 production.

The present study expanded their knowledge of the molecular interactions of AEG-1.

“We are continuing to test combination therapies involving AEG-1 inhibition and retinoic acid in animal models, and the initial results are promising,” Dr Sarkar said. “If we continue to see these results in more complex experiments, we hope to eventually propose a phase 1 clinical trial in patients with liver cancer.”

Nude mouse

Credit: Armin Kübelbeck

Preclinical experiments may have revealed why some cancer patients do not respond to retinoic acid.

Investigators found that a protein known as AEG-1 blocks the effects of retinoic acid in acute myeloid leukemia (AML) and liver cancer.

They also noted that AEG-1 is overexpressed in nearly every cancer type, so these findings could impact the care of countless cancer patients.

The team reported their findings in Cancer Research.

The group’s experiments revealed that AEG-1 binds to retinoid X receptors (RXR), which help regulate cell growth and development. RXR is typically activated by retinoic acid, but the overexpressed AEG-1 proteins found in cancer cells block these signals and help promote tumor growth.

“Our findings are the first to show that AEG-1 interacts with the retinoid X receptor,” said study author Devanand Sarkar, MBBS, PhD, of Virginia Commonwealth University Massey Cancer Center in Richmond.

Specifically, he and his colleagues found that AEG-1 protected hepatocellular carcinoma cells and AML cells from retinoid- and rexinoid-induced cell death.

But in nude mouse models, blocking the production of AEG-1 allowed all-trans retinoic acid to kill hepatocellular carcinoma cells.

The investigators therefore believe that targeting AEG-1 could sensitize AML patients and those with hepatocellular carcinoma to retinoid- and rexinoid-based therapies.

“This research has immediate clinical relevance, such that physicians could begin screening cancer patients for AEG-1 expression levels in order to determine whether retinoic acid should be prescribed,” Dr Sarkar added.

He and his colleagues have been studying AEG-1 for years. They were the first to create a mouse model demonstrating the role of AEG-1 in liver cancer, and they have been working to develop targeted therapies that block AEG-1 production.

The present study expanded their knowledge of the molecular interactions of AEG-1.

“We are continuing to test combination therapies involving AEG-1 inhibition and retinoic acid in animal models, and the initial results are promising,” Dr Sarkar said. “If we continue to see these results in more complex experiments, we hope to eventually propose a phase 1 clinical trial in patients with liver cancer.”

Recently, Federal Practitioner talked with Benjamin Powers, MD, and Suman Kambhampati, MD, about factors that come into play when treating patients with chronic myelogenous leukemia (CML) and the dramatic improvements in treatment that have been made. To find out more about these factors and improvements, read Blast Phase Chronic Myelogenous Leukemia from the August 2014 issue.

Dr. Powers is a fellow and Dr. Kambhampati is an associate professor of medicine, both in the Department of Internal Medicine, Division of Hematology/Oncology, at the University of Kansas Medical Center in Kansas City, Kansas. Dr. Kambhampati is also a staff physician in the Hematology/Oncology Division at the Kansas City VAMC in Kansas City, Missouri.

Recently, Federal Practitioner talked with Benjamin Powers, MD, and Suman Kambhampati, MD, about factors that come into play when treating patients with chronic myelogenous leukemia (CML) and the dramatic improvements in treatment that have been made. To find out more about these factors and improvements, read Blast Phase Chronic Myelogenous Leukemia from the August 2014 issue.

Dr. Powers is a fellow and Dr. Kambhampati is an associate professor of medicine, both in the Department of Internal Medicine, Division of Hematology/Oncology, at the University of Kansas Medical Center in Kansas City, Kansas. Dr. Kambhampati is also a staff physician in the Hematology/Oncology Division at the Kansas City VAMC in Kansas City, Missouri.

Recently, Federal Practitioner talked with Benjamin Powers, MD, and Suman Kambhampati, MD, about factors that come into play when treating patients with chronic myelogenous leukemia (CML) and the dramatic improvements in treatment that have been made. To find out more about these factors and improvements, read Blast Phase Chronic Myelogenous Leukemia from the August 2014 issue.

Dr. Powers is a fellow and Dr. Kambhampati is an associate professor of medicine, both in the Department of Internal Medicine, Division of Hematology/Oncology, at the University of Kansas Medical Center in Kansas City, Kansas. Dr. Kambhampati is also a staff physician in the Hematology/Oncology Division at the Kansas City VAMC in Kansas City, Missouri.

ALL cells in the bone marrow

Two genes appear to play a key role in acute lymphoblastic leukemia (ALL), particularly for patients who also have Down syndrome.

Researchers found evidence suggesting that 2 in 3 cases of ALL among patients with Down syndrome may be caused by mutations in RAS or JAK2, but the mutations tend not to occur together.

