Jessica Altman, MD1, Zhuoxin Sun, PhD2*, Alexander E. Perl, MD3, Richard F. Little, MD, MPH4, Steven D. Gore, MD5, Laura C. Michaelis, MD6, Geoffrey L. Uy, MD7, Yasmin Abaza, MD1, Sameem Abedin, MD8, John L. Reagan, MD9, Ehab L. Atallah, MD10, Selina Luger, MD, FRCPC11 and Mark R. Litzow, MD12
1Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
2Dana-Farber Cancer Institute, Boston, MA
3Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
4National Cancer Institute, National Institutes of Health, Bethesda, MD
5National Cancer Institute, National Institutes of Health, Rockville, MD
6Division of Hematology/Oncology, Department of Medicine, The Medical College of Wisconsin Inc, Milwaukee, WI
7Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
8Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI
9Brown University Health Cancer Insitute, Warren Alpert Medical School of Brown University, Providence, RI
10Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI
11Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA
12Division of Hematology, Mayo Clinic, Rochester, MN
Background: Randomized studies in newly diagnosed (ND) AML patients with a
FLT3 mutation show that adding 14 days of a FLT3 inhibitor to each intensive chemotherapy cycle improves overall survival. For patients unsuitable for intensive chemotherapy due to older age or comorbidities, the presence of a
FLT3-ITD mutation is associated with high rates of early relapse and short remission duration. There is a limited survival benefit of venetoclax (ven) plus azacitidine (aza) compared to aza alone among patients with AML with a
FLT3-ITD mutation. Accordingly, there is significant interest in adding FLT3-targeted therapy to lower intensity chemotherapy for patients with ND AML and
FLT3 mutations, but to date no randomized data have demonstrated a survival benefit for this approach.
Gilteritinib (gilt) is a highly potent and FLT3-selective oral tyrosine kinase inhibitor that is the standard therapy of relapsed/refractory FLT3-mutated AML, based upon superior survival in randomized studies. Gilt can also be combined safely with ven and/or aza, though myelosuppression remains a concern. Despite this, single institution studies of ven, aza, and gilt therapy of ND AML patients with FLT3-mutations show that this three-drug regimen is associated with near-universal complete remission rates (CR 90%, CRi 6%) and a majority of studied patients eliminate detectable FLT3-ITD (<1 x10-5) within four cycles by an ultrasensitive, amplicon-based NGS assay (Short, et al. JCO 2024). Rates of CR with full count recovery and survival appear superior to historical comparisons, but myelosuppression is potentially increased with the triplet regimen. These data demonstrate a need for multi-institutional comparative trials, not only to determine whether adding FLT3-inhibitors to ven and aza improve deep remission rates, but also to refine schedules of the triplet combination that improve tolerability for widespread use.
Methods: This tier 1 MyeloMATCH substudy is an open-label, randomized phase 2 trial that will enroll ND AML patients older than age 60 or individuals judged by their treating physician to be best served by azanucleoside + ven-based therapy due to comorbidity. Subjects provide samples to the central MyeloMATCH Master Screening and Reassessment Protocol (MSRP, NCT05564390 ) and are assigned to the MM1OA-EA02 substudy (NCT06317649) based upon the presence of a FLT3-ITD or FLT3-TKD (D835) mutation by NGS. Subjects are randomized to one of three arms (regimens 1, 2, or 3), stratified by age (<70 years vs. older) and FLT3-ITD burden (ITD VAF>33% vs. lower VAF or D835). All study arms contain aza and ven administered in 28-day cycles with two study arms also including gilt. Regimen 1 is ven and aza administered as per the pivotal VIALE-A study. Regimen 2 adds gilt 80 mg once daily on days 1-28 and regimen 3 adds gilt on days 8-21 only. A marrow biopsy is performed during the first cycle (day 14-21, depending on study arm) and all chemotherapy is held until count recovery if a morphologic leukemia-free state or aplasia is seen. Patients receive up to two induction cycles to achieve remission and then receive ongoing consolidation cycles of therapy with a similar pattern of gilt administration up to 2 years. To minimize risk of cumulative myelosuppression, during consolidation azacitidine administration is reduced to days 1-5 on regimens 2 and 3 and ven limited to days 1-7 on regimen 2 and days 1-14 on regimen 3. For all arms, treatment-related adverse events prompt further reduction in ven, aza, or gilt dose or duration. Response will be measured after cycles 2 and 4, including centrally-performed MRD by flow cytometry. The primary endpoint is the rate of MRD(-) CR (<1 x 10-3) after up to 4 cycles. Key secondary endpoints include safety data, response rate, EFS, and OS. The study is powered to detect a 25% absolute improvement in MRD(-) CR rate in either triplet arm from a target accrual of 147 patients. A safety run-in for regimens 2 and 3 to confirm tolerability and feasibility will be performed after 20 subjects enroll to these arms; an interim futility analysis will be performed once response assessment of 50% of all planned accrual occurs. Study was activated on June 6, 2024 and is expected to continue until December 2025.
