phase 1 study of alvocidib followed by 7+3 (cytarabine + … · 2020. 9. 30. · page 1 of 30 phase...

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Phase 1 Study of Alvocidib Followed by 7+3 (Cytarabine + Daunorubicin) in

Newly Diagnosed Acute Myeloid Leukemia

Joshua F. Zeidner1, Daniel J. Lee

2, Mark Frattini

2,3, Gil D. Fine

4, Judy Costas

4, Kathryn

Kolibaba4, Stephen P. Anthony

4, David Bearss

4, B. Douglas Smith

5

1 University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC

2Columbia University Medical Center, New York, NY

3Celgene, Summit, NJ

4Sumitomo Dainippon Pharma Oncology, Lehi, UT

5Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center,

Baltimore, MD

Running title: Alvocidib + 7+3 in Newly Diagnosed AML

Keywords: Alvocidib, AML, 7+3, CDK9, MCL-1

Authorship contributions:

J.F.Z. and D.L. contributed to study design, enrolled patients, collected and interpreted the data,

and wrote the manuscript. M.F. and B.D.S. contributed to study design, enrolled patients, and

wrote the manuscript. G.D.F. contributed to study design and interpreted the data. J.C. and K.K.

collected the data. S.A. and D.B. contributed to study design and wrote the manuscript. All

authors provided critical review and final approval of the manuscript.

Address for Correspondence:

Joshua F. Zeidner, MD

Associate Professor of Medicine

170 Manning Drive

Houpt Building, CB# 7305

Chapel Hill, NC 27599

Office: (919) 962-5164

Fax: (919) 966-6735

[email protected]

Research. on August 19, 2021. © 2020 American Association for Cancerclincancerres.aacrjournals.org Downloaded from

Author manuscripts have been peer reviewed and accepted for publication but have not yet been edited. Author Manuscript Published OnlineFirst on September 30, 2020; DOI: 10.1158/1078-0432.CCR-20-2649

mailto:[email protected]

http://clincancerres.aacrjournals.org/

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Conflict of interest disclosures:

JFZ has received honoraria from AbbVie, Agios, Bristol Myers Squibb/Celgene, Daiichi-

Sankyo, Genentech, Pfizer, Takeda, and Tolero, consultancy fees from AsystBio Laboratories,

Celgene and Takeda, and institutional research funding from AROG, Forty Seven, Merck,

Takeda and Tolero.

DJL has served as a consultant for Celgene and received institutional research funding from

AbbVie, Bayer, Forty Seven, Genentech, Novartis, and Tolero.

BDS has received consulting fees from Jazz Pharmaceuticals, Novartis, and Celgene and

received research funding from Novartis, AbbVie, and Agios, and serves on a DSMB and

adjudication board for Celgene.

MF is an employee at Celgene.

GDF, JC, and DB are employees of Sumitomo Dainippon Pharma Oncology, formerly Tolero

Pharmaceuticals.

KK has received research funding from Acerta, Celgene, Genentech, Gilead, Novartis,

Pharmacyclics, Seattle Genetics, TG Therapeutics; consulting from Atara Biotech, Boston

Biomedical, TG Therapeutics, Tolero; and is employed by Compass Oncology

SPA is an employee of Sumitomo Dainippon Pharma Oncology, formerly Tolero

Pharmaceuticals, and consultant for Exact Sciences.

Word Count (Abstract): 237

Word Count (Main text): 3637

Total Number of Tables, Figures: 6




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Supplementary Files: 1




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TRANSLATIONAL RELEVANCE:

Standard frontline therapy for younger fit patients with newly diagnosed AML includes

induction chemotherapy with continuous infusion cytarabine and an anthracycline (i.e., 7+3)

with or without targeted agents such as midostaurin or gemtuzumab ozogamicin. However,

overall outcomes are poor with 5-year survival rates <50%. Alvocidib is a cyclin-dependent

kinase-9 (CDK9) inhibitor that leads to transcriptional suppression of MCL-1, an anti-apoptotic

BCL-2 family member that is up-regulated in AML. Prior studies showed that alvocidib followed

by cytarabine and mitoxantrone has anti-leukemic activity in both newly diagnosed and

relapsed/refractory AML. This phase 1 study revealed that alvocidib 30 mg/m2 IV over 30-

minutes followed by 60 mg/m2 IV over 4-hours on days 1-3 can be administered prior to 7+3

induction in newly diagnosed AML patients with overall CR rates of 69% in patients with non-

favorable cytogenetics. Preliminary clinical activity was seen in secondary AML patients who

have poor outcomes with conventional chemotherapy.




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ABSTRACT

Purpose: Alvocidib is a cyclin-dependent kinase-9 inhibitor leading to down-regulation of the

anti-apoptotic BCL-2 family member, MCL-1. Alvocidib has shown clinical activity in a timed-

sequential regimen with cytarabine and mitoxantrone in relapsed/refractory and newly diagnosed

AML but has not been studied in combination with traditional 7+3 induction therapy.

Experimental Design: A multi-institutional phase 1 dose-escalation study of alvocidib on days

1-3 followed by 7+3 (cytarabine 100 mg/m2/day IV infusion days 5-12 and

daunorubicin 60 mg/m2

IV days 5-7) was performed in newly diagnosed AML ≤65 years. Core-

binding factor AML was excluded.

Results: There was no maximum tolerated dose on this study; the recommended phase 2 dose of

alvocidib was 30 mg/m2 IV over 30-minutes followed by 60 mg/m

2 IV infusion over 4-hours.

There was 1 dose-limiting toxicity of cytokine release syndrome. The most common grade ≥3

non-hematologic toxicities were diarrhea (44%) and tumor lysis syndrome (34%). Overall,

69% (22/32) of patients achieved complete remission (CR). In an exploratory cohort, 8/9 (89%)

CR patients had no measurable residual disease, as determined by a centralized flow cytometric

assay. Clinical activity was seen in patients with secondary AML, AML with MDS-related

changes, and a genomic signature of secondary AML (50%, 50% and 92% CR rates,

respectively).

Conclusions: Alvocidib can be safely administered prior to 7+3 induction with encouraging

clinical activity. These findings warrant further investigation of alvocidib combinations in newly

diagnosed AML. This study was registered at clinicaltrials.gov identifier NCT03298984.