The group therefore believes that if we can begin to identify which of the genes is mutated in ALL patients, we can tailor therapy accordingly.

“We believe our findings are a breakthrough in understanding the underlying causes of leukemia, and, eventually, we hope to design more tailored and effective treatment for this cancer, with less toxic drugs and less side effects,” said study author Dean Nizetic, MD, PhD, a professor at both Queen Mary University of London in the UK and Lee Kong Chian School of Medicine in Singapore.

He and his colleagues reported their findings in Nature Communications.

The researchers conducted full-exome or targeted sequencing in 42 samples from 39 patients with ALL and Down syndrome. The team found similar recurrence rates for driver mutations in RAS (15/42), JAK2 mutations (12/42), and P2RY8-CRLF2 fusions (14/42).

Together, RAS and JAK2 mutations drove two-thirds of the ALL cases, though the mutations were almost completely mutually exclusive (P=0.016).

The researchers also noted that, in two-thirds of patients with relapsed ALL, there was a switch from a primary JAK2- or PTPN11-mutated subclone to a RAS-mutated subclone in relapse.

Moving forward, the team plans to conduct more studies to determine how else RAS and JAK2 might affect children who have ALL, with or without Down syndrome.

ALL cells in the bone marrow

Two genes appear to play a key role in acute lymphoblastic leukemia (ALL), particularly for patients who also have Down syndrome.

Researchers found evidence suggesting that 2 in 3 cases of ALL among patients with Down syndrome may be caused by mutations in RAS or JAK2, but the mutations tend not to occur together.

The group therefore believes that if we can begin to identify which of the genes is mutated in ALL patients, we can tailor therapy accordingly.

“We believe our findings are a breakthrough in understanding the underlying causes of leukemia, and, eventually, we hope to design more tailored and effective treatment for this cancer, with less toxic drugs and less side effects,” said study author Dean Nizetic, MD, PhD, a professor at both Queen Mary University of London in the UK and Lee Kong Chian School of Medicine in Singapore.

He and his colleagues reported their findings in Nature Communications.

The researchers conducted full-exome or targeted sequencing in 42 samples from 39 patients with ALL and Down syndrome. The team found similar recurrence rates for driver mutations in RAS (15/42), JAK2 mutations (12/42), and P2RY8-CRLF2 fusions (14/42).

Together, RAS and JAK2 mutations drove two-thirds of the ALL cases, though the mutations were almost completely mutually exclusive (P=0.016).

The researchers also noted that, in two-thirds of patients with relapsed ALL, there was a switch from a primary JAK2- or PTPN11-mutated subclone to a RAS-mutated subclone in relapse.

Moving forward, the team plans to conduct more studies to determine how else RAS and JAK2 might affect children who have ALL, with or without Down syndrome.

ALL cells in the bone marrow

Two genes appear to play a key role in acute lymphoblastic leukemia (ALL), particularly for patients who also have Down syndrome.

Researchers found evidence suggesting that 2 in 3 cases of ALL among patients with Down syndrome may be caused by mutations in RAS or JAK2, but the mutations tend not to occur together.

The group therefore believes that if we can begin to identify which of the genes is mutated in ALL patients, we can tailor therapy accordingly.

“We believe our findings are a breakthrough in understanding the underlying causes of leukemia, and, eventually, we hope to design more tailored and effective treatment for this cancer, with less toxic drugs and less side effects,” said study author Dean Nizetic, MD, PhD, a professor at both Queen Mary University of London in the UK and Lee Kong Chian School of Medicine in Singapore.

He and his colleagues reported their findings in Nature Communications.

The researchers conducted full-exome or targeted sequencing in 42 samples from 39 patients with ALL and Down syndrome. The team found similar recurrence rates for driver mutations in RAS (15/42), JAK2 mutations (12/42), and P2RY8-CRLF2 fusions (14/42).

Together, RAS and JAK2 mutations drove two-thirds of the ALL cases, though the mutations were almost completely mutually exclusive (P=0.016).

The researchers also noted that, in two-thirds of patients with relapsed ALL, there was a switch from a primary JAK2- or PTPN11-mutated subclone to a RAS-mutated subclone in relapse.

Moving forward, the team plans to conduct more studies to determine how else RAS and JAK2 might affect children who have ALL, with or without Down syndrome.

Preparing pills for a trial

Credit: Esther Dyson

The US Food and Drug Administration (FDA) has granted fast track designation for AG-221 to treat acute myelogenous leukemia (AML) patients with mutated isocitrate dehydrogenase-2 (IDH2).

AG-221 is an IDH2 inhibitor under evaluation in a phase 1 trial of patients with advanced hematologic malignancies.

Results from this trial were presented at the 19th Congress of the European Hematology Association, which took place in Milan in June.