Disclosures: Altman: Gilead: Other: advisory board; VJ HemOnc: Other: advisory board and education; Treadwell Therapeutics: Other: advisory board; Dark Blue Therapeutics: Other: advisory board; Curio: Other: advisory board; Astellas: Honoraria, Other: advisory board, Research Funding; Aptitude Health: Other: advisor; Rigel: Other: advisory board; MD Educations: Other: advisory board and education; Daiichi Sankyo: Other: advisory board. Perl: Bristol Myers Squibb: Membership on an entity's Board of Directors or advisory committees; Genentech: Membership on an entity's Board of Directors or advisory committees; Schrödinger,: Membership on an entity's Board of Directors or advisory committees; Syndax: Membership on an entity's Board of Directors or advisory committees, Research Funding; Daiichi Sankyo, Inc.: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: grant, consulting fees; Curis: Membership on an entity's Board of Directors or advisory committees; Rigel Pharmaceuticals, Inc.: Membership on an entity's Board of Directors or advisory committees; ImmunoGen: Membership on an entity's Board of Directors or advisory committees; Syndax Pharmaceuticals, Inc.: Other: grant, Research Funding; BeatAML, LLC: Other: DSMC member; Astellas: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: grant, consulting fees, Research Funding; AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: grant, consulting fees, Research Funding; Aptose Biosciences: Membership on an entity's Board of Directors or advisory committees; Foghorn: Consultancy. Michaelis: Disc Medicine: Consultancy; Kura Oncology: Consultancy; Merck Pharmaceuticals: Consultancy, Honoraria; Nkarta: Consultancy. Abedin: AbbVie, Daichii Sankyo, Servier: Consultancy, Honoraria; Actinium Pharmaceutical, AltruBio, Incyte: Research Funding. Reagan: Bristol Myers Squibb: Membership on an entity's Board of Directors or advisory committees; Pfizer: Research Funding; Sanofi: Consultancy. Atallah: Novartis Pharmaceuticals Corporation: Honoraria. Luger: Marker Therapeutics: Membership on an entity's Board of Directors or advisory committees; Daiichi Sankyo: Membership on an entity's Board of Directors or advisory committees; Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; AbbVie: Membership on an entity's Board of Directors or advisory committees; Takeda: Research Funding; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Astellas: Consultancy. Litzow: Abbvie: Research Funding; Amgen: Research Funding, Speakers Bureau; Actinium: Research Funding; Astellas: Research Funding; Pluristem: Research Funding; Sanofi: Research Funding; Beigene: Speakers Bureau; Biosight: Other: Data Safety Monitoring Committee.
OffLabel Disclosure: Gilteritinib is a FLT3 inhibitor approved for relapsed/refractory FLT3m AML. We are studying it in combination with HMA/ven in adults with newly diagnosed AML with a FLT3 mutation.
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