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967 A Phase 3 Randomized Trial for Patients with De Novo AML Comparing Standard Therapy Including Gemtuzumab Ozogamicin (GO) to CPX-351 with GO – a Report from the Children’s Oncology Group

Program: Oral and Poster Abstracts
Type: Oral
Session: 617. Acute Myeloid Leukemias: Commercially Available Therapies: Optimizing Regimens in Children/Young Adults and Around the World
Hematology Disease Topics & Pathways:
Research, Clinical trials, Acute Myeloid Malignancies, AML, Clinical Research, Diseases, Myeloid Malignancies
Monday, December 9, 2024: 4:30 PM

Jessica A. Pollard, MD1, Todd A. Alonzo, PhD2*, Robert Gerbing, MS3*, Matthew A. Kutny, MD4, Betsy Hirsch, PhD5*, Gordana Raca, MD, PhD6, Kasey Leger, MD, MSc7, Jennifer J. Wilkes, MD, MSCE8, Aman Wadhwa, MD9, Zachary Graff, MD10, Reena Pabari, MD, MSc, FRCPC11*, Samir Kahwash, MD12*, Karen M Chisholm, MD, PhD13, Joseph Chewning, MD14, John T. Horan, MD15, Richard Aplenc16, Katherine Tarlock, MD17, Sarah Menig, PharmD, BCOP18*, Olga Militano, PharmD19*, Bonnie Ky, MD20*, Chad A. Hudson, MD, PhD21, Lisa Eidenschink Brodersen, PhD16*, Michael R. Loken, PhD21*, Soheil Meshinchi, MD, PhD22, Anders Kolb, MD23 and Todd M Cooper, DO24

1Dana Farber Cancer Institute and Boston Children’s Hospital, Boston, MA
2Univ. of Southern California Keck School of Med., Monrovia, CA
3Children's Oncology Group, Arcadia, CA
4University of Alabama Birmingham, Birmingham, AL
5University of Minnesota, Minneapolis, MN
6Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, CA
7Seattle Children’s Hospital, Seattle, WA
8Pediatrics, University of Washington School of Medicine, Seattle, WA
9Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
10Medical College of Wisconsin, Milwaukee, WI
11The Hospital for Sick Children, Toronto, ON, Canada
12Nationwide Children's Hospital, The Ohio State University, Columbus, OH
13University of Washington, Seattle, WA
14Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
15University of Rochester Medical Center, Rochestser
16Children's Hospital of Philadelphia, Philadelphia, PA
17Division of Pediatric Hematology, Oncology, Bone Marrow Transplant & Cellular Therapy, Seattle Children's Hospital, Seattle, WA
18Cancer and Blood Disorders Center, Seattle Children's Hospital, Seattle, WA
19Children's Oncology Group, Monrovia, CA
20University of Pennsylvania School of Medicine, Philadelphia, PA
21Hematologics, Inc., Seattle, WA
22Translational Science and Therapeutics, Fred Hutchinson Cancer Center, Seattle, WA
23Leukemia & Lymphoma Society, Bronx, NY
24Division of Pediatric Hematology, Oncology, Bone Marrow Transplant & Cellular Therapy, Seattle Childrens Hospital, Seattle, WA

Introduction:

Survival in childhood AML has plateaued and new therapeutic strategies are essential. CPX-351 (Vyxeos) is a liposomal preparation of cytarabine and daunorubicin with superior pharmacokinetic properties when compared to free drug. The Children’s Oncology Group (COG) Phase III clinical trial AAML1831 tested the hypothesis that CPX-351 given during Inductions 1 and 2 would improve treatment outcomes and reduce long-term toxicities compared to a standard chemotherapy.