The FDA’s fast track drug development program is designed to expedite clinical development and submission of a new drug application (NDA) for drugs with the potential to treat serious or life-threatening conditions and address unmet medical needs.

Fast track designation facilitates meetings between the FDA and the company developing a drug to discuss all aspects of development to support approval. It also affords the developer the opportunity to submit sections of an NDA on a rolling basis as data become available, so the FDA does not have wait for the entire NDA submission before beginning its review.

AG-221 also recently received orphan designation as a treatment for AML. The FDA grants orphan status to support the development of drugs for underserved patient populations or rare disorders that affect fewer than 200,000 people in the US.

Orphan designation affords the drug’s developer certain benefits, including market exclusivity upon regulatory approval, exemption of FDA application fees, and tax credits for qualified clinical trials.

Phase 1 trial results

Thus far in the phase 1 study, AG-221 has proven active and well-tolerated in patients with AML, myelodysplastic syndromes (MDS), and chronic myelomonocytic leukemia (CMML).

The trial included 35 patients with a median age of 68 years (range, 48-81).

Twenty-seven patients had relapsed/refractory AML, 4 had relapsed/refractory MDS, 2 had untreated AML, 1 had CMML, and 1 had granulocytic sarcoma. Thirty-one patients had R140Q IDH2 mutations, and 4 had R172K IDH2 mutations.

The patients received AG-221 at doses ranging from 30 mg BID to 150 mg QD. Patients completed a median of 1 cycle of treatment (range, <1-5+) and a mean of 2 cycles.

The drug was generally well-tolerated, largely prompting grade 1 or 2 adverse events. Grade 3 or higher events included thrombocytopenia (n=3), anemia (n=1), febrile neutropenia (n=3), sepsis (n=3), diarrhea (n=1), fatigue (n=1), leukocytosis (n=2), neutropenia (n=1), and rash (n=1).

Four patients had serious events possibly related to treatment. One patient had grade 3 confusion and grade 5 respiratory failure. One patient had grade 3 leukocytosis, grade 3 anorexia, and grade 1 nausea. One patient had grade 3 diarrhea. And 1 patient had grade 3 leukocytosis.

Twenty-five patients were evaluable for response. There were 6 complete responses (CRs), 2 CRs with incomplete platelet recovery, 1 CR with incomplete hematologic recovery, and 5 partial responses. Five patients had stable disease, and 6 had progressive disease.

The most responses occurred among patients who received AG-221 at 50 mg BID, and most responses occurred in cycle 1.

Twelve of the 14 responses are ongoing. Of the 8 patients who achieved a CR or CR with incomplete platelet recovery, 5 have lasted more than 2.5 months (range, 1-4+ months). And the 5 patients with stable disease remain on study.

This study is sponsored by Agios Pharmaceuticals Inc., the company developing AG-221 in collaboration with Celgene.

Preparing pills for a trial

Credit: Esther Dyson

The US Food and Drug Administration (FDA) has granted fast track designation for AG-221 to treat acute myelogenous leukemia (AML) patients with mutated isocitrate dehydrogenase-2 (IDH2).

AG-221 is an IDH2 inhibitor under evaluation in a phase 1 trial of patients with advanced hematologic malignancies.

Results from this trial were presented at the 19th Congress of the European Hematology Association, which took place in Milan in June.

The FDA’s fast track drug development program is designed to expedite clinical development and submission of a new drug application (NDA) for drugs with the potential to treat serious or life-threatening conditions and address unmet medical needs.

Fast track designation facilitates meetings between the FDA and the company developing a drug to discuss all aspects of development to support approval. It also affords the developer the opportunity to submit sections of an NDA on a rolling basis as data become available, so the FDA does not have wait for the entire NDA submission before beginning its review.

AG-221 also recently received orphan designation as a treatment for AML. The FDA grants orphan status to support the development of drugs for underserved patient populations or rare disorders that affect fewer than 200,000 people in the US.

Orphan designation affords the drug’s developer certain benefits, including market exclusivity upon regulatory approval, exemption of FDA application fees, and tax credits for qualified clinical trials.

Phase 1 trial results

Thus far in the phase 1 study, AG-221 has proven active and well-tolerated in patients with AML, myelodysplastic syndromes (MDS), and chronic myelomonocytic leukemia (CMML).

The trial included 35 patients with a median age of 68 years (range, 48-81).

Twenty-seven patients had relapsed/refractory AML, 4 had relapsed/refractory MDS, 2 had untreated AML, 1 had CMML, and 1 had granulocytic sarcoma. Thirty-one patients had R140Q IDH2 mutations, and 4 had R172K IDH2 mutations.

