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2883 Clinical Outcomes Using Frontline “Triplet” Regimens for Newly Diagnosed IDH-Mutated Acute Myeloid Leukemia (AML): A Pooled Analysis of Two Phase Ib/2 Clinical Trials

Program: Oral and Poster Abstracts
Session: 616. Acute Myeloid Leukemias: Investigational Drug and Cellular Therapies: Poster II
Hematology Disease Topics & Pathways:
Combination therapy, Treatment Considerations
Sunday, December 8, 2024, 6:00 PM-8:00 PM

Jennifer Marvin-Peek, MD1, Himachandana Atluri, MD1, Nicholas J. Short, MD1, Abhishek Maiti, MBBS1, Koichi Takahashi, MD, PhD2, Sanam Loghavi, MD3, Curtis A Lachowiez, MD4, Yesid Alvarado Valero, MD1, Guillermo Montalban-Bravo, MD1, Koji Sasaki, MD1, Fadi G. Haddad, MD1, Ghayas C. Issa, MD1, Lucia Masarova, MD1, Hussein A. Abbas, MD, PhD1, Michael Andreeff, MD, PhD5, Gautam Borthakur, MD5, Jillian Mullin, BA, RN, MN1*, George Donovan Tippett, BS, BSN, RN1*, Kelly S. Chien, MD6, Danielle Hammond, MD1, Jo Ishizawa, MD, PhD5, Nitin Jain, MD1, Patrick K. Reville, MD, MPH1, Mahesh Swaminathan, MD7, Musa Yilmaz, MD1*, Naval Daver, MD8, Tapan M. Kadia, MD1, Farhad Ravandi, MBBS9, Guillermo Garcia-Manero, MD1, Hagop M. Kantarjian, MD1 and Courtney D. DiNardo, MD, MSc1

1Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
2Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
3Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
4Knight Cancer Institute, Oregon Health & Science University, Houston, TX
5Section of Molecular Hematology and Therapy, Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
6Department of Leukemia, MD Anderson, Houston, TX
7Department of Leukemia, The University of Texas MD Anderson Cancer Center, Missouri City, TX
8MD Anderson Cancer Center, Houston, TX
9Department of Leukemia, University of Texas- MD Anderson Cancer Center, Houston, TX

Background: Isocitrate dehydrogenase (IDH) mutations occur in ~20% of patients (pts) with acute myeloid leukemia (AML). Long-term follow up of the VIALE-A trial demonstrated a median overall survival (mOS) of 10.2 and 27.5 months for those with IDH1 and IDH2 mutations, respectively, with composite complete remission (CRc) rates of 66.7% and 86%. Targeted IDH inhibitors (IDHi) such as ivosidenib (IVO) and enasidenib (ENA) are also effective, either as single agents or in combination with azacitidine (AZA). All these regimens are effective, yet not curative, and when relapse occurs it is frequently due to the emergence or expansion of signaling mutations. “Triplet” regimens may more optimally prevent common resistance mechanisms by targeting multiple pathways simultaneously. In this pooled analysis, we report the clinical outcomes and patterns of relapse among pts with newly diagnosed (ND) IDH mutant AML who are not eligible for intensive chemotherapy treated with frontline triplet regimens containing a HMA + venetoclax (VEN) + IDHi.

Methods: Adults with ND IDH-mutated AML treated on IDHi “triplet” trials at our institution were included in this pooled analysis (NCT03471260 and NCT04774393). Pts received either frontline AZA + VEN + IVO or oral Decitabine/Cedazuridine (ASTX727) + VEN + IVO/ENA (arms for IDH1 or IDH2 mutant disease, respectively). OS, event free survival (EFS), and duration of remission (DOR) were assessed by Kaplan-Meier method, with EFS defined by lack of response, relapse, or death. CRc was defined as CR + CRi + CRh and overall response rate (ORR) as CR + CRi + CRh + PR + MLFS within five cycles.

