a phase ii study of lenalidomide as initial treatment of elderly patients with chronic lymphocytic...
TRANSCRIPT
A Phase II Study of Lenalidomide as Initial
Treatment of Elderly Patients with Chronic Lymphocytic
Leukemia
Xavier Badoux, William Wierda, Susan O'Brien, Stefan Faderl, Steven Kornblau,
Kimberly Yerrow, Zeev Estrov, Hagop Kantarjian,
Michael Keating and Alessandra Ferrajoli
DisclosuresXavier Badoux, MB BS
Research Support/P.I. No disclosures
Employee No disclosures
Consultant No disclosures
Major Stockholder No disclosures
Speakers’ Bureau No disclosures
Scientific Advisory Board No disclosures
Presentation includes discussion of off-label use of lenalidomide in CLL.
Lenalidomide in Elderly CLL: Introduction
• Median age at diagnosis of CLL: 72 years • Elderly patients with CLL
– Under-represented in clinical trials– Increased toxicity with chemoimmunotherapy
• Lenalidomide – Immunomodulatory drug– Oral administration – Active in relapsed CLL
SEER Cancer Statistics Review, NCI (2009); Eichhorst B, Leuk & Lymph (2009); Chanan-Khan A et al. JCO (2006); Ferrajoli A et al. Blood (2008).
Lenalidomide in Elderly CLL: Study Design
• Phase II, 60 patients
• Untreated and symptomatic (NCI-WG)
• Age ≥ 65 yrs
• Creatinine <2 mg/dL, bilirubin<2 mg/dL
• Performance status 0-2
• Response assessed at end of Cycle 3, then every 6 cycles (2008 NCI-WG)
ClinicalTrials.gov (ID# NCT00535873)
Lenalidomide in Elderly CLL: Treatment Schedule
• Lenalidomide
– 5 mg orally daily x 2 cycles (56 days)
– Increase by 5 mg/cycle (28 days) to maximum 25 mg daily
– Treatment continued until progression• Allopurinol 300 mg d1-14
• No mandated antibiotic, anti-viral, DVT or tumor flare prophylaxis
• Efficacy: 1. Progression-free survival 2. Clinical Responses (2008 NCI-WG)
• Toxicity:Grade 3-4 non-hematological
• Correlative Studies:Lymphocyte subsets analysis: blood and
marrowSerum immunoglobulin levels
Lenalidomide in Elderly CLL: Study Endpoints
Lenalidomide in Elderly CLL: Patient Pre-treatment Characteristics
Characteristic N (%); median [range]
Age, years 71 [66-85]
Rai stage, III or IV 18 (30)
Lymphocytes, x 109/L 76 [2.5 – 227]
2-microglobulin, mg/L 4.3 [2.0 – 10.2]
IGHV, unmutated 33/55* (60)
11q deletion 14 (23)
17p deletion 6 (10)
Marrow CD38, ≥30% 30/59** (51)Not evaluable: *IgVH: n=5, **CD38: n=1
Lenalidomide in Elderly CLL: Response (2008 NCI-WG Criteria)
N = 60 NCI Response
n patients %
CR* 6 10
CRi* 3 5
Nodular PR 3 5
PR 25 42
ORR 37 62
*4 patients with flow cytometry negative CR
Analysis time 3 cycles 9 cycles 15 cycles 21 cycles
ITT/No on Rx. 60/54 60/43 59/38 53/30
NCI Response n (%) n (%) n (%) n (%)
CR/CRi* - 1 (2) 5 (8) 7 (13)
Nodular PR - 6 (10) 4 (7) 5 (9)
PR 24 (40) 27 (45) 27 (46) 18 (34)
ORR 24 (40) 34 (57) 36 (61) 30 (57)
Lenalidomide in Elderly CLL: Responses at Assessment Times
Patient characteristicNCI-WG Response (%)
n CR/CRi/nPR OR
Age, years65 - 74 43 26 72
≥ 75 17 6 35*
Rai stage0 – II 42 21 64
III or IV 18 17 56
β2-M, mg/L< 4 26 27 69
≥ 4 34 15 56
IGHV genesMutated 22 5* 50
Unmutated 33 30 73
FISH hierarchy
Deletion 13q 15 33 73
Negative 12 8 50
Trisomy 12 13 15 92
Deletion 11q 14 29 57
Deletion 17p 6 0 0*
Lenalidomide in Elderly CLL: Responses by Pre-treatment Characteristics
*p<0.05
Lenalidomide in Elderly CLL: Overall and Progression-free Survival
Median follow-up 23 months:
OS = 90%
PFS = 60%
Lenalidomide in Elderly CLL: Normalization of PB Lymphocytes (n=38)
*p<0.001
Lenalidomide in Elderly CLL: Reconstitution of BM Lymphocytes (n=38)
*p<0.001,**p<0.01
(%)
Lenalidomide in Elderly CLL: Improvement in Serum Igs (n=37)
8 / 16 (50%) patients with IgG<600mg/dl → normalized serum IgG
* p<0.001
Cycles of therapy Cycles of therapy
Hematological toxicity*Toxicity as % of cycles
Grade 3 Grade 4
Neutropenia 26 12
Thrombocytopenia 13 <1
Anemia 0 0
Lenalidomide in Elderly CLL: Hematological Toxicity
*NCI-working group criteria
Infections (N=60)Grade ≥ 3
n episodes n (%) patients
Sepsis 1 1 (2)
Pneumonia/Bronchitis 3 2 (3)
Upper Respiratory 0 0 (0)
Urinary 0 0 (0)
Other infections 1 1 (2)
Fever, neutropenic 3 3 (5)
Fever, non-neutropenic 3 2 (3)
Lenalidomide in Elderly CLL: Infections
Toxicity (N=60)Grade 1 - 2 Grade ≥3
n of patients %n of
patients%
Fatigue 53 88 2 3
Constipation 30 50 1 2
Diarrhea 30 50 0 0
Tumor flare 30 50 0 0
Rash 28 47 0 0
Nausea 21 35 0 0
Dyspnea 20 33 1 2
Pruritus 20 33 1 2
Neuropathy: sensory 9 15
0 0
Neuropathy: motor 4 7 0 0
Lenalidomide in Elderly CLL: Other Toxicities
• Lenalidomide as frontline therapy in elderly CLL– Estimated 2-year OS 90%; 2-year PFS 60%
– ORR 62 %; CR/CRi 15%
– Quality of response improves with time• Myelosuppression most common toxicity• No severe tumor flare or tumor lysis syndrome• ↑ serum Ig levels• Normalization of lymphocyte populations
Lenalidomide in Elderly CLL: Conclusions
Thank you
Lenalidomide dose NNCI-WG Response (%)
CR/CRi/nPR OR
Mean DoseCycles 1 - 6
< 5mg 26 4 35
≥ 5mg 34 32* 82**
Lenalidomide in Elderly CLL: Clinical Responses by Dose Intensity
*p<0.01, **p<0.001
Lenalidomide in Elderly CLL: Best Clinical Response: 2008 NCI-WG