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Kopmar NE, Quach K, Gooley TA, Martino CH, Cherian S, Percival MEM, Halpern AB, Ghiuzeli CM, Oehler VG, Abkowitz JL, Walter RB, Cassaday RD. Dose-Adjusted EPOCH Plus Inotuzumab Ozogamicin in Adults With Relapsed or Refractory B-Cell ALL: A Phase 1 Dose-Escalation Trial. JAMA Oncol 2024:2818572. [PMID: 38722664 PMCID: PMC11082746 DOI: 10.1001/jamaoncol.2024.0967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/14/2023] [Indexed: 05/12/2024]
Abstract
Importance Options for adults with relapsed or refractory B-cell acute lymphoblastic leukemia or lymphoma (B-ALL) are limited, and new approaches are needed. Inotuzumab ozogamicin (InO) has been combined with low-intensity chemotherapy, with modest improvements over historical controls, and dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (DA-EPOCH) treatment is safe and active for newly diagnosed ALL. Objective To assess the safety and clinical activity of DA-EPOCH and InO in adults with relapsed or refractory B-ALL. Design, Setting, and Participants This single-center, single-arm, nonrandomized, phase 1 dose-escalation trial included adults with relapsed or refractory CD22+ B-ALL and was conducted between September 2019 and November 2022. At least 5% blood or marrow blasts or measurable extramedullary disease (EMD) was required for enrollment. Interventions DA-EPOCH was given on days 1 to 5, while InO was given on day 8 and day 15 of a 28-day cycle. Three dose levels were studied using a bayesian optimal interval design. Main Outcomes and Measures The primary outcome was the maximum tolerated dose of InO when combined with DA-EPOCH, defined as the highest dose level that produced a rate of dose-limiting toxicity below 33%. Secondary objectives included response rates, survival estimates, and descriptions of toxic effects. Results A total of 24 participants were screened and enrolled (median age, 46 [range, 28-76] years; 15 [62%] male). The median number of lines of prior therapy was 3 (range, 1-12). Three of 11 participants (27%) treated at the highest dose level (InO, 0.6 mg/m2, on day 8 and day 15) experienced dose-limiting toxicity, making this the maximum tolerated dose. No deaths occurred during the study, and only 1 patient (4%; 95% CI, 0.1%-21%) developed sinusoidal obstructive syndrome after poststudy allograft. The morphologic complete response rate was 84% (95% CI, 60%-97%), 88% (95% CI, 62%-98%) of which was measurable residual disease negative by flow cytometry. Five of 6 participants with EMD experienced treatment response. The overall response rate was 83% (95% CI, 63%-95%). Median overall survival, duration of response, and event-free survival were 17.0 (95% CI, 8.4-not reached), 15.0 (95% CI, 6.7-not reached), and 9.6 (95% CI, 4.5-not reached) months, respectively. Conclusions In this study, adding InO to DA-EPOCH in adults with relapsed or refractory B-ALL was feasible, with high response rates and sinusoidal obstructive syndrome occurring rarely in a heavily pretreated population. Many patients were able to proceed to poststudy consolidative allogeneic hematopoietic cell transplant and/or chimeric antigen receptor T-cell therapy. Further investigation of this combination is warranted. Trial Registration ClinicalTrials.gov Identifier: NCT03991884.