Results: From October 2019 to March 2024, 50 pts with ND IDH-mutated AML were enrolled; 12 pts (24%) received AZA + VEN + IVO and 38 (76%) received ASTX727 + VEN + IDHi. Median age was 71 years (range: 62 – 87) and ELN 2022 risk was favorable for 10 (20%), intermediate for 4 (8%), and adverse for 36 (72%). Twelve pts (24%) had treated secondary AML (tsAML) with prior HMA ± VEN from antecedent MDS or MPN. NPM1 mutations were present in 12 (24%), FLT3-ITD in 3 (6%), K/NRAS in 10 (20%), and TP53 in 3 (6%).

At a median (m) follow up of 18.1 months, the mOS and mEFS have not been reached with a 2-year OS of 82% (95% CI: 70 – 95%), 2-year EFS of 63% (49 – 82%), and mDOR of 27 months. The ORR was 96% (48/50) with CRc of 92% (36/40). Measurable residual disease negativity by flow cytometry was achieved in 78% (36/46) of evaluable pts. Twelve responding pts (24%) transitioned to stem cell transplantation (SCT). For pts who did not undergo SCT, the median number of completed treatment cycles is 6 (IQR: 3 – 15) with 20/36 (56%) of responding pts still on active treatment.

There was no difference in outcomes between pts with IDH1 or IDH2 mutations, treatment with AZA + VEN + IVO versus ASTX727 + VEN + IDHi, or in pts with baseline signaling mutations. However, pts with tsAML experienced significantly worse outcomes compared to non-tsAML with a CRc rate of 75% (9/12) versus 98% (37/38) respectively (p=0.038). tsAML pts experienced mOS of 11 months, mEFS of 7.6 months, and mDOR of 8.5 months; treatment naïve participants experienced a 2-year OS of 94% (95% CI: 84 – 100%) and 92% (95% CI: 79 – 100%) for IDH1 and IDH2 mutant AML, respectively.

Ten of the 48 responding pts relapsed (21%). Five of the 6 pts with IDH1 mutations at baseline had no detectable IDH1 mutation at relapse, similar to 2 of the 4 pts with IDH2 mutations. Only 2 of 9 tested pts developed emergent signaling mutations: one gained a FLT3-ITD mutation along with new ETNK1, GNAS, SETBP1, and TET2 mutations, while the other with baseline NPM1, IDH2, and NRAS mutations gained a KRAS and a second NRAS mutation.

Overall the triplet regimens were well tolerated. 30-day and 60-day mortality were 0% and 2% (1/50), respectively. Grade 3 or higher non-hematologic adverse events were experienced in 10% of pts (5/50), including 2 cases of indirect hyperbilirubinemia and 1 case each of mucositis, QTc prolongation, and differentiation syndrome.

Conclusions: Pts with IDH mutant AML experience excellent outcomes with frontline HMA + VEN + IDHi triplets. There do not appear to be any recurrent mutational patterns at relapse on IDHi triplet regimens, with most IDH1 mutant pts and 50% of IDH2 mutant pts relapsing with an IDH wildtype clone. Given these promising frontline results, prospective studies comparing triplet versus doublet regimens for IDH mutant AML are warranted. Enrollment on both HMA + VEN + IDHi triplet trials is ongoing.

