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Ponatinib for FLT3-ITD Acute Myelogenous Leukemia (PONATINIB-AML)

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ClinicalTrials.gov Identifier: NCT02428543
Recruitment Status : Recruiting
First Posted : April 29, 2015
Last Update Posted : November 24, 2017
Sponsor:
Information provided by (Responsible Party):
Philippe ROUSSELOT, Versailles Hospital

Brief Summary:

This project is part of a joint ALFA and GOELAM strategy aiming to improve the survival of patients with newly diagnosed Acute Myeloid Leukemia (AML) aged 18-70 years. The basis of this strategy is to evaluate intensified conventional chemotherapy and targeted drugs in selected disease-risk subgroups of adult patients with non promyelocytic AML. Participation will be proposed to almost all adult patients in France aged 18-70 years and diagnosed with AML.

FLT3 genetic alterations include FLT3 somatic point mutations within the second tyrosine kinase domain and internal duplications of the juxta-membrane domain. This alteration is refered to as FLT3-ITD. The FLT3-ITD mutation is found in around 30% of patients with cytogenetically normal AML. Patients with the FLT3-ITD genotype have been reported to have a poor outcome when treated with conventional chemotherapy with an estimated 4-year relapse-free survival of 25% (Schlenk et al. N Engl J Med 2008). More recently, the prognostic relevance of FLT3-ITD has been studied in the context of integrated genetic profiling. This confirmed the genetic complexity of AML and also that FLT3-ITD was associated with reduced overall survival in intermediate-risk AML. A multivariate analysis of several genetic alterations revealed that FLT3-ITD was the primary predictor of patient outcome. FLT3-ITD mutations were classified in 3 categories: 1) FLT3-ITD with +8, TET2, DNMT3A or MLL-PTD mutations (3-year OS 14.5%); 2) FLT3-ITD with wild type CEBPA, TET2, DNMT3 and MLL-PTD (3-year OS 35.2%) and 3) FLT3-ITD with CEBPA mutations (3-year OS 42%) (Patel JP et al. N Engl J Med 2012). However, FLT3-ITD was not a predictor of response to induction therapy, allowing the introduction of targeted therapies after the induction course.

Several FLT3 inhibitors have been evaluated or are currently being tested in the setting of relapsing AML. In most trials to date, patients were only eligible if the FLT3-ITD mutation was present. Disappointing results were reported with the first generation of FLT3 inhibitors, including lestaurtinib (CEP-701), midostaurin (PKC-412) and sorafenib. Second generation FLT3 inhibitors such as quizartinib (AC220) are currently under investigation with promising results. However, the hematologic toxicity of AC220 will likely present a major limitation in evaluating AC220 combined with standard or high-dose chemotherapy.

Ponatinib (AP24534) is a third generation tyrosine kinase inhibitor targeting the BCR-ABL tyrosine kinase domain. Ponatinib was rationally designed with an extensive network of optimized molecular contacts and triple bonds to accommodate the T315I mutation, a major cause of resistance to tyrosine kinase inhibitors in chronic and advanced phase chronic myelogenous leukemia (CML). Ponatinib also inhibits SRC (IC50: 5.4 nM) and members of the VEGFR, FGFR, and PDGFR families of receptor tyrosine kinases (O'Hare T, Cancer Cell 2009). Despite low activity against FLT3 based on the IC50 value (FLT3 IC50: 12.6 nM compared to BCR IC50: 0.37 nM), ponatinib has recently been reported to have significant cellular activity against the MV4-11 cell line which harbors an FLT3-ITD activating mutation. Ponatinib-induced apoptosis was maximal at 10 nM in vitro and a single dose of 5 and 10 mg/kg had a strong inhibitory effect in vivo in mice bearing MV4-11 xenografts. Primary blast cells from 4 FLT3-ITD AML patients were also tested and ponatinib reduced their viability (IC50: 4 nM) whereas no activity was shown on FLT3-ITD-negative blast cells (Gozgit JM et al. Mol Cancer Ther 2011).

Preliminary data from the phase I clinical trial showed that 15 mg ponatinib was associated with a Cmax of 51.1 nM. Cmax was increased to 111 nM and 149 nM in the 30 mg and 45 mg cohorts respectively. The trough concentrations were 55.3 nM and 61.9 nM for the 30 mg and 45 mg doses respectively (Ariad clinical investigator's brochure, version 3). Results from the ongoing phase II trial in CML patients suggest that the hematological toxicity profile of ponatinib is comparable with that of nilotinib or dasatinib, both of which have been successfully combined with conventional chemotherapy.

Investigators thus aim to combine ponatinib with cytarabine in FLT3-ITD AML patients in first complete remission.