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INTRODUCTION

Overall outcomes remain poor in patients with Acute Myeloid Leukemia (AML) which affects

approximately 20,000 patients and more than 11,000 patients will die each year from this disease

in the United States (1). In younger patients (i.e., those <60-65 years), induction therapy with

7+3 remains the mainstay of treatment despite suboptimal long-term outcomes, particularly in

patients with adverse-risk disease whereby median overall survival (OS) is <1 year (2). In those

with a FLT3 mutation, midostaurin, an oral FLT3 inhibitor, improves OS but not complete

remission (CR) rates when added to 7+3 induction (3). However, FLT3 mutations are only

present in approximately 25-30% of newly diagnosed AML. The addition of Gemtuzumab

ozogamicin (GO), an antibody-drug-conjugate targeting CD33, to 7+3 induction was shown to

improve event-free survival (EFS) but not OS in newly diagnosed AML patients 50-70 years (4).

However, those with adverse-risk disease do not benefit from the addition of GO (5). Novel

agents are needed to improve clinical outcomes in the front-line treatment of AML, particularly

those with adverse-risk disease.

Alvocidib is a potent, non-selective cyclin-dependent kinase (CDK)-9 inhibitor with activity

against CDK4, 5, 7, 8 and 11. CDK9 forms a complex with cyclin T1 (PTEF-b) which is

recruited by bromodomain-containing protein-4 and mediator to superenhancer DNA complexes

to regulate the activity of RNA polymerase II. In turn, RNA polymerase II catalyzes the

transcription of genes regulating cell survival and proliferation, such as STAT3, c-MYC and

MCL-1. MCL-1 is up-regulated in AML and contributes to leukemia cell survival and resistance

to apoptosis (6,7) MCL-1 is also necessary for survival of leukemic stem cells, the population of

cells responsible for minimal residual disease (MRD), and facilitates AML progression (8).




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Blockade of MCL-1 has anti-leukemia activity in vivo (6,8). Inhibition of CDK9 prior to S-phase

specific cytotoxic chemotherapy agents may lead to synergistic apoptosis of leukemia cells (9).

Alvocidib has been investigated in a timed-sequential therapy (TST) approach in combination

with cytarabine and mitoxantrone (ACM) in 405 patients with both newly diagnosed (n=256)

and relapsed/refractory (n=149) AML with encouraging findings (10-17). To date, there have

been two dosing strategies done with alvocidib: a 60-minute IV bolus versus a “hybrid” dosing

of a 30-minute loading dose followed by a 4-hour infusion. Hybrid dosing was developed to

mitigate protein binding of alvocidib and maintain more sustained pharmacokinetic activity of

alvocidib (18). A randomized phase 2 trial of bolus versus hybrid ACM in newly diagnosed

poor-risk revealed similar clinical activity between both regimens though a lower dose of hybrid

alvocidib was studied compared with previous MTD seen and overall CR was non-significantly

higher in hybrid arm (74% vs. 62%, respectively) (15). Given the ease of administration, bolus

alvocidib was chosen for further development in newly diagnosed AML. Subsequently, a

randomized phase 2 clinical trial of bolus ACM led to higher CR rates compared with 1 or 2

cycles of 7+3 induction therapy (70% vs. 57%; p=0.07) in newly diagnosed AML patients with

non-favorable-risk cytogenetics (17,19). However, alvocidib has not been studied in the context

of conventional induction therapy with 7+3. Therefore, we designed a phase 1 dose-escalation

study of alvocidib followed by 7+3 in newly diagnosed AML patients with non-favorable-risk

cytogenetics to assess the safety, maximal tolerated dose (MTD), and clinical activity of this

regimen. We chose to utilize the hybrid dosing of alvocidib based on our prior experience.

MATERIALS AND METHODS

Study Population:




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This was a Phase 1, open-label, multicenter, dose-escalation study of alvocidib followed by

cytarabine/daunorubicin (7+3) in patients with AML (NCT03298984). Patients aged 18-65 years

with newly diagnosed, previously untreated AML were eligible. Hydroxyurea was permitted

prior to enrollment. Full eligibility criteria are listed in Supplementary Appendix. Patients were

excluded if they had previous treatment for AML, acute promyelocytic leukemia, or core-binding

factor AML. All patients provided written informed consent. This study was conducted as per the

Declaration of Helsinki after approval by ethics committee of each participating center.

Treatment Plan:

Alvocidib was dose-escalated starting at dose level 1: 20 mg/m2 30-minute IV bolus followed by

30 mg/m2 IV infusion over 4 hours on days 1-3 (Figure 1). Daunorubicin 60 mg/m

2 IV bolus

over 15 minutes was initiated on days 5-7, and cytarabine 100 mg/m2/day IV continuous 24-hour

infusion was administered on days 5-11. A BM aspirate/biopsy was performed on day 14 (+/-3

days) and patients with residual leukemia (>5% BM blasts and >10% cellularity) were

recommended to receive a second induction cycle with alvocidib days 1–3 (same dose level as

induction) followed by daunorubicin 45 mg/m2/day IV over 15 minutes on days 5-6 and

cytarabine 100 mg/m2/day IV continuous infusion days 5-9.

Patients who achieved CR received 2-4 cycles of consolidation therapy with high dose

cytarabine (HiDAC) 1.5-3 gm/m2 IV every 12 hours days 1, 3 and 5 upon full hematological

recovery. Allogeneic stem cell transplantation (alloSCT) was permitted after induction.

Toxicity and Response Assessments:

Dose limiting toxicities (DLT’s) were defined based on the NCI CTCAE version 4.03 and

outlined in Supplementary Appendix.




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Response assessment was performed by a BM aspirate/biopsy at the time of full hematologic

recovery or by day 50 and 60 of 1 versus 2 induction cycles, respectively, and assessed by

standardized ELN Guidelines (20).

Minimal Residual Disease (MRD) Analysis:

MRD was assessed in BM samples at the time of response by a uniform central assay

(Hematologics, Inc.) in an exploratory cohort, as has been previously described (21). 200,000

events were analyzed for each sample. The sensitivity of this assay was 0.02%. Details on the

methodology of this assay are included in the Supplementary Appendix.

Mitochondrial priming:

Leukemia dependence on BH3 member proteins was assessed, as previously described (22). For

evaluation of MCL-1 dependence, we utilized the MCL-1 binding protein, MS1, with

modifications allowing for improved cell penetrance, termed T-MS1 (23). T-MS1 has higher

potency and affinity for MCL-1 than NOXA (24). Details on methodology of this assay are

described in Supplementary Appendix.

