Adult acute lymphoblastic leukemia (ALL) includes Ph-positive (Phpos) ALL, Ph-negative (Phneg) B-cell precursor (BCP) ALL and T-ALL/lymphoblastic lymphoma (LL), accounting for approximately 25, 50 and 25% of all cases, respectively. In younger adults, the results associated with standard therapy have markedly improved in these 3 groups, due to chemotherapy intensification in the BCP and T groups and addition of TKIs in the Phpos group, respectively. This led to reevaluate the role of allogeneic hematopoietic stem cell transplantation (HSCT) in first remission, which is generally now indicated only in higher-risk patients, mostly defined as those with persistent high levels of minimal residual disease (MRD). Nevertheless, event-free survival (EFS) remains at 60-70% at 3 years, meaning there is still room for further improvements. Fortunately, new immunotherapies have been approved to treat relapsed/refractory (R/R) BCP-ALL patients, including the anti-CD19 bispecific T-cell engager blinatumomab (BLINA, Blincyto®, Amgen). 4 BLINA is also approved for the frontline treatment of patients with persistent high measurable residual disease (MRD) levels after initial therapy (IG/TR MRD ≥0.1% (≥1.10-3 )). BLINA has been also evaluated frontline in combination with TKI in the Phpos group leading to promising outcome improvements. Toxicities associated with these combined treatments seem to be limited and manageable. In the Phpos ALL subset, the third-generation tyrosine kinase inhibitor ponatinib (PONA, Iclusig®, Incyte) has also been evaluated frontline with promising results when compared to 1st or even 2nd generation TKI. In the T-ALL/LL subset, anti-CD38 antibodies, approved to treat patients with multiple myeloma, are potential drugs of interest. The anti-CD38 antibody isatuximab (ISA, Sarclisa®, Immunogen, Sanofi-Aventis) is currently approved to treat myeloma patients in 2nd line. In vitro and in vivo preclinical studies suggest that CD38 is a relevant target in T-ALL and that isatuximab may be useful to eradicate residual disease in this subgroup of patients. Incorporation/combination of these new agents into frontline adult ALL therapy could allow reducing relapse incidence and prolonging survival in these patients, challenging the indication for HSCT in first complete remission (CR). The present GRAALL-2024 study is a prospective multicenter multi-country 3-cohort randomized clinical trial. The 3 cohorts are : GRAALL-2024/B : Phneg BCP-ALL GRAAPH-2024 : Phpos ALL GRAALL-2024/T : T-ALL/LL Eligible patients will be allocated to one on the 3 study cohorts during a common treatment prephase. The primary objective of the study is to improve the outcome of younger adults with ALL through optimal frontline incorporation of new antibody-based therapies, including BLINA in Phneg/pos BCP-ALL patients and ISA in T-ALL/LL patients, and to refine indication for allogeneic HSCT in first remission in Phneg/pos BCP-ALL patients.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
1,200
Rando 1 : BLINA will be given at 28 µg/day IVC from D1 to D28 for 2 to 4 cycles (first cycle starts with 9 µg/day for 7 days)
Rando 3 : standard of care
Rando 3 : ISA will be given at 10 mg/kg IV for a maximum of 28 infusions starting at induction up to maintenance phase.
Rando 2 : * PONA will be given at 45 mg/day PO during 2 cycles, 30 mg/day during 2 additional cycles, and 15 mg/day during maintenance phase or after alloHSCT * BLINA will be given at 28 µg/day IVC from D1 to D28 for 2 to 5 cycles (first cycle starts with 9 µg/day for 7 days). Patients allografted will receive two courses before transplant.
Rando 1 : standard of care - Allogeneic Hematopoietic Stem Cell Transplantation
Rando 2 : standard of care
Hôpital Saint Louis
Paris, France
RECRUITINGOverall survival
For GRAAL-2024/B HR patients (phase 3)
Time frame: At 5 years
Overall survival
For GRAAL-2024/B SR patients (phase 2)
Time frame: At 5 years
Event-Free Survival
For GRAAL-2024/T patients (phase 3)
Time frame: At 5 years
Overall survival
For GRAAPH-2024 patients (phase 3) - Phpos ALL
Time frame: At 5 years
Overall survival
in the T-ALL/LL cohorts
Time frame: At 5 years
Event Free Survival
Time frame: At 5 years
Relapse Free Survival
Time frame: At 5 years
Hematological complete response rate
After induction
Time frame: At 45 days
Hematological complete response rate
After consolidation
Time frame: At 4 months
Measurable residual disease (MRD) response level
(IG/TR and BCR::ABL1 markers) at diagnosis
Time frame: At inclusion
Measurable residual disease (MRD) response level - non graft patients
(IG/TR and BCR::ABL1 markers) After each treatment cycle until maintenance (4 to 5 times)
Time frame: Up to 6 months
Measurable residual disease (MRD) response level - graft patients
(IG/TR and BCR::ABL1 markers) At day 100 post-HSCT and every 3 months post HSCT for patients receiving allo-HSCT during maintenance up to 2 years
Time frame: Through study completion, approximately 5 years
Measurable residual disease (MRD) response level
(IG/TR and BCR::ABL1 markers) At relapse
Time frame: Up to 5 years
Early mortality
Time frame: At day 30
Early mortality
Time frame: At day 60
Early mortality
Time frame: At day 90
Cumulative incidence of relapse (CIR)
Time frame: At 5 years
Cumulative incidence of non relapse mortality
Time frame: At 5 years
Transplant-related mortality (TRM)
For graft patients
Time frame: At 5 years
Graft-versus-host-disease (GvHD) incidence
For graft patients
Time frame: At 5 years
Number of patients who experience one or more Adverse Event (AEs) or Serious Adverse Event (SAEs)
Time frame: At 5 years
Rate of patients who experience one or more Adverse Event (AEs) or Serious Adverse Event (SAEs)
Time frame: At 5 years
Quality of life level
Assessed with EQ5D 5L It evaluates five dimensions : mobility, self-care, usual activities, pain/discomfort and anxiety/depression and each dimension has five levels : no problems, slight problems, moderate problems, severe problems and extreme problems. Answers are given on a 5-point scale by domain, the higher the score, the poorer the quality of life. At each study visit
Time frame: Until 5 years
Incremental cost effectiveness and cost utility ratio
Defined as the difference in total costs divided by the difference in survival and in quality adjusted life years
Time frame: At 5 years
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