Acute Myeloid Leukemia (AML) is a diverse disease that is fatal in the majority of patients. Acute promyelocytic leukemia (APL) however, a subtype of AML accounting for 5% of all cases, is very curable. APL cells are highly sensitive to the retinoid all-trans-retinoic acid (ATRA), which effectively differentiates the leukemic clone. Over 80% of APL patients can be cured with ATRA based therapies. For patients with non-APL AML, ATRA has little effect. Consequently, 85% of these patients will succumb to their disease despite conventional approaches. Little is known about mechanisms of resistance to ATRA in non-APL AML. This knowledge gap limits the use of ATRA in a disease that already has few effective therapies. The investigators' preliminary data suggest that non-APL AML cells can be re-sensitized to ATRA when combined with lysine-specific demethylase 1 (LSD 1) inhibitors. The investigators' publication in Nature Medicine showed that LSD1 inhibition with tranylcypromine (TCP), unlocked the ATRA-driven therapeutic response in non-APL AML. Notably, treatment with ATRA and TCP markedly diminished the engraftment of primary human AML cells in murine models, indicating that the combination may target leukemia-initiating cells (LIC). The investigators' data identify LSD1 as a therapeutic target and strongly suggest that it may contribute to ATRA resistance in non-APL AML. The investigators' central hypothesis is that ATRA combined with TCP will be safe and effective in a clinical population, and that this approach will suppress LICs and restore myeloid differentiation programs in patients with non-APL AML. Testing this hypothesis with the phase I clinical trial outlined in this protocol, will establish a new treatment paradigm in AML and extend the important anti-cancer effects of ATRA to all AML subtypes.
Study Type
INTERVENTIONAL
Allocation
NON_RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
17
Tranylcypromine (TCP) to be administered orally twice a day (12 hours apart) for up to 16 cycles of 21 days each.
45 mg/m2 of ATRA to be administered orally twice a day (12 hours apart), beginning on day 4 for up to 16 cycles of 21 days each.
University of Miami
Miami, Florida, United States
Rate of Toxicity in Study Participants Receiving TCP/ATRA Combination Therapy
The safety and tolerability of TCP/ATRA combination therapy in patients with Acute Myelogenous Leukemia (AML) and Myelodysplastic Syndromes (MDS). This will be measured by the rate of adverse events, serious adverse events and other toxicities in study participants receiving protocol therapy.
Time frame: 24 months
Rate of Preliminary Efficacy of TCP/ATRA Combination Therapy
Best response to TCP/ATRA combination therapy will be determined using serial blood and bone marrow sampling throughout the course of treatment. Responses will be documented according to revised/modified International Working Group (IWG) Response Criteria - Cheson et al. 2003 for AML and Cheson et al. 2006 for MDS. Morphologic complete remission (CR), cytogenetic CR, and molecular CR will be assessed by blood counts and simultaneous examination of the bone marrow fpr percentage of bone marrow blasts, as well as cytogenetics and molecular studies of bone marrow mononuclear cells
Time frame: 24 months
Pharmacokinetics (PK) effects of TCP in plasma when combined with ATRA
Pharmacokinetics (PK) parameters will be determined using serial blood sampling at specified time points to determine PK effects of TCP in plasma when combined with ATRA. Non-compartmental methods of analysis will be used to determine TCP PK parameters following oral dosing of patients in Cycle 1. The following will be calculated: Observed maximum concentration (Cmax), the time at which Cmax occurred (Tmax), the area under the plasma concentration-time curve from time 0 to 24 hours post-dose (AUC24hr), the terminal disposition phase half-life (t1/2).
Time frame: Baseline, Cycle 1, Cycle 2, 30 Days (+/-10 days) Post-End of Treatment
Pharmacodynamic (PD) effects of TCP in peripheral blood and bone marrow when combined with ATRA.
Pharmacodynamics (PD) measurements will be obtained from serial blood and bone marrow sampling at specified time points to describe the PD effects of TCP when combined with ATRA. The following will be measured: Expression of CD11b by flow cytometry, gene expression analysis of leukemic blasts, measurement of Retinoic acid receptor alpha (RARα) and lysine (K)-specific demethylase 1A (LSD1) within leukemic blasts, leukemic engraftment of treated cells in immunodeficient mice.
Time frame: Baseline, Cycle 1, Cycle 2, 30 Days (+/-10 days) Post-End of Treatment
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