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Affiliation(s)
- Noam E. Kopmar
- Division of Hematology-Oncology, Department of Medicine, University of Washington School of Medicine, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Kim Quach
- Division of Hematology-Oncology, Department of Medicine, University of Washington School of Medicine, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Ted A. Gooley
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Christen H. Martino
- Division of Hematology-Oncology, Department of Medicine, University of Washington School of Medicine, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Sindhu Cherian
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle
| | - Mary-Elizabeth M. Percival
- Division of Hematology-Oncology, Department of Medicine, University of Washington School of Medicine, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Anna B. Halpern
- Division of Hematology-Oncology, Department of Medicine, University of Washington School of Medicine, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Cristina M. Ghiuzeli
- Division of Hematology-Oncology, Department of Medicine, University of Washington School of Medicine, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Vivian G. Oehler
- Division of Hematology-Oncology, Department of Medicine, University of Washington School of Medicine, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Janis L. Abkowitz
- Division of Hematology-Oncology, Department of Medicine, University of Washington School of Medicine, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Roland B. Walter
- Division of Hematology-Oncology, Department of Medicine, University of Washington School of Medicine, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
| | - Ryan D. Cassaday
- Division of Hematology-Oncology, Department of Medicine, University of Washington School of Medicine, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
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Kopmar NE, Othus M, Quach K, Rasmussen A, Schonhoff K, Becker PS, Walter RB, Halpern AB, Salit R, Cassaday RD, Shustov A, Stewart FM, Oehler VG, Scott BL, Sandmaier BM, Lee SJ, Estey EH, Percival MEM. Intensive Re-Induction Chemotherapy Followed by Early Allogeneic Hematopoietic Cell Transplant for Relapsed/Refractory High-Grade Myeloid Neoplasms. Transplant Cell Ther 2024:S2666-6367(24)00376-2. [PMID: 38710302 DOI: 10.1016/j.jtct.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 03/01/2024] [Accepted: 05/03/2024] [Indexed: 05/08/2024]
Abstract
Outcomes for adults with relapsed/refractory (R/R) high-grade myeloid neoplasms remain poor, with allogeneic hematopoietic cell transplant (HCT) the only therapy likely to result in cure. Therefore, we conducted a study to determine the feasibility of early HCT - within 60 days of beginning reinduction chemotherapy - to see if getting patients to HCT in an expeditious manner would facilitate a larger number of patients being offered this curative option. In this proof-of-principle feasibility study, we included adults 18-75 with R/R myeloid malignancies with ≥10% blood/marrow blasts at diagnosis, who were eligible for a reduced-intensity HCT. Subjects received reinducton chemotherapy with cladribine, cytarabine, mitoxantrone, and filgrastim (CLAG-M) and proceeded to HCT with reduced-intensity conditioning (fludarabine/melphalan). We enrolled 30 patients: all received CLAG-M reinduction, although only 9 received HCT within 60 days (< 15, the predetermined threshold for feasibility "success"), with a median time to HCT of 48 days (range 42-60). Eleven additional subjects received HCT beyond the target 60 days (off-study), with a median time to transplant of 83 days (range 53-367). Barriers to early HCT included infection, physician preference, lack of an HLA-matched donor, logistical delays, and disease progression, all of which may limit real-world uptake of such early-to-transplant protocols.
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Affiliation(s)
- Noam E Kopmar
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Megan Othus
- Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Kim Quach
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Allegra Rasmussen
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Kelda Schonhoff
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | | | - Roland B Walter
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA; Department of Epidemiology, University of Washington, Seattle, WA
| | - Anna B Halpern
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Rachel Salit
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Ryan D Cassaday
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Andrei Shustov
- Department of Epidemiology, University of Washington, Seattle, WA
| | | | - Vivian G Oehler
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Cellectar Biosciences, Florham Park, NJ
| | - Bart L Scott
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Brenda M Sandmaier
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Stephanie J Lee
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Elihu H Estey
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Mary-Elizabeth M Percival
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
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Kopmar NE, Gooley T, Curley N, Russell K, Shaw C, Schonhoff K, Lim J, Halpern AB, Walter RB, Scott BL, Appelbaum J, Hendrie PC, Estey EH, Percival MEM. Results from a phase I study of continuous infusion cladribine, high-dose cytarabine, and mitoxantrone for relapsed/refractory high-grade myeloid neoplasms. Leuk Lymphoma 2023; 64:1057-1059. [PMID: 36896478 PMCID: PMC10330652 DOI: 10.1080/10428194.2023.2185087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/15/2023] [Accepted: 02/20/2023] [Indexed: 03/11/2023]
Affiliation(s)
- Noam E Kopmar
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ted Gooley
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Niall Curley
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Kathryn Russell
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Carole Shaw
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Kelda Schonhoff
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - John Lim
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Anna B Halpern
- Department of Medicine, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Roland B Walter
- Department of Medicine, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Department of Laboratory Medicine & Pathology, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Bart L Scott
- Department of Medicine, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Jacob Appelbaum
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Paul C Hendrie
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Elihu H Estey
- Department of Medicine, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Mary-Elizabeth M Percival
- Department of Medicine, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
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Kopmar NE, Cassaday RD. How I prevent and treat central nervous system disease in adults with acute lymphoblastic leukemia. Blood 2023; 141:1379-1388. [PMID: 36548957 PMCID: PMC10082377 DOI: 10.1182/blood.2022017035] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/28/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
The central nervous system (CNS) is the most important site of extramedullary disease in adults with acute lymphoblastic leukemia (ALL). Although CNS disease is identified only in a minority of patients at the time of diagnosis, subsequent CNS relapses (either isolated or concurrent with other sites) occur in some patients even after the delivery of prophylactic therapy targeted to the CNS. Historically, prophylaxis against CNS disease has included intrathecal (IT) chemotherapy and radiotherapy (RT), although the latter is being used with decreasing frequency. Treatment of a CNS relapse usually involves intensive systemic therapy and cranial or craniospinal RT along with IT therapy and consideration of allogeneic hematopoietic cell transplant. However, short- and long-term toxicities can make these interventions prohibitively risky, particularly for older adults. As new antibody-based immunotherapy agents have been approved for relapsed/refractory B-cell ALL, their use specifically for patients with CNS disease is an area of keen interest not only because of the potential for efficacy but also concerns of unique toxicity to the CNS. In this review, we discuss data-driven approaches for these common and challenging clinical scenarios as well as highlight how recent findings potentially support the use of novel immunotherapeutic strategies for CNS disease.
