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265 CLAG-M or FLAG-Ida Followed Immediately By Allogeneic Hematopoietic Cell Transplantation for Adults with Relapsed/Refractory Acute Myeloid Leukemia or Other High-Grade Myeloid Neoplasm

Program: Oral and Poster Abstracts
Type: Oral
Session: 721. Allogeneic Transplantation: Conditioning Regimens, Engraftment and Acute Toxicities: Optimizing Outcomes in Adult Patients
Hematology Disease Topics & Pathways:
Research, Clinical trials, Clinical Research
Saturday, December 7, 2024: 2:00 PM

Filippo Milano, MD1,2, Brenda M. Sandmaier, MD3, Mary-Elizabeth M. Percival, MD4,5, Sarah M Mahan6*, Laura C Roberts6*, Raya Mawad, MD2,6, Anna B. Halpern, MD2,6, Madi Brunette6*, Cristina Maria Ghiuzeli, MD2,6, Jacob S. Appelbaum, MD, PhD4,7, Naveed Ali, MD, MBBS2,6 and Roland B. Walter, MD, PhD, MS6

1Fred Hutchinson Cancer Research Center, Seattle, WA
2University of Washington, Seattle, WA
3Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, WA
4Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
5Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA
6Fred Hutchinson Cancer Center, Seattle, WA
7University of Washington School of Medicine, Seattle, WA

Background: Allogeneic hematopoietic cell transplantation (HCT) is critical for cure for most adults with relapsed/refractory (R/R) acute myeloid leukemia (AML) or other high-grade myeloid neoplasm. Commonly, remission induction is attempted but is associated with long cytopenia and risk of HCT-prohibitive toxicities. Direct allografting is pursued as alternative but typically includes conditioning with agents that have limited anti-leukemia efficacy. Here, we developed a new HCT platform that combines high-intensity chemotherapy with CLAG-M (cladribine, cytarabine, G-CSF, and mitoxantrone) or FLAG-Ida (fludarabine, cytarabine, idarubicin, and G-CSF) followed immediately by lower dose total body irradiation (TBI) and allografting to maximize the treatment’s anti-leukemia efficacy and minimize its duration of cytopenia.

Methods: Adults ≥18 years with AML or other high-grade myeloid neoplasm (≥10% blasts in marrow and/or blood) were eligible for this Phase 1 study if they were in morphologic remission with evidence of measurable residual disease or had R/R disease. Patients (pts) received CLAG-M or FLAG-Ida starting on day -9 and then received 3, 4 or 5 Gy TBI in a dose escalation trial on days -1/0, followed by allografting on day 0 using HLA-matched related/unrelated (RD/URD) or HLA-haploidentical donors. GVHD prophylaxis included post-transplant cyclophosphamide (PTCy), mycophenolate mofetil, and cyclosporine. The primary objective was to identify which one of 3 doses of TBI was associated with acceptable rates of HCT failure (combined, graft rejection and/or disease progression ≤50%) and non-relapse mortality (NRM; ≤25%) within 200 days of HCT. The initial 12 pts received CLAG-M with 3 Gy TBI. Because of a HCT failure rate of >50%, subsequent CLAG-M pts received 4 Gy TBI. Following the observation of delayed chimerism in a subset of CLAG-M pts, a parallel arm used FLAG-Ida with 4 Gy TBI, hypothesizing fludarabine might facilitate engraftment better than cladribine. Donor/host chimerism studies were performed at day 28, at days 80, and at 1-year post-HCT on unsorted bone marrow (BM) and on peripheral blood (PB) FACS isolated CD33+ and CD3+ cells.

Results: Between December 2020 and June 2024, 46 pts were enrolled (CLAG-M with 3 Gy TBI (1st cohort) n=12; CLAG-M with 4 Gy TBI (2nd cohort) n=24, FLAG-Ida with 4 Gy TBI (3rd cohort) n=10). Pts characteristics were similar between the 3 groups. The median age of the entire population was 67 (34–76) years; 21 pts (45%) had an HCT-CI of ≥3. Pts had either AML (n=27) or MDS (n=19). Thirty-seven pts (80%) received HCT from an URD, 6 (13%) from a RD, and 3 (7%) from a haplo donor. Active disease was present in 17 pts (37%) with a median of 10% (6-70%) BM blasts, with 11/17 pts having circulating blasts. The remaining pts had measurable residual disease by flow cytometry, cytogenetics, and/or NGS. Median time to neutrophil and platelet engraftment was 22 (15-37) and 24 (11-89) days, respectively. Four pts experienced graft failure (3 in the 1st cohort and 1 in the 2nd cohort). At day+28 post-HCT, 43 (94%) and 29 (63%) pts had BM and CD3 PB donor chimerism >90%, respectively. Five (10%) pts died before day +28 BM evaluation (fungal infection [n=3], cardiac arrest [n=1], disease progression [n=1]). 37 of 41 evaluable pts achieved a complete remission with/without full hematologic recovery. Median follow-up of the surviving pts was 11 (2-36) months (30 months in 1st cohort, 11 months in 2nd cohort, 4 months in 3rd cohort). A total of 7 pts relapsed (4 in 1st cohort, 3 in 2nd cohort) and 12 pts died (6 in 1st cohort, 5 in 2nd cohort, 1 in 3rd cohort). Across all pts, the 1-year overall survival (OS) and disease-free survival (DFS) were 77% (95% CI: 60-87) and 57% (39-71), respectively. OS and DFS estimates were lower for pts treated in the 1st cohort (65% [33-86%] and 33% [10-58%]) than the 2nd cohort (76% [50-89%] and 59% [35-77%]); follow-up was too short for survival estimates in the 3rd cohort. Grade III-IV GVHD was observed in 3 pts.

Conclusions: CLAG-M or FLAG-Ida followed directly by TBI in combination with PTCy-based GVHD prophylaxis is well tolerated, has significant anti-leukemic efficacy, and enables stable engraftment of HLA-matched or haploidentical allografts in pts with R/R AML or other high-grade myeloid neoplasm. Efforts are ongoing to explore augmentation of this HCT platform with additional anti-leukemic agents.

Disclosures: Sandmaier: Actinium Pharmaceuticals: Other: Attended Advisory Board Meeting; Royalty agreement with employer (Fred Hutch. Percival: Trillium: Research Funding; Abbvie: Research Funding; Ascentage: Research Funding; VinceRx: Research Funding; Astex: Research Funding; Biosight: Research Funding; BMS/Celgene: Research Funding; Cardiff Oncology: Research Funding; Glycomimetics: Research Funding; Immunogen: Research Funding; Nohla Therapeutics: Research Funding; Oscotec: Research Funding; Pfizer: Research Funding; Telios: Research Funding. Halpern: Karyopharm Therapeutics: Research Funding; Incyte Corporation: Research Funding; Jazz: Research Funding; Gilead: Research Funding; Bayer: Research Funding; Imago Biosciences: Research Funding; Agios: Consultancy; Notable Lab: Consultancy; Disc Medicine: Research Funding; AbbVie: Consultancy. Appelbaum: Incyte: Honoraria. Walter: VOR: Research Funding; Pfizer: Research Funding; Kura: Research Funding; Kite: Research Funding; Jazz: Research Funding; Janssen: Research Funding; ImmunoGen: Research Funding; Celgene/Bristol Myers Squibb: Research Funding; Aptevo: Research Funding; Wugen, Inc.: Consultancy.

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