Statistical Analysis:

The primary objective of this study was to establish an MTD of alvocidib prior to 7+3 induction.

Alvocidib dose was escalated using a 3+3 design (Figure 1). Successive cohorts of patients (3-6

per cohort) were treated with escalated doses until the MTD was established.

Secondary objectives included assessment of overall response rates (CR/CRi + partial remission

[PR]), OS, relapse-free survival (RFS) and EFS. Kaplan-Meier time-to-event analyses was




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performed on OS, EFS, RFS and duration of CR. Database lock was on April 30, 2020. All

statistical analyses were performed using SAS software version 9.4 or higher.

RESULTS

Patient Characteristics:

Between December 2017 and September 2019, 32 patients were enrolled to this study. Patient

characteristics are shown in Table 1. The median age was 58 years, 6 (19%) had secondary

AML, while 12 (38%) had AML with myelodysplasia-related changes (MRC) (defined by MDS-

related cytogenetics (25) or history of MDS/CMML). By ELN classification, 9 (28%) were

favorable, 7 (22%) were intermediate, and 16 (50%) were adverse-risk. Similarly, 12 (38%)

patients had unfavorable-risk cytogenetics by Southwest Oncology Group (SWOG) classification

(26). The most common mutations seen in this cohort were NPM1 (31%), ASXL1 (19%) and

RUNX1 (16%) mutations.

Safety:

The most common overall treatment-emergent adverse events included diarrhea (n=29, 91%,

Grade ≥3=14, 44%), nausea (n=20, 63%, Grade≥3=0, 0%), vomiting (n=13, 41%,

Grade≥3=0, 0%), fatigue (n=11, 34%, Grade≥3=0, 0%) and TLS

(n=11, 34%, Grade≥3=11, 34%) (Supplementary Table S1). The most common ≥grade 3

treatment-emergent adverse events were diarrhea (44%) and TLS (34%) (Table 2). These

toxicities resolved with supportive interventions as outlined in Methods and were not considered

dose-limiting. Diarrhea did not lead to any modifications or delays with alvocidib dosing. One

patient experienced a DLT (TLS, acute kidney injury, cytokine release syndrome: CRS) at the

highest alvocidib dose level studied (30 mg/m2 IV bolus followed by 60 mg/m

2 IV over 4 hours).




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Dexamethasone was initiated for CRS with rapid resolution of symptoms. The MTD was not

reached and the highest alvocidib dose level was determined to be the recommended Phase 2

dose (RP2D).

An expansion cohort enrolled 23 patients at the RP2D (Table 1). Overall, 30-day and 60-day

mortality was 3%. One patient died on day 26 due to septic shock during reinduction. In those

who achieved CR, the median time to partial and full neutrophil recovery (i.e., ≥0.5x109/L and

≥1x109/L, respectively) and partial and full platelet recovery (i.e., ≥50x10

9/L and ≥100x10

9/L,

respectively) was 34 and 36 days and 30 and 35 days.

Clinical Activity:

Among all enrolled patients, ORR and CR rates were 75% and 69%, respectively (Table 3). All

patients who achieved a CR achieved full hematologic recovery. Among response-evaluable

patients, the ORR and CR rates were 77% and 71%, respectively (one patient died on day 26 of

re-induction without a response assessment). Twenty-nine (91%) patients had no evidence of

residual leukemia on day 14 assessment (CR: 22/29 = 76% after 1 cycle of induction) whereas

3 (9%) received re-induction for residual leukemia on day 14. None of the patients who received

re-induction therapy achieved CR. Overall CR rates were 89% (8/9), 71% (5/7), and 56% (9/16)

for favorable-, intermediate-, and adverse-risk patients by ELN classification, respectively. Fifty

percent of patients with secondary AML (3/6) and AML with MRC (6/12) achieved CR. At the

RP2D, 15/23 (65%) achieved CR.

Of the 22 patients who achieved CR, 19 (86%) received consolidation therapy with intermediate

or HiDAC consolidation (median # of cycles: 2; Range: 1-4). Eleven (34%) proceeded to

alloSCT (ELN favorable-risk: n= 3, intermediate-risk: n=3, adverse-risk: n=5), all of whom




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achieved CR with induction therapy. Of the 11 patients who achieved CR and did not receive an

alloSCT, 5 (45%), 2 (18%), and 4 (36%) were ELN favorable-risk, intermediate-risk and

adverse-risk, respectively.

MRD Exploratory Cohort:

Twelve (38%) patients on the expansion cohort were included in a centralized MRD flow

cytometry assessment. Nine (75%) achieved CR and 8/9 (89%) were determined to be MRD-

negative (Intermediate-risk: 7/7; Adverse-risk: 1/2; Supplementary Table S3).

Genomic Signatures Predictive of Response:

A heatmap of genomic signatures obtained at diagnosis by institutional standard NGS panel

outlined by overall mutational landscape is demonstrated in Figure 2 and by proportion of CR

versus no CR in Supplementary Fig S1. As expected, the majority of patients with NPM1

mutations achieved CR (8/10 = 80% CR). Interestingly, overall CR rate was 83% (5/6) and

80% (4/5) among patients with ASXL1 and RUNX1 mutations, respectively. Only 1/3 (33%)

patients with a TP53 mutation achieved CR. Notably, among patients with a previously classified

genomic signature specific for secondary AML (i.e. ASXL1, BCOR, EZH2, SF3B1, SRSF2,

STAG2, U2AF1, or ZRSR2) (27), 11/12 (92%) achieved CR. Next, we analyzed overall response

among patients subdivided into the proposed genomic classification by Pappaemmanuil et al (28)

(Supplementary Fig S2). The most common genomically-defined subgroups in this cohort were

AML with NPM1 mutation (n=10) and AML with mutated chromatin, RNA-splicing genes, or

both (n=10). CR rates were 80% (8/10) and 90% (9/10) in patients classified as AML with

NPM1 mutation and AML with mutated chromatin, RNA-splicing genes, or both, respectively.




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Clinical Outcomes:

Figure 3 displays a Swimmer’s Plot of all patients enrolled (n=32). Of the 22 CR patients,

7 (32%) relapsed to date (median duration of CR: 8.6 months; Range: 1.4-13.6 months)]. Two

(18%) patients who achieved CR without MRD relapsed (including one who underwent an

alloSCT) while 9 (82%) who achieved CR without MRD remain in CR. Eleven (34%) patients

died. Causes of death were leukemia-related complications (n=9), septic shock during re-

induction therapy (n=1) and disseminated mucormycosis after consolidation therapy while in CR

(n=1).