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Affiliation(s)
- Noam E. Kopmar
- Division of Hematology, Department of Medicine, University of Washington School of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Ryan D. Cassaday
- Division of Hematology, Department of Medicine, University of Washington School of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
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Kopmar NE, Estey EH. New drug approvals in acute myeloid leukemia: an unprecedented paradigm shift. Clin Adv Hematol Oncol 2019; 17:569-575. [PMID: 31730583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
We are witnessing an unprecedented paradigm shift in the treatment of acute myeloid leukemia (AML). For nearly 4 decades-since the introduction of cytarabine- and anthracycline-based induction chemotherapy in the 1970s-treatment options for patients with AML have remained limited, and outcomes remain poor for the majority of patients, particularly the elderly. Over the past 10 to 15 years, we have better elucidated the genetic and molecular basis of AML, which has led to our current understanding of disease heterogeneity. We now appreciate that numerous distinct disease subtypes exist, each with their own disease characteristics and risk profile. In keeping with this improved understanding, we have seen the introduction of numerous new agents that are mechanistically targeted against a specific mutation, a deranged cellular pathway, and/or a specific AML disease subset. Within the last 3 years alone, the US Food and Drug Administration has approved 8 new targeted agents for the treatment of AML. With their introduction comes a new sense of optimism, along with questions about how to best use these agents. In this article, we discuss the recently approved agents in AML, the rationale behind their development and the trials that served as the basis for their approval, and the implications of their introduction into the treatment armamentarium.
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Affiliation(s)
| | - Elihu H Estey
- Fred Hutchinson Cancer Research Center, Seattle, Washington
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Kopmar NE, Tseng YD, Holmberg LA, Becker PS, Green DJ, Tuazon S, Libby EN, Coffey DG, Gopal AK, Cowan AJ. Safety and Toxicities of Radiotherapy As Consolidation or Cytoreduction Around the Time of Autologous Stem Cell Transplantation for Multiple Myeloma Patients: A Single Center Retrospective Report. Biol Blood Marrow Transplant 2019. [DOI: 10.1016/j.bbmt.2018.12.833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Sabo MC, Boonyaratanakornkit J, Cybulski R, Kopmar NE, Freeman RV, Fang FC, Graham SM. Getting to the Heart of the Matter: A 20-Year-Old Man With Fever, Rash, and Chest Pain. Open Forum Infect Dis 2018; 5:ofx272. [PMID: 29399597 PMCID: PMC5788053 DOI: 10.1093/ofid/ofx272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 12/19/2017] [Indexed: 02/05/2023] Open
Abstract
Infection with Helicobacter cinaedi can encompass a wide spectrum of clinical manifestations, including fever, rash, endocarditis, osteomyelitis, and meningitis. The present case demonstrates the ability of H cinaedi to masquerade as acute rheumatic fever and represents the first reported case of cardiac tamponade caused by H cinaedi.
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Affiliation(s)
- Michelle C Sabo
- Department of Laboratory Medicine, University of Washington, Seattle
| | | | - Robert Cybulski
- Department of Laboratory Medicine, University of Washington, Seattle
| | - Noam E Kopmar
- Department of Medicine, University of Washington, Seattle
| | | | - Ferric C Fang
- Department of Medicine, University of Washington, Seattle.,Department of Laboratory Medicine, University of Washington, Seattle
| | - Susan M Graham
- Department of Medicine, University of Washington, Seattle.,Department of Global Health, University of Washington, Seattle.,Department of Epidemiology, University of Washington, Seattle, University of Washington, Seattle
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