Disclosures: Short: Astellas Pharma, Inc.: Honoraria, Research Funding; Xencor: Research Funding; Stemline Therapeutics: Research Funding; Adaptive Biotechnologies: Honoraria; NextCure: Research Funding; GSK: Consultancy, Research Funding; Autolus: Honoraria; Novartis: Honoraria; Sanofi: Honoraria; Pfizer Inc.: Honoraria; Takeda Oncology: Honoraria, Research Funding; Amgen: Honoraria; BeiGene: Honoraria. Maiti: CytoMed Therapeutics: Research Funding; Indapta Therapeutics: Research Funding; Inspirna: Research Funding; Lin Biosciences: Research Funding; Hibercell Inc.: Research Funding; Chimeric Therapeutics: Research Funding. Loghavi: Pathology Education Partners; VJ HemeOnc, College of American Pathologists, OncLive, ICCS, MD Education, NCCN, MashUp Media, NCTN, Aptitude Health: Honoraria; Guidepoint; QualWorld; Gerson Lehrman Group, AlphaSight, Arima, Qiagen, Opinion Health: Consultancy; Astellas, Amgen: Research Funding; Abbvie: Current holder of stock options in a privately-held company; Syndx, Servier, BMS: Membership on an entity's Board of Directors or advisory committees; Abbvie, Daiichi Sankyo, BluePrint Medicine, Caris Diagnostics, Recordati, Servier: Consultancy. Montalban-Bravo: Rigel: Research Funding; Takeda: Research Funding. Sasaki: Otsuka: Other: Lecture fees; Novartis: Consultancy, Research Funding; Daiichi-Sankyo: Consultancy; Enliven: Research Funding; Chugai: Other: Lecture fees; Pfizer: Consultancy. Issa: AstraZeneca: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: consultancy/ad board fees; Merck: Research Funding; Astex: Research Funding; Kura Oncology: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: consultancy/ad board fees, Research Funding; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: consultancy/ad board fees, Research Funding; NuProbe: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: consultancy/ad board fees, Research Funding; Syndax Pharmaceuticals, Inc.: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: consultancy/ad board fees, Research Funding; AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: consultancy/ad board fees; Sanofi: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: consultancy/ad board fees; Celgene: Research Funding. Masarova: PharmaEssentia: Other: Advisory Board Participant; GSK: Consultancy, Other: Travel support; Cogent: Other: Advisory Board Participant; MorphoSys: Other: Advisory Board Participant. Abbas: Genentech: Research Funding; Molecular Partners: Consultancy; Alamar Biosciences: Honoraria; Enzyme By Design: Research Funding; Blueprint Medicines Corporation: Research Funding; Ascentage: Research Funding; GlaxoSmithKline: Research Funding; Illumina: Honoraria, Other: Inkind Support, Research Funding. Andreeff: SentiBio: Current holder of stock options in a privately-held company, Honoraria, Research Funding; Aptose: Honoraria; Oxford Biomedical: Research Funding; Oncolyze: Current holder of stock options in a privately-held company; Daiichi-Sankyo: Research Funding; Ellipses: Research Funding; Boehringer-Ingelheim: Honoraria; Glycomimetics: Honoraria; Syndax: Honoraria, Research Funding; Sellas: Honoraria, Research Funding; Kintor Pharmaceutical: Research Funding; Ona: Honoraria; Chimerix: Current holder of stock options in a privately-held company; Roivant: Honoraria; Paraza: Honoraria; Eterna: Current holder of stock options in a privately-held company, Honoraria, Research Funding. Borthakur: Catamaran Bio, AbbVie, PPD Development, Protagonist Therapeutics, Janssen: Consultancy; Pacylex, Novartis, Cytomx, Bio Ascend: Membership on an entity's Board of Directors or advisory committees; Astex Pharmaceuticals, Ryvu, PTC Therapeutics: Research Funding. Chien: Rigel Pharmaceuticals: Consultancy; AbbVie: Consultancy. Jain: BeiGene: Consultancy, Honoraria, Other: Travel Support; Newave: Research Funding; Loxo Oncology: Research Funding; TG Therapeutics: Consultancy, Honoraria, Other: Travel Support; Kite, a Gilead Company: Consultancy, Honoraria, Other: Travel Support, Research Funding; TransThera Sciences: Research Funding; Precision Biosciences: Consultancy, Honoraria, Other: Travel Support, Research Funding; Pharmacyclics: Consultancy, Honoraria, Other: Travel Support, Research Funding; MEI Pharma: Consultancy, Honoraria, Other: Travel Support; Aprea Therapeutics: Research Funding; ADC Therapeutics: Research Funding; AstraZeneca: Consultancy, Honoraria, Other: Travel Support, Research Funding; Dialectic Therapeutics: Research Funding; Incyte: Research Funding; Bristol Myers Squibb: Consultancy, Honoraria, Other: Travel Support, Research Funding; CareDx: Consultancy, Honoraria, Other: Travel Support; Cellectis: Consultancy, Honoraria, Other: Travel Support, Research Funding; Genentech: Consultancy, Honoraria, Other: Travel Support, Research Funding; Takeda: Research Funding; MingSight: Honoraria, Research Funding; NovalGen: Research Funding; Fate Therapeutics: Research Funding; Medisix: Research Funding; Pfizer: Research Funding; Servier: Research Funding; Janssen: Consultancy, Honoraria, Other: Travel Support; Ipsen: Consultancy, Honoraria, Other: Travel Support; Adaptive Biotechnologies: Consultancy, Honoraria, Other: Travel Support, Research Funding; AbbVie: Consultancy, Honoraria, Other: Travel Support, Research Funding. Swaminathan: Sobi: Membership on an entity's Board of Directors or advisory committees. Yilmaz: daiichi sankyo: Honoraria, Research Funding. Daver: Agios: Consultancy; Servier: Consultancy, Research Funding; Astellas: Consultancy, Research Funding; Arog: Consultancy; Trillium: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Shattuck Labs: Consultancy; Trovagene: Research Funding; Hanmi: Research Funding; Syndax: Consultancy; Novimmune: Research Funding; Celgene: Consultancy; Gilead: Consultancy, Research Funding; Genentech: Consultancy, Research Funding; Jazz: Consultancy; Menarini Group: Consultancy; KITE: Research Funding; Novartis: Consultancy; FATE Therapeutics: Other: Consulting Fees, Research Funding; Bristol Myers Squibb: Consultancy, Research Funding; Daiichi-Sankyo: Consultancy, Research Funding; Glycomimetics: Research Funding. Kadia: Incyte: Research Funding; ASTEX: Research Funding; JAZZ: Research Funding; AstraZeneca: Research Funding; Novartis: Honoraria; Cellenkos: Research Funding; Genentech: Consultancy, Research Funding; DrenBio: Consultancy, Research Funding; Abbvie: Consultancy, Research Funding; Servier: Consultancy; Rigel: Honoraria; Sellas: Consultancy, Research Funding; Ascentage: Research Funding; Amgen: Research Funding; Pfizer: Research Funding; BMS: Consultancy, Research Funding; Regeneron: Research Funding. Ravandi: Amgen: Research Funding; Prelude: Consultancy, Honoraria, Research Funding; Syros: Consultancy, Honoraria, Research Funding; Astellas: Consultancy, Honoraria; BMS: Consultancy, Honoraria; Abbvie: Consultancy, Honoraria; Xencor: Research Funding; Astyex/Taiho: Research Funding; Syndax: Honoraria. Garcia-Manero: Helsinn: Research Funding; Genentech: Research Funding; Helsinn: Other: Personal fees; Janssen: Research Funding; Forty Seven: Research Funding; Aprea: Research Funding; Novartis: Research Funding; Astex: Other: Personal fees; Bristol Myers Squibb: Other: Personal fees, Research Funding; AbbVie: Research Funding; Astex: Research Funding; Onconova: Research Funding; Merck: Research Funding; Curis: Research Funding; H3 Biomedicine: Research Funding; Amphivena: Research Funding; Genentech: Other: Personal fees. Kantarjian: AbbVie, Amgen, Ascentage, Ipsen Biopharmaceuticals, KAHR Medical, Novartis, Pfizer, Shenzhen Target Rx, Stemline,Takeda: Consultancy, Honoraria. DiNardo: Genetech: Honoraria; Notable Labs: Honoraria; AstraZeneca: Honoraria; Stemline: Consultancy; Jazz: Consultancy, Honoraria; Riegel: Honoraria; GSK: Consultancy, Honoraria; Amgen: Consultancy; Astellas: Consultancy, Honoraria; Schrodinger: Consultancy, Honoraria; BMS: Consultancy, Honoraria, Research Funding; GenMab: Consultancy, Honoraria, Other: data safety board; Servier: Consultancy, Honoraria, Other: meetingsupport, Research Funding; Gilead: Consultancy; Abbvie: Consultancy, Honoraria, Research Funding; Immunogen: Honoraria; Astex: Research Funding; Rigel: Research Funding; Loxo: Research Funding; Foghorn: Research Funding; ImmuneOnc: Research Funding; Cleave: Research Funding.

*signifies non-member of ASH