Figure 3 depicts the OS, EFS and RFS of the 32 patients enrolled on this study. Mean and

median duration of follow-up was 11.4 and 9.2 months, respectively. The median OS was not

reached due to relatively short duration of follow-up. Landmark 1-year OS was

62.4% (95% CI: 41.9, 77.4%). Median EFS was 10.0 months (95% CI: 2.0, NA) while median

RFS was not reached. Landmark 1-year and 2-year EFS was 40.9 % (95% CI: 21.9, 59.1 %) and

34.1% (95% CI: 15.4, 53.8%) respectively. Landmark 1-year RFS was 59.5%

(95% CI: 31.7, 79.1%).

Mitochondrial Priming Correlates:

MCL-1 dependence was assessed by mitochondrial profiling from pre-treatment diagnostic BM

samples in 27/31 (87%) response-evaluable patients. Median MCL-1 score was 25.2% (range:

7.0-46.8%). There was no significant correlation of MCL-1 score among CR versus no CR

(Supplementary Fig S3). Twelve (44%) and 2 (7%) patients had MCL-1 priming scores >30%

and >40%, respectively. CR rate was 83% (10/12) and 67% (10/15) among those with MCL-1

dependence > and <30%, respectively. Eleven out of 12 patients with genomically-defined




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secondary AML (27) had MCL-1 analysis performed (median MCL-1: 31.5%; Range: 7-38.9%).

Of those analyzed, 7 (64%) had MCL-1 priming >30% while 4 (36%) were <30%.

DISCUSSION

Our findings demonstrate that alvocidib combined with standard 7+3 induction chemotherapy is

feasible and effective for younger patients (≤65 years) with newly diagnosed AML. As seen in

our previous studies with alvocidib in AML, the most frequent treatment-related AEs were

fatigue, nausea, diarrhea, and TLS (11-15,17,19). The most significant of these, TLS and

diarrhea, were manageable with appropriate prophylaxis and supportive interventions and were

not dose-limiting. TLS occurred rapidly after the first dose, was predominantly laboratory-based,

and generally resolved without clinical sequelae. Similarly, we observed a secretory diarrhea

associated with alvocidib, as seen previously (10), that occurs rapidly after the first dose and

responds to anti-diarrheal medications. There was 1 DLT of CRS leading to acute kidney injury

requiring temporary dialysis seen at the highest dose level. Although CRS was not separated

from adverse events documented as TLS in previous studies with alvocidib in AML, ≥grade 4

TLS was often accompanied by symptoms of CRS. In fact, infusional alvocidib has been shown

to increase pro-inflammatory cytokines, such as IL-6, potentially inciting an inflammatory milieu

that can lead to CRS (29). This is the first report to specify alvocidib-associated CRS in AML;

however, based on the toxicities seen in prior studies and noted TLS overlap, this is unlikely a

new phenomenon and rigorous monitoring for both TLS and CRS is required with alvocidib.

There was not an appreciable delay in hematologic recovery seen in patients on this study despite

the addition of alvocidib 3 days prior to 7+3 induction. The median time to partial neutrophil and

platelet recovery was 34 and 30 days, respectively, which is similar to CPX-351 (29) and TST

(17) and may be comparable to conventional 7+3 treatment regimens (30). Moreover, treatment-




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related mortality was low with only one (3%) patient expiring within 60 days of treatment. The

RP2D from this study – 30 mg/m2 IV bolus followed by 60 mg/m

2 IV over 4 hours – is

consistent with the MTD of a previous phase 1 study of alvocidib followed by cytarabine and

mitoxantrone (14).

The primary endpoint of this study was to establish an MTD and RP2D of alvocidib followed by

7+3 in newly diagnosed AML. Small numbers of patients enrolled on this study precluded

rigorous assessment of clinical activity of this regimen in comparison to historical controls.

Achieving CR is associated with longer RFS and OS when compared with non-responders and

those achieving CR without full recovery (31). All of the patients who achieved CR on this study

obtained full neutrophil and platelet recovery. The CR of alvocidib followed by 7+3 appears to

be similar to the composite CR of TST ACM treatment in newly diagnosed AML (69% vs. 68%)

though a direct comparison is not possible due to disparate patient populations studies (15,17).

Although we excluded patients with favorable-risk cytogenetics, it is worth noting that 28% of

enrolled patients were favorable-risk by ELN criteria due to either NPM1 mutation (n=8) or

CEBPA biallelic mutation (n=1). Notably, however, only 9% of patients on this study had

residual AML on day 14 BM assessment thus negating the need for re-induction therapy for the

vast majority of treated patients. In contrast, 25% and 44% of patients treated with ACM and

7+3, respectively, were found to have residual AML on day 14 in a randomized phase 2 study

(17). Re-induction therapy increases the risk of comorbidities such as organ toxicity, infectious

complications, and anthracycline-induced cardiotoxicity, delays hematologic recovery and

prolongs hospitalization. Increasing the efficacy of induction therapy without the need for

subsequent cytotoxic chemotherapy cycles would be highly advantageous.




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Patients with secondary AML and/or AML with MRC have dismal outcomes with conventional

chemotherapy. In a randomized phase 3 trial of cytarabine plus amonafide versus 7+3 in newly

diagnosed secondary AML, induction therapy with 7+3 yielded CR rates of 45% and median OS

of 7 months (32). Further, a randomized phase 3 study of CPX-351, liposomal cytarabine and

daunorubicin, versus 7+3 in newly diagnosed AML with MRC in patients 60-75 years revealed

CR rates of 37% versus 26%, respectively, and approximately 33% of patients in both arms

required re-induction therapy (33). In comparison, 50% of the patients with secondary AML or

AML with MRC achieved CR on this study though 50% and 42% were <60 years, respectively,

which could account for some of these differences.

Lindsley and colleagues previously reported that mutations in one of 8 genes (ASXL1, BCOR,

EZH2, SF3B1, SRSF2, STAG2, U2AF1, or ZRSR2) is highly specific for secondary AML (27).

Although ASXL1 mutations are defined as adverse-risk by ELN criteria, the other 7 mutations

specific for secondary AML are not specifically listed as adverse-risk by standardized criteria.