Methods:

COG AAML1831 randomized patients (pts) <22 years of age with de novo AML to 2 different induction regimens. Pts with FLT3 mutations were offered enrollment onto gilteritinib-containing regimens and are not included in this analysis. Arm A patients received cytarabine, daunorubicin and gemtuzumab ozogamicin (DA+GO) during Induction 1 and DA during Induction 2. Patients on Arm B received, during Induction 1, CPX-351 on days 1, 3 and 5 and GO on day 6; the CPX-351 dosing was repeated in Induction 2. Centralized risk stratification occurred after Induction 1 and was based on cytomolecular findings and end of induction 1 (EOI 1) minimal residual disease (MRD) >0.05% by central multidimensional flow cytometry. Pts were designated as low risk 1 (LR1; favorable genetics and MRD negative), low risk 2(LR2; pts not in LR1 or HR), or high risk (HR; MRD+ without favorable genetics or any high risk genetics) and received 4 (LR1) versus 5 (LR2) cycles of chemotherapy or 2-3 cycles followed by hematopoietic stem cell transplant (HSCT; HR).

Results:

A total of 721 eligible pts without FLT3 mutations were randomized to Arm A (n=358) or Arm B (n=363). Age, race, ethnicity and sex were similar for the 2 arms; distribution of risk-defining cytomolecular features were also comparable, with exception of higher rates of inv(16)(p13.1q22.1) (Arm A: 10% vs Arm B: 6%; p=0.03) but not t(16;16)(p13.1;q22) CBFB-MYH11 AML. Pts on Arm A were also more likely to be CNS negative at time of initial assessment (Arm A: 86%; Arm B: 79%; p=0.026). EOI 1 MRD was comparable (Arm A: 23%; Arm B: 23%) and elective withdrawal rates at EOI1 did not differ significantly between the 2 arms (Arm A: 9%; Arm B: 11%). However, Induction 2 treatment toxicities [grade 3 infection (Arm A: 7.4%; Arm B: 27.2%), grade 3 sepsis (Arm A: 3.5%; Arm B: 5.1%)] and median cycle length (Arm A: 35 days; Arm B: 44 days) were higher in Arm B though this did not translate into higher Induction 2 treatment related mortality.

Protocol-specified interim analyses using data available on 12/31/23 were performed to monitor efficacy and futility of event-free survival (EFS) for Arm A and Arm B patients without FLT3 mutations. Closure of this randomization was recommended given the futility monitoring rule was crossed. Using a 6/30/24 data cutoff, 2-year EFS from study entry for Arm A was 60.9% (95% CI: 54.3-66.8%) vs. 51.2% (95% CI: 44.7-57.4%) for Arm B (p=0.019) though overall survival (OS) was not significantly different [Arm A: 75.5% (95% CI-69.3-80.5%); Arm B: 74.5% (95% CI – 68.4-79.6%]; p=0.782]. Outcomes for HR patients were comparable for both arms whereas EFS was significantly lower and relapse rates (RR) higher for LR patients on Arm B [2-yr EFS from EOI1: Arm A: 71.9% vs. Arm B 57.8% (p=0.006); 2-year RR Arm A: 16.1% vs. Arm B: 25.4%, p=0.018). EFS from EOI1 in the LR1 patients was particularly impacted (Arm A: 78.3%; Arm B: 62.6%, p=0.029) while LR2 EFS from EOI is Arm A: 67.2 % vs. Arm B: 54.6% (p=0.079); most events reported for either group were relapse.

Conclusion

The primary randomization of the Phase III study COG AAML1831, a comparison between standard induction therapy and CPX-351, was terminated early because the futility boundary was crossed. The difference in EFS observed was driven mainly by events in LR pts, particularly those that received 4 cycles of chemotherapy (LR1). Further analysis is underway to determine additional factors that may have contributed to the inferior outcomes observed for pts enrolled on Arm B.

Disclosures: Pollard: Servier: Research Funding. Kutny: Syndax Pharmaceuticals: Research Funding; Novartis Pharmaceuticals: Research Funding; SUTRO Biopharma: Research Funding; Jazz Pharmaceuticals: Research Funding; Incyte Corporation: Research Funding; Celgene Corporation: Research Funding; Astellas Pharma: Research Funding. Leger: Jazz Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees. Hudson: Hematologics Inc: Current Employment. Loken: Hematologics: Current Employment.

OffLabel Disclosure: CPX-351 is not approved for use in children with de novo AML

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