Condition or disease Intervention/treatment Phase
Acute Myeloid Lukemia Drug: Ponatinib and Cytarabine Phase 1 Phase 2

Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 40 participants
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: A Phase I - II Study to Assess Safety and Efficacy of the Combination of Ponatinib With High or Intermediate-Dose Cytarabine as Consolidation Therapy for Patients With Intermediate-Risk Cytogenetic FLT3-ITD AML iIn First Complete Remission
Study Start Date : July 2013
Estimated Primary Completion Date : November 2017
Estimated Study Completion Date : September 2020


Arm Intervention/treatment
Experimental: Ponatinib arm
dose-escalation Arm _ 15, 30, 45mg Ponatinib per day. Each cohort will consist of 3 evaluable patients
Drug: Ponatinib and Cytarabine
Prospective, non-randomized, open-label, multicenter, dose-escalation phase I-II trial; an adaptive Bayesian logistic regression dose-escalation model incorporating escalation with overdose control will be used (Babb 1998, Tighiouart 2005). Each cohort will consist of 3 evaluable patients




Primary Outcome Measures :
  1. dose-limiting toxicity (DLT) of ponatinib during consolidation 1 with HDAC or IDAC [ Time Frame: 12 months ]
    assess the safety of increased doses of ponatinib in combination with high or intermediate -dose cytarabine in AML FLT3-ITD patients in first complete remission


Secondary Outcome Measures :
  1. Overall survival [ Time Frame: 5 years ]
    To determine disease-free survival from achievement of first complete remission

  2. Relapse-free survival [ Time Frame: 5 years ]
    To determine overall survival from achievement of first complete remission

  3. Event-free survival [ Time Frame: 5 years ]
    To determine overall survival from diagnosis

  4. Minimal residual disease based on FLT3-ITD quantification, WT1 expression and/or NPM1 mutation quantification [ Time Frame: 18 months ]
    To study minimal residual disease after induction and consolidation courses based on the quantification of the FLT3-ITD signal and /or WT1, NPM if available

  5. relationship between minimal residual disease and outcome [ Time Frame: 18 months ]
    To study the relationship between minimal residual disease and outcome

  6. To study ponatinib resistance mechanisms [ Time Frame: 18 months ]
    To assess FLT3-ITD mutant before and after ponatinib treatment



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Ages Eligible for Study:   18 Years to 70 Years   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  1. a. Patients aged 18 to 55-60 years: Cohort A b. Patients aged 55-60 to 70 years: Cohort B
  2. Signed informed consent
  3. Acute myeloid leukemia in first complete remission
  4. Platelets ≥ 100 Giga/l; Neutrophils ≥ 1 Giga/l
  5. Intermediate risk karyotype with FLT3-ITD activating mutant detected at diagnosis (mutant FLT3/wild-type allelic ratio higher than 10%) (appendix 16)
  6. Induction with intensive chemotherapy, dose dense sequential induction or 3 + 7 like regimen (daunorubicin or idarubicin) for Cohort A and inclusion in the ALFA backbone for cohort B.
  7. Pancreatic functions within the normal range
  8. AST or ALT less or equal to 2.5 fold upper normal range, bilirubin less or equal to 1.5 fold upper normal range
  9. Serum creatinine less or equal to 1.5 fold upper normal range
  10. Two planned consolidation courses with high-dose cytarabine (HDAC, Cohort A) or intermediate dose cytarabine (IDAC, Cohort B).

Exclusion Criteria:

  1. Acute promyelocytic leukemia
  2. Transformation of myeloproliferative or myelodysplastic syndromes
  3. Known central nervous system involvement
  4. Uncontrolled bacterial, viral or fungal infection
  5. Other active malignancy
  6. Previous episode of pancreatitis
  7. Hypertriglyceridemia > 4.5 g/L
  8. Lipase > 1.5 × ULN, amylase > 1.5 x ULN not related to leukemia
  9. QTc > 470 ms (Bazett formula, see Appendix 1)
  10. Patients at high or very high risk of cardiovascular disease with any of the following f) Established cardiovascular disease

    • Cardiac disease:

      • Congestive heart failure greater than class II NYHA or
      • Left ventricular ejection fraction (LVEF) < 50% or
      • Unstable angina (anginal symptoms at rest) or
      • New onset angina (began within the last 3 months) or
      • Myocardial infarction, coronary/peripheral artery disease, congestive heart failure, cerebrovascular accident including transient ischemic attack within the past 12 months or
      • History of thrombolic or embolic events
    • Arrhythmias

      - Any history of clinically significant cardiac arrhythmias requiring anti-arrhythmic therapy.

      g) Diabetes Mellitus untreated or not equilibrated with therapy h) Arterial Hypertension,