Recent data suggest that, among older patients with intermediate-risk AML, mutations associated

with secondary AML had significantly worse outcomes. A 2-class risk assessment from this

analysis defined patients with adverse-risk and those with intermediate-risk with secondary AML

mutations as “high-risk” disease (34). We noted an encouraging CR rate of 92% (11/12) in

patients with a genomic profile consistent with secondary AML. These findings are consistent

with previous studies showing particular clinical activity of alvocidib-containing induction

regimens in newly diagnosed secondary AML suggesting that the addition of alvocidib to

cytotoxic chemotherapy backbones may overcome at least some of the adverse-risk biology of

secondary AML (12,13,15,17).




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MRD determined by multicolor flow cytometry, quantitative PCR, or next-generation

sequencing is an important prognostic factor impacting the likelihood for relapse and survival

after induction and prior to alloSCT (35-38). Multicolor flow cytometric evidence of MRD in

CR1 leads to significantly worse outcomes compared with MRD-negative CR after induction

therapy (39-41). In a large prospective MRD analysis from the National Cancer Research

Institute (NCRI) AML17 trial, only 40% of younger patients treated with diverse “7+3”

induction therapy backbones achieved CR without MRD after 1 cycle. Further, 5-year OS was

63% versus 44% among patients with CR and MRD-negative versus MRD-positive after 1 cycle

of induction therapy (41). These studies reinforce the significant clinical impact of achieving an

MRD-negative CR after induction therapy and suggest that new approaches are needed to target

MRD. To evaluate alvocidib’s role in eliminating MRD, an exploratory cohort of 12 patients

were treated at the RP2D to prospectively assess MRD status after one cycle of induction by

centralized flow cytometry. Of these 12 patients, 9 (75%) achieved CR, and 8 (67%) achieved an

MRD-negative CR with a detection threshold of <0.02%. New approaches are imperative to

target leukemic cells in order to convert MRD-positive patients to an MRD-negative particularly

before alloSCT. Further study is warranted to specifically address whether the addition of

alvocidib to 7+3 can decrease MRD-positivity, lead to deeper responses and subsequently

improve clinical outcomes.

Based on alvocidib’s mechanism of action as a CDK9 inhibitor, we hypothesized that AML

patients whose leukemia cells are dependent on MCL-1 for survival may have a predilection for

response to alvocidib. Mitochondrial profiling assesses the relative dependence of anti-apoptotic

BCL-2 peptides in mediating cell survival within a tumor (43). NOXA is a BH3 sensitizer that

selectively binds to and antagonizes MCL-1 leading to apoptosis in cells dependent on MCL-1




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for survival. A NOXA mimetic peptide (T-MS1) “primes” cells for apoptosis, and high priming

scores reflect cells that are considered to be MCL-1 dependent. We previously found that MCL-1

dependence was associated with response to treatment with TST ACM induction in newly

diagnosed AML (44). Thus, we performed an exploratory prospective analysis of MCL-1

dependence on response to alvocidib followed by 7+3. We defined the criteria of MCL-1

dependence as a priming threshold of >30%. Although there are no uniform criteria for defining

MCL-1 dependence, the 30% threshold is consistent with our revised eligibility criteria for a

randomized phase 2 trial of cytarabine plus mitoxantrone with or without alvocidib in patients

with relapsed/refractory MCL-1 dependent AML (45). We did not appreciate any significant

differences in response to alvocidib in patients with or without MCL-1 dependence though this

exploratory analysis was limited by small numbers of patients in each cohort. Further, we did not

assess for dependence on other pro-survival mechanisms such as BCL-2 or BCL-XL dependence

which should be further explored in future studies. Nonetheless, 83% (10/12) of patients with

MCL-1 dependence achieved CR. Given alvocidib’s multi-CDK inhibitory activity and

subsequent inhibition of RNA polymerase II, it is likely that alvocidib exerts anti-leukemia

activity more broadly than direct MCL-1 inhibition (9,46) and may provide a therapeutic

advantage over selective CDK9 and MCL-1 inhibitors even in patients considered to be MCL-1

dependent. A randomized phase 2 clinical trial is warranted comparing standard induction

chemotherapy with or without the addition of alvocidib with prospective evaluation and

stratification based on MCL-1 dependence.

In conclusion, alvocidib administration prior to 7+3 induction is tolerable, feasible, and showed

encouraging clinical activity in newly diagnosed AML with non-favorable risk cytogenetics.

TLS and diarrhea are the most common severe toxicities that can be managed adequately with




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supportive care measures. Most notably, alvocidib followed by 7+3 led to a 92% CR rate in a

genomically-defined signature of secondary AML that has traditionally poor clinical outcomes.

In an exploratory cohort, high rates of MRD-negative CR rates were obtained with alvocidib

followed by 7+3. These data warrant a randomized clinical trial of alvocidib with or without 7+3

in newly diagnosed AML.

ACKNOWLEDGEMENTS

This study was supported by Tolero Pharmaceuticals, acquired by Sumitomo Dainippon Pharma.

This data was presented in part at the annual 2019 European Hematology Association (EHA)

meeting in Amsterdam, Netherlands as a poster presentation and at the 2020 Virtual EHA

meeting as a poster presentation.

The authors would like to thank Dr. Judith Karp for her contribution to the study design and

development plan of alvocidib. We would like to thank the research staff and all co-investigators

at University of North Carolina, Johns Hopkins, and Columbia University. We would also like to

thank all patients and their families for trusting us in their care and allowing us to conduct this

study.

Sonali Lokhande MD, a medical writer from Criterion Edge supported by funding from

Sumitomo Dainippon Pharma Oncology/Tolero Pharmaceuticals, provided editorial assistance to

the authors during preparation of this manuscript.




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REFERENCES

1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA: a cancer journal for

clinicians 2020;70(1):7-30 doi 10.3322/caac.21590.

2. Mrozek K, Marcucci G, Nicolet D, Maharry KS, Becker H, Whitman SP, et al.

Prognostic significance of the European LeukemiaNet standardized system for reporting

cytogenetic and molecular alterations in adults with acute myeloid leukemia. Journal of

clinical oncology : official journal of the American Society of Clinical Oncology

2012;30(36):4515-23 doi 10.1200/jco.2012.43.4738.