The patients received AG-221 at doses ranging from 30 mg BID to 150 mg QD. Patients completed a median of 1 cycle of treatment (range, <1-5+) and a mean of 2 cycles.

The drug was generally well-tolerated, largely prompting grade 1 or 2 adverse events. Grade 3 or higher events included thrombocytopenia (n=3), anemia (n=1), febrile neutropenia (n=3), sepsis (n=3), diarrhea (n=1), fatigue (n=1), leukocytosis (n=2), neutropenia (n=1), and rash (n=1).

Four patients had serious events possibly related to treatment. One patient had grade 3 confusion and grade 5 respiratory failure. One patient had grade 3 leukocytosis, grade 3 anorexia, and grade 1 nausea. One patient had grade 3 diarrhea. And 1 patient had grade 3 leukocytosis.

Twenty-five patients were evaluable for response. There were 6 complete responses (CRs), 2 CRs with incomplete platelet recovery, 1 CR with incomplete hematologic recovery, and 5 partial responses. Five patients had stable disease, and 6 had progressive disease.

The most responses occurred among patients who received AG-221 at 50 mg BID, and most responses occurred in cycle 1.

Twelve of the 14 responses are ongoing. Of the 8 patients who achieved a CR or CR with incomplete platelet recovery, 5 have lasted more than 2.5 months (range, 1-4+ months). And the 5 patients with stable disease remain on study.

This study is sponsored by Agios Pharmaceuticals Inc., the company developing AG-221 in collaboration with Celgene.

Preparing pills for a trial

Credit: Esther Dyson

The US Food and Drug Administration (FDA) has granted fast track designation for AG-221 to treat acute myelogenous leukemia (AML) patients with mutated isocitrate dehydrogenase-2 (IDH2).

AG-221 is an IDH2 inhibitor under evaluation in a phase 1 trial of patients with advanced hematologic malignancies.

Results from this trial were presented at the 19th Congress of the European Hematology Association, which took place in Milan in June.

The FDA’s fast track drug development program is designed to expedite clinical development and submission of a new drug application (NDA) for drugs with the potential to treat serious or life-threatening conditions and address unmet medical needs.

Fast track designation facilitates meetings between the FDA and the company developing a drug to discuss all aspects of development to support approval. It also affords the developer the opportunity to submit sections of an NDA on a rolling basis as data become available, so the FDA does not have wait for the entire NDA submission before beginning its review.

AG-221 also recently received orphan designation as a treatment for AML. The FDA grants orphan status to support the development of drugs for underserved patient populations or rare disorders that affect fewer than 200,000 people in the US.

Orphan designation affords the drug’s developer certain benefits, including market exclusivity upon regulatory approval, exemption of FDA application fees, and tax credits for qualified clinical trials.

Phase 1 trial results

Thus far in the phase 1 study, AG-221 has proven active and well-tolerated in patients with AML, myelodysplastic syndromes (MDS), and chronic myelomonocytic leukemia (CMML).

The trial included 35 patients with a median age of 68 years (range, 48-81).

Twenty-seven patients had relapsed/refractory AML, 4 had relapsed/refractory MDS, 2 had untreated AML, 1 had CMML, and 1 had granulocytic sarcoma. Thirty-one patients had R140Q IDH2 mutations, and 4 had R172K IDH2 mutations.

The patients received AG-221 at doses ranging from 30 mg BID to 150 mg QD. Patients completed a median of 1 cycle of treatment (range, <1-5+) and a mean of 2 cycles.

The drug was generally well-tolerated, largely prompting grade 1 or 2 adverse events. Grade 3 or higher events included thrombocytopenia (n=3), anemia (n=1), febrile neutropenia (n=3), sepsis (n=3), diarrhea (n=1), fatigue (n=1), leukocytosis (n=2), neutropenia (n=1), and rash (n=1).

Four patients had serious events possibly related to treatment. One patient had grade 3 confusion and grade 5 respiratory failure. One patient had grade 3 leukocytosis, grade 3 anorexia, and grade 1 nausea. One patient had grade 3 diarrhea. And 1 patient had grade 3 leukocytosis.

Twenty-five patients were evaluable for response. There were 6 complete responses (CRs), 2 CRs with incomplete platelet recovery, 1 CR with incomplete hematologic recovery, and 5 partial responses. Five patients had stable disease, and 6 had progressive disease.

The most responses occurred among patients who received AG-221 at 50 mg BID, and most responses occurred in cycle 1.

Twelve of the 14 responses are ongoing. Of the 8 patients who achieved a CR or CR with incomplete platelet recovery, 5 have lasted more than 2.5 months (range, 1-4+ months). And the 5 patients with stable disease remain on study.

This study is sponsored by Agios Pharmaceuticals Inc., the company developing AG-221 in collaboration with Celgene.