    • - Uncontrolled hypertension defined as systolic blood pressure greater than 140 mmHg or diastolic pressure greater than 90 mmHg, despite optimal medical management and optimal measurement (http://www.has-sante.fr/portail/display.jsp?id=c_272459)
    • - Any history of hypertension with

      • Hypertensive encephalopathy
      • Posterior leucoencephalopathy
      • Aortic or artery dissection i) Familial dysplipidemia. j) Taking medications that are known to be associated with Torsades de Pointes (see Appendix 11)

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02428543


Contacts
Contact: Morisset Laure 0033 1 39 23 97 85 lmorisset@ch-versailles.fr

Locations
France
Dr Abdelaziz CHAIB Recruiting
Aix-en-Provence, France, 13600
Contact: Abdelaziz CHAIB       achaib@ch-aix.fr   
Principal Investigator: Abdelaziz CHAIB         
Chu Amiens Recruiting
Amiens, France, 80054
Contact: MAROLLEAU Jean Pierre         
Principal Investigator: MAROLLEAU Jean Pierre         
CHU d'Angers Recruiting
Angers, France, 49033
Contact: Martine GARDEMBAS       Magardembas@chu-angers.fr   
Principal Investigator: Martine GARDEMBAS         
Hôpital VICTOR DUPOUY Recruiting
Argenteuil, France, 95107
Contact: AL JIJAKLI Ahmad       ahmad.aljijakli@ch-argenteuil.fr   
Principal Investigator: AL JIJAKLI Ahmad         
Dr Edouard RANDIAMALALA Recruiting
Bayonne, France, 64100
Contact: Edouard RANDIAMALALA       erandiamalala@ch-cotebasque.fr   
Principal Investigator: Edouard RANDIAMALALA         
CHU de Besançon Recruiting
Besançon, France, 25030
Contact: Fabrice LAROSA       flarosa@chu-besançon.fr   
Principal Investigator: Fabrice LAROSA         
Dr Thorsten BRAUN Recruiting
Bobigny, France, 93000
Contact: Thorsten BRAUN       thorsten.braun@aphp.fr   
Principal Investigator: Thorsten BRAUN         
CHU Boulogne Sur Mer Recruiting
Boulogne Sur Mer cedex, France, 62321
Contact: CHOUFI Bachra       b.choufi@ch-boulogne.fr   
Principal Investigator: CHOUFI Bachra         
Chr Clemenceau Recruiting
Caen Cedex, France, 14033
Contact: REMAN Oumédaly       reman-o@chu-caen.fr   
Principal Investigator: REMAN Oumédaly         
Hôpital d'Instruction des Armées PERCY Recruiting
Clamart, France, 92141
Contact: Jean Valère MALFUSSON       jvmalf@free.fr   
Principal Investigator: Jean Valère MALFUSSON         
Dr Stéphanie HAÏAT Recruiting
Corbeil-essonnes, France, 91100
Contact: Stéphanie HAÏAT         
Principal Investigator: Stéphanie HAÏAT         
Hôpital Henri Mondor Recruiting
Créteil, France, 94010
Contact: PAUTAS Cécile       cecile.pautas@hmn.aphp.fr   
Principal Investigator: PAUTAS Cécile         
CHU de Dijon Not yet recruiting
Dijon, France, 21079
Contact: CAILLOT Denis       denis.caillot@chu-dijon.fr   
Principal Investigator: CAILLOT Denis         
Centre hospitalier de Versailles Recruiting
Le Chesnay cedex, France, 78157
Contact: Rousselot Philippe    003339638622    phrousselot@ch-versailles.fr   
Principal Investigator: Rousselot Philippe         
Hôpital Claude Huriez Recruiting
Lille cedex, France, 59037
Contact: QUESNEL Bruno       bquesnel@chru-lille.fr   
Principal Investigator: QUESNEL Bruno         
CHRU Dupuytren Not yet recruiting
Limoges cedex, France, 87042
Contact: TURLURE Pascal       pascal.turlure@chu-limoges.fr   
Principal Investigator: TURLURE Pascal         
Hôpital Edouard Herriot Recruiting
Lyon cedex 03, France, 69437
Contact: THOMAS Xavier       xavier.thomas@chu-lyon.fr   
Principal Investigator: THOMAS Xavier         
Dr Regis COSTELLO Recruiting
Marseille, France, 13000
Contact: Regis COSTELLO       regis.costello@ap-hm.fr   
Principal Investigator: Regis COSTELLO         
Centre Hospitalier de Meaux Recruiting
Meaux, France, 77104