3. Stone RM, Mandrekar SJ, Sanford BL, Laumann K, Geyer S, Bloomfield CD, et al.

Midostaurin plus Chemotherapy for Acute Myeloid Leukemia with a FLT3 Mutation. N

Engl J Med 2017;377(5):454-64 doi 10.1056/NEJMoa1614359.

4. Lambert J, Pautas C, Terre C, Raffoux E, Turlure P, Caillot D, et al. Gemtuzumab

ozogamicin for de novo acute myeloid leukemia: final efficacy and safety updates from

the open-label, phase 3 ALFA-0701 trial. Haematologica 2018 doi

10.3324/haematol.2018.188888.

5. Hills RK, Castaigne S, Appelbaum FR, Delaunay J, Petersdorf S, Othus M, et al.

Addition of gemtuzumab ozogamicin to induction chemotherapy in adult patients with

acute myeloid leukaemia: a meta-analysis of individual patient data from randomised

controlled trials. The Lancet Oncology 2014;15(9):986-96 doi 10.1016/s1470-

2045(14)70281-5.

6. Xiang Z, Luo H, Payton JE, Cain J, Ley TJ, Opferman JT, et al. Mcl1 haploinsufficiency

protects mice from Myc-induced acute myeloid leukemia. The Journal of clinical

investigation 2010;120(6):2109-18 doi 10.1172/jci39964.

7. Kaufmann SH, Karp JE, Svingen PA, Krajewski S, Burke PJ, Gore SD, et al. Elevated

expression of the apoptotic regulator Mcl-1 at the time of leukemic relapse. Blood

1998;91(3):991-1000.

8. Opferman JT, Iwasaki H, Ong CC, Suh H, Mizuno S, Akashi K, et al. Obligate role of

anti-apoptotic MCL-1 in the survival of hematopoietic stem cells. Science

2005;307(5712):1101-4 doi 10.1126/science.1106114.

9. Karp JE, Ross DD, Yang W, Tidwell ML, Wei Y, Greer J, et al. Timed sequential

therapy of acute leukemia with flavopiridol: in vitro model for a phase I clinical trial.

Clinical cancer research : an official journal of the American Association for Cancer

Research 2003;9(1):307-15.

10. Zeidner JF, Karp JE. Clinical activity of alvocidib (flavopiridol) in acute myeloid

leukemia. Leuk Res 2015;39(12):1312-8 doi 10.1016/j.leukres.2015.10.010.

11. Karp JE, Passaniti A, Gojo I, Kaufmann S, Bible K, Garimella TS, et al. Phase I and

pharmacokinetic study of flavopiridol followed by 1-beta-D-arabinofuranosylcytosine

and mitoxantrone in relapsed and refractory adult acute leukemias. Clinical cancer

research : an official journal of the American Association for Cancer Research

2005;11(23):8403-12 doi 10.1158/1078-0432.ccr-05-1201.

12. Karp JE, Smith BD, Levis MJ, Gore SD, Greer J, Hattenburg C, et al. Sequential

flavopiridol, cytosine arabinoside, and mitoxantrone: a phase II trial in adults with poor-

risk acute myelogenous leukemia. Clinical cancer research : an official journal of the

American Association for Cancer Research 2007;13(15 Pt 1):4467-73 doi 10.1158/1078-

0432.ccr-07-0381.




of 30

13. Karp JE, Blackford A, Smith BD, Alino K, Seung AH, Bolanos-Meade J, et al. Clinical

activity of sequential flavopiridol, cytosine arabinoside, and mitoxantrone for adults with

newly diagnosed, poor-risk acute myelogenous leukemia. Leuk Res 2010;34(7):877-82

doi 10.1016/j.leukres.2009.11.007.

14. Karp JE, Smith BD, Resar LS, Greer JM, Blackford A, Zhao M, et al. Phase 1 and

pharmacokinetic study of bolus-infusion flavopiridol followed by cytosine arabinoside

and mitoxantrone for acute leukemias. Blood 2011;117(12):3302-10 doi 10.1182/blood-

2010-09-310862.

15. Karp JE, Garrett-Mayer E, Estey EH, Rudek MA, Smith BD, Greer JM, et al.

Randomized phase II study of two schedules of flavopiridol given as timed sequential

therapy with cytosine arabinoside and mitoxantrone for adults with newly diagnosed,

poor-risk acute myelogenous leukemia. Haematologica 2012;97(11):1736-42 doi

10.3324/haematol.2012.062539.

16. Litzow MR, Wang XV, Carroll MP, Karp JE, Ketterling RP, Zhang Y, et al. A

randomized trial of three novel regimens for recurrent acute myeloid leukemia

demonstrates the continuing challenge of treating this difficult disease. American journal

of hematology 2019;94(1):111-7 doi 10.1002/ajh.25333.

17. Zeidner JF, Foster MC, Blackford AL, Litzow MR, Morris LE, Strickland SA, et al.

Randomized multicenter phase II study of flavopiridol (alvocidib), cytarabine, and

mitoxantrone (FLAM) versus cytarabine/daunorubicin (7+3) in newly diagnosed acute

myeloid leukemia. Haematologica 2015;100(9):1172-9 doi

10.3324/haematol.2015.125849.

18. Byrd JC, Lin TS, Dalton JT, Wu D, Phelps MA, Fischer B, et al. Flavopiridol

administered using a pharmacologically derived schedule is associated with marked

clinical efficacy in refractory, genetically high-risk chronic lymphocytic leukemia. Blood

2007;109(2):399-404 doi 10.1182/blood-2006-05-020735.

19. Zeidner JF, Foster MC, Blackford AL, Litzow MR, Morris LE, Strickland SA, et al. Final

results of a randomized multicenter phase II study of alvocidib, cytarabine, and

mitoxantrone versus cytarabine and daunorubicin (7 + 3) in newly diagnosed high-risk

acute myeloid leukemia (AML). Leuk Res 2018;72:92-5 doi

10.1016/j.leukres.2018.08.005.

20. Dohner H, Estey E, Grimwade D, Amadori S, Appelbaum FR, Buchner T, et al.

Diagnosis and management of AML in adults: 2017 ELN recommendations from an

international expert panel. Blood 2017;129(4):424-47 doi 10.1182/blood-2016-08-

733196.

