This is a non-randomized prospective open-label single-arm clinical phase I trial investigating dose finding, feasibility and safety of the combined treatment of HDM201 and midostaurin in patients with relapsed/refractory acute myeloid leukemia (AML) with FLT3mut applying an accelerated titration design.
Background and Rationale: Acute myeloid leukemia (AML) is a clonal hematopoietic malignant disease characterized by genetic and epigenetic alterations leading to inactivation of the tumor suppressor p53. This contributes to a block in normal differentiation of the various blood type lineages and to an accumulation of leukemic blasts in the blood and bone marrow. The disease variants have been grouped into favorable, intermediate and poor risk categories. The largest group of poor risk AML is characterized by the genetic alterations of the FLT3 receptor gene termed FLT3-ITD or FLT3-TKD. The prognosis for this specific subset which comprises 25-35% of all AML patients is generally poor, particularly in elderly or in relapsed patients, highlighting the unmet need for novel treatments. Targeting the mutated FLT3 receptor is a promising approach to treat this specific poor risk AML subset. Midostaurin is particularly effective to induce cell death in FLT3-ITD/-TKD and TP53wt cells. Targeting MDM2 is a novel approach to restore the crucial p53 tumor suppressor function in AML cells. Preliminary data indicate that the MDM2 inhibitor HDM201 is active in AML cell lines in vitro and in vivo. Like midostaurin HDM201 is specifically effective to induce cell death in FLT3-ITD and TP53wt cells. The combination of midostaurin and HDM201 targets FLT3-ITD AML cells, with little effect on FLT3 wt cells and healthy blood cells. Both compounds induce apoptosis and cell death in a dose-dependent manner in FLT3-ITD TP53wt AML cells, with enhanced effects in the combination treatment. The combination treatment with midostaurin and HDM201 ought to be superior to the current best available treatment which utilizes intensive genotoxic induction therapy. In order to confirm inhibition of mutated FLT3 receptor and restoration of p53 tumor suppressor function, blood samples will be analyzed in this trial before, during and after treatment with HDM201 and midostaurin for changes in the expression of FLT3 and p53 target genes as well as induction of pro- apoptotic genes. These gene expression levels will be correlated with clinical response and outcome. Objectives: Primary objective: The primary objective of this trial is to establish the recommended dose for a subsequent phase II (RP2D) of HDM201 in combination with midostaurin in patients with relapsed or refractory FLT3mut TP53wt AML. Secondary objectives: The secondary objectives are to determine the safety and tolerability of HDM201 in combination with midostaurin and to assess the preliminary antitumor activity of HDM201 in combination with midostaurin in patients with relapsed or refractory FLT3mut TP53wt AML and in newly diagnosed AML with FLT3mut and TP53wt. Study Duration: The trial study duration encompasses the time from when the first participant signs the informed consent until the last protocol-specific procedure of the last patient in the trial has been completed. This phase I trial involves a minimum of 3 and a maximum of 24 subjects. Accordingly, the Investigator anticipate a duration of recruitment of between 3 and 18 months. All patients will be followed up for up to 12 months after end of treatment, adding to a total study duration of between 15 and 33 months depending on the effective number of patients in the various dose cohorts.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
2
Dose level 0: HDM201 40 mg QD d1,2 (midday)/ Dose level 1: HDM201 40 mg QD d1,2,3 (midday) = Starting dose/ Dose level 2: HDM201 40 mg QD d1,2,3,4,5 (midday)/ Dose level 3: HDM201 60 mg QD d1,2,3,4,5 (midday)/ Dose level 4: HDM201 80 mg QD d1,2,3,4,5 (midday)
Midostaurin 50mg bid d1-28 (morning, evening)
Departement of Medical Oncology, University Hospital Berne
Bern, Switzerland
Dose finding
to identify the incidence of dose limiting toxicities (DLT) at each dose level and to determine the maximum tolerated dose (MTD) of HDM201 and its recommended dose that will be used in a later phase II study (recommended phase II dose; RP2D) when added to midostaurin
Time frame: 30 days
Overall response rate (ORR)
CR, CRi, CRp, PR including assessment of minimal residual disease by molecular diagnostics and flowcytometry after cycles 1 and 2.
Time frame: 60 days
Adverse Events
Number of patients experiencing adverse events and severity of the adverse events
Time frame: 33 months
Progression free survival
Time from end of treatment (after bone marrow assessment after cycle 2) until progression of disease or death as a result of any cause.
Time frame: 33 months
Overall survival
Time from end of treatment (after bone marrow assessment after cycle 2) until death as a result of any cause.
Time frame: 33 months
Infectious complications of study treatment
Assessment of the number of febrile episodes requiring antibiotic/antifungal treatment as well as assessment of identified causing germs.
Time frame: 33 months
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