Contact: FRAYFER Jamilé       j-frayfer@ch-meaux.fr   
Principal Investigator: FRAYFER Jamilé         
Dr Mario OJEDA-URIBE Recruiting
Mulhouse, France, 68000
Contact: Mario OJEDA-URIBE       ojedam@ch-mulhouse.fr   
Principal Investigator: Mario OJEDA-URIBE         
Dr Jacques DELAUNAY Recruiting
Nantes, France, 44000
Contact: Jacques DELAUNAY       jacques.delaunay@chu-nantes.fr   
Principal Investigator: Jacques DELAUNAY         
CHU Nice, Hôpital Archet 1 Recruiting
Nice cedex 3, France, 06202
Contact: MANNONE Lionel       mannone.l@chu-nice.fr   
Principal Investigator: MANNONE Lionel         
CHU de Nîmes Recruiting
Nîmes, France, 30029
Contact: Eric JOURDAN       eric.jourdan@chu-nimes.fr   
Principal Investigator: Eric Jourdan         
Hôpital Saint Antoine Recruiting
Paris cedex 12, France, 75751
Contact: ISNARD Françoise       francoise.isnard@sat.aphp.fr   
Principal Investigator: ISNARD Françoise         
Hôpital Necker Enfants Malades Recruiting
Paris cedex 15, France, 75743
Contact: SUAREZ Felipe       felipe.suarez@nck.aphp.fr   
Principal Investigator: SUAREZ Felipe         
Hôpital Saint Louis Recruiting
Paris, France, 75010
Contact: RAFFOUX Emmanuel       emmanuel.raffoux@sls.ap-hop-paris.fr   
Principal Investigator: RAFFOUX Emmanuel         
Hôpital La Pitié Salpêtrière Recruiting
Paris, France, 75013
Contact: UZUNOV Madalina       madalina.uzunov@psl.aphp.fr   
Principal Investigator: UZUNOV Madalina         
Dr Laurence SANHES Suspended
Perpignan, France, 66000
Dr Arnaud PIGNEUX Recruiting
Pessac, France, 33604
Contact: Arnaud PIGNEUX       arnaud.pigneux@chu-bordeaux.fr   
Principal Investigator: Arnaud PIGNEUX         
Centre Hospitalier René Dubos Recruiting
Pontoise Cedex, France, 95303
Contact: VAIDA Iona Dana       ioana.vaida@ch-pontoise.fr   
Principal Investigator: VAIDA Iona Dana         
Marc BERNARD Recruiting
Rennes, France, 35000
Contact: Marc BERNARD       marc.bernard@chu-rennes.fr   
Principal Investigator: Marc BERNARD         
Dr Emilie LEMASLE Recruiting
Rouen, France, 76000
Contact: Emilie LEMASLE       emilie.lemasle@chb.unicancer.fr   
Principal Investigator: Emilie LEMASLE         
Centre Hospitalier René Huguenin Suspended
Saint Cloud, France, 92210
Institut de Cancérologie de la Loire Recruiting
Saint-Priest-en-Jarez, France, 42270
Contact: Emmanuelle TAVERNIER-TARDY       emmanuelle.tavernier@icloire.fr   
Principal Investigator: Emmanuelle TAVERNIER-TARDY         
Dr Réda GARIDI Recruiting
Saint-Quentin, France, 02100
Contact: Réda GARIDI         
Principal Investigator: Réda GARIDI         
Dr Christian RECHER Recruiting
Toulouse, France, 31000
Contact: Christian RECHER         
Principal Investigator: Christian RECHER         
Centre Hospitalier de Valenciennes Recruiting
Valenciennes, France, 59322
Contact: FERNANDES José       fernandes-j@ch-valenciennes.fr   
Principal Investigator: FERNANDES José         
Sponsors and Collaborators
Versailles Hospital
Investigators
Principal Investigator: Rousselot Philippe, Pr CH Versailles

Responsible Party: Philippe ROUSSELOT, Clinical coordinator, Versailles Hospital
ClinicalTrials.gov Identifier: NCT02428543     History of Changes
Other Study ID Numbers: 2013-000268-27
First Posted: April 29, 2015    Key Record Dates
Last Update Posted: November 24, 2017
Last Verified: November 2017

Keywords provided by Philippe ROUSSELOT, Versailles Hospital:
FLT3-ITD patients in first complete remission

Additional relevant MeSH terms:
Cytarabine
Ponatinib
Antimetabolites, Antineoplastic
Antimetabolites
Molecular Mechanisms of Pharmacological Action
Antineoplastic Agents
Antiviral Agents
Anti-Infective Agents
Immunosuppressive Agents
Immunologic Factors
Physiological Effects of Drugs
Protein Kinase Inhibitors
Enzyme Inhibitors