21. Sievers EL, Division of Pediatric Oncology FHCRC, WADivision of Pediatric

Hematology/Oncology, University of Washington, Seattle and Childrens Cancer

GroupArcadia, CA, Lange BJ, Division of Oncology CsHoPCG, Buckley JD,

Department of Preventive Medicine UoSCACG, et al. Prediction of Relapse of Pediatric

Acute Myeloid Leukemia by Use of Multidimensional Flow Cytometry. JNCI: Journal of

the National Cancer Institute 2020;88(20):1483-8 doi 10.1093/jnci/88.20.1483.

22. Ryan JA, Brunelle JK, Letai A. Heightened mitochondrial priming is the basis for

apoptotic hypersensitivity of CD4+ CD8+ thymocytes. Proc Natl Acad Sci U S A

2010;107(29):12895-900 doi 10.1073/pnas.0914878107.

23. Burrer CM, Foight GW, Keating AE, Chan GC. Selective peptide inhibitors of

antiapoptotic cellular and viral Bcl-2 proteins lead to cytochrome c release during latent




of 30

Kaposi's sarcoma-associated herpesvirus infection. Virus Res 2016;211:86-8 doi

10.1016/j.virusres.2015.10.007.

24. Foight GW, Ryan JA, Gulla SV, Letai A, Keating AE. Designed BH3 peptides with high

affinity and specificity for targeting Mcl-1 in cells. ACS Chem Biol 2014;9(9):1962-8 doi

10.1021/cb500340w.

25. Arber DA, Orazi A, Hasserjian R, Thiele J, Borowitz MJ, Le Beau MM, et al. The 2016

revision to the World Health Organization classification of myeloid neoplasms and acute

leukemia. Blood 2016;127(20):2391-405 doi 10.1182/blood-2016-03-643544.

26. Slovak ML, Kopecky KJ, Cassileth PA, Harrington DH, Theil KS, Mohamed A, et al.

Karyotypic analysis predicts outcome of preremission and postremission therapy in adult

acute myeloid leukemia: a Southwest Oncology Group/Eastern Cooperative Oncology

Group Study. Blood 2000;96(13):4075-83.

27. Lindsley RC, Mar BG, Mazzola E, Grauman PV, Shareef S, Allen SL, et al. Acute

myeloid leukemia ontogeny is defined by distinct somatic mutations. Blood

2015;125(9):1367-76 doi 10.1182/blood-2014-11-610543.

28. Papaemmanuil E, Gerstung M, Bullinger L, Gaidzik VI, Paschka P, Roberts ND, et al.

Genomic Classification and Prognosis in Acute Myeloid Leukemia. New England

Journal of Medicine 2016;374(23):2209-21 doi 10.1056/nejmoa1516192.

29. Messmann RA, Ullmann CD, Lahusen T, Kalehua A, Wasfy J, Melillo G, et al.

Flavopiridol-related proinflammatory syndrome is associated with induction of

interleukin-6. Clinical cancer research : an official journal of the American Association

for Cancer Research 2003;9(2):562-70.

30. Castaigne S, Pautas C, Terre C, Raffoux E, Bordessoule D, Bastie JN, et al. Effect of

gemtuzumab ozogamicin on survival of adult patients with de-novo acute myeloid

leukaemia (ALFA-0701): a randomised, open-label, phase 3 study. Lancet

2012;379(9825):1508-16 doi 10.1016/s0140-6736(12)60485-1.

31. Walter RB, Kantarjian HM, Huang X, Pierce SA, Sun Z, Gundacker HM, et al. Effect of

Complete Remission and Responses Less Than Complete Remission on Survival in

Acute Myeloid Leukemia: A Combined Eastern Cooperative Oncology Group, Southwest

Oncology Group, and M. D. Anderson Cancer Center Study. Journal of Clinical

Oncology 2010;28(10):1766-71 doi 10.1200/jco.2009.25.1066.

32. Stone RM, Mazzola E, Neuberg D, Allen SL, Pigneux A, Stuart RK, et al. Phase III

open-label randomized study of cytarabine in combination with amonafide L-malate or

daunorubicin as induction therapy for patients with secondary acute myeloid leukemia.

Journal of clinical oncology : official journal of the American Society of Clinical

Oncology 2015;33(11):1252-7 doi 10.1200/jco.2014.57.0952.

33. Lancet JE, Uy GL, Cortes JE, Newell LF, Lin TL, Ritchie EK, et al. CPX-351

(cytarabine and daunorubicin) Liposome for Injection Versus Conventional Cytarabine

Plus Daunorubicin in Older Patients With Newly Diagnosed Secondary Acute Myeloid

Leukemia. Journal of Clinical Oncology 2018;36(26):2684-92 doi

10.1200/jco.2017.77.6112.

34. Gardin C, Pautas C, Fournier E, Itzykson R, Lemasle E, Bourhis JH, et al. Added

prognostic value of secondary AML-like gene mutations in ELN intermediate-risk older

AML: ALFA-1200 study results. Blood Adv 2020;4(9):1942-9 doi

10.1182/bloodadvances.2019001349.




of 30

35. Kern W, Voskova D, Schoch C, Hiddemann W, Schnittger S, Haferlach T. Determination

of relapse risk based on assessment of minimal residual disease during complete

remission by multiparameter flow cytometry in unselected patients with acute myeloid

leukemia. Blood 2004;104(10):3078-85 doi 10.1182/blood-2004-03-1036.

36. Ivey A, Hills RK, Simpson MA, Jovanovic JV, Gilkes A, Grech A, et al. Assessment of

Minimal Residual Disease in Standard-Risk AML. New England Journal of Medicine

2016;374(5):422-33 doi 10.1056/NEJMoa1507471.

37. Hourigan CS, Dillon LW, Gui G, Logan BR, Fei M, Ghannam J, et al. Impact of

Conditioning Intensity of Allogeneic Transplantation for Acute Myeloid Leukemia With

Genomic Evidence of Residual Disease. Journal of clinical oncology : official journal of

the American Society of Clinical Oncology 2020;38(12):1273-83 doi

10.1200/jco.19.03011.

38. Walter RB, Gooley TA, Wood BL, Milano F, Fang M, Sorror ML, et al. Impact of

pretransplantation minimal residual disease, as detected by multiparametric flow

cytometry, on outcome of myeloablative hematopoietic cell transplantation for acute

myeloid leukemia. Journal of clinical oncology : official journal of the American Society

of Clinical Oncology 2011;29(9):1190-7 doi 10.1200/jco.2010.31.8121.

39. Terwijn M, van Putten WL, Kelder A, van der Velden VH, Brooimans RA, Pabst T, et al.

High prognostic impact of flow cytometric minimal residual disease detection in acute

myeloid leukemia: data from the HOVON/SAKK AML 42A study. Journal of clinical

oncology : official journal of the American Society of Clinical Oncology

2013;31(31):3889-97 doi 10.1200/jco.2012.45.9628.

40. Freeman SD, Virgo P, Couzens S, Grimwade D, Russell N, Hills RK, et al. Prognostic

relevance of treatment response measured by flow cytometric residual disease detection

in older patients with acute myeloid leukemia. Journal of clinical oncology : official

journal of the American Society of Clinical Oncology 2013;31(32):4123-31 doi

10.1200/jco.2013.49.1753.

41. Freeman S, Hills R, Virgo P, Khan N, Couzens S, Dillon R, et al. Measurable Residual

Disease at Induction Redefines Partial Response in Acute Myeloid Leukemia and

Stratifies Outcomes in Patients at Standard Risk Without NPM1 Mutations. Journal of

clinical oncology : official journal of the American Society of Clinical Oncology

2018;36(15) doi 10.1200/JCO.2017.76.3425.

42. Issa GC, Benton CB, Mohanty V, Shen Y, Alaniz Z, Wang F, et al. Identification of

Gene Expression Signatures in Leukemia Stem Cells and Minimal Residual Disease

Following Treatment of Adverse Risk Acute Myeloid Leukemia. Blood

2019;134(Supplement_1):2717- doi 10.1182/blood-2019-130540.

43. Villalobos-Ortiz M, Ryan J, Mashaka TN, Opferman JT, Letai A. BH3 profiling

discriminates on-target small molecule BH3 mimetics from putative mimetics. Cell Death

Differ 2020;27(3):999-1007 doi 10.1038/s41418-019-0391-9.

44. Smith BD, Warner SL, Whatcott C, Siddiqui-Jain A, Bahr B, Dettman E, et al. An

alvocidib-containing regimen is highly effective in AML patients through a mechanism

dependent on MCL1 expression and function. Journal of Clinical Oncology

2015;33(15):7062- doi 10.1200/jco.2015.33.15_suppl.7062.

45. Zeidner JF, Lin T, Vigil CE, Dalovisio A, Wang ES, Levy MY, et al. Zella 201: A

biomarker-guided phase II study of alvocidib followed by cytarabine and mitoxantrone in




of 30

MCL-1 dependent relapsed/refractory acute myeloid leukemia (AML). Blood

2018;2018(132):30 doi 10.1182/blood-2018-99-115018.

46. Nelson D, Joseph B, Hillion J, Segal J, Karp J, Resar L. Flavopiridol Induces BCL-2

Expression and Represses Oncogenic Transcription Factors in Leukemic Blasts From

Adults With Refractory Acute Myeloid Leukemia. Leukemia & lymphoma

2011;52(10):1999-2006 doi 10.3109/10428194.2011.591012.




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TABLES




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Table 1 Patient Characteristics

Patient Characteristics

Alvocidib Dose

<MTD

(<30/60mg/m2)

N=9

Alvocidib Dose at

MTD

(30/60mg/m2)

N=23

Study Total

N=32

Age, median (range), years 60 (31, 65) 51 (33, 65) 58 (31, 65)

Age >60, years 5 (55.6%) 6 (26.1%) 11 (34.4%)

Male, n (%) 4 (44.4%) 14 (60.9%) 18 (56.3%)

ECOG performance status

0 5 (55.6%) 8 (34.8%) 13 (40.6%)

1 3 (33.3%) 13 (56.5%) 16 (50.0%)

2 1 (11.1%) 2 (8.7%) 3 (9.4%)

Bone Marrow Blasts (%) median (range) 49 (23, 92) 47 (12, 98) 48 (12, 98)

Baseline WBC (x109/L)- median (range) 3.1 (1.60, 15.54) 3.99 (0.50, 16.00) 3.87 (0.50, 16.00)

Secondary AML, n (%) 2 (22.2%) 4 (17.4%) 6 (18.8%)

t-AML 0 (0.0%) 3 (13.0%) 3 (9.4%)

Prior MDS, n (%) 1 (11.1%) 2 (8.7%) 3 (9.4%)

Prior CMML 0 (0.0%) 1 (4.3%) 1 (3.1%)

Prior MPN 1 (11.1%) 0 (0.0%) 1 (3.1%)

AML with MRC, n (%) 4 (44.4%) 8 (34.8%) 12 (38.0 %)

Genomically-defined secondary AML 2 (22.2%) 10 (43.5%) 12 (38.0%)

ELN classification, n (%)

Favorable 3 (33.3%) 6 (26.1%) 9 (28.1%)

Intermediate 3 (33.3%) 4 (17.4%) 7 (21.9%)

Adverse-risk 3 (33.3%) 13 (56.5%) 16 (50.0%)

SWOG cytogenetics classification, n (%)

Favorable 0 (0.0%) 0 (0.0%) 0 (0.0%)

Intermediate 4 (44.4%) 16 (69.6%) 20 (63%)

Unfavorable 5 (55.6%) 7 (30.4%) 12 (38%)

Genetic mutations, n (%)

ASXL1 0 (0.0%) 6 (26.1%) 6 (18.8%)

CEBPA 0 (0.0%) 2 (8.7%) 2 (6.3%)

DNMT3A 2 (22.2%) 3 (13.0%) 5 (15.6%)

EZH2 0 (0.0%) 2 (8.7%) 2 (6.3%)

FLT3-ITD 0 (0.0%) 3 (13.0%) 3 (9.4%)

FLT3-TKD 1 (11.1%) 0 (0.0%) 1 (3.1%)

IDH1 1 (11.1%) 2 (8.7%) 3 (9.4%)

IDH2 0 (0.0%) 4 (17.4%) 4 (12.5%)

NPM1 3 (33.3%) 7 (30.4%) 10 (31.3%)

RUNX1 0 (0.0%) 5 (21.7%) 5 (15.6%)

TET2 0 (0.0%) 4 (17.4%) 4 (12.5%)

TP53 3 (33.3%) 1 (4.3%) 4 (12.5%)

U2AF1 1 (11.1%) 2 (8.7%) 3 (9.4%)




of 30

Abbreviations: CMML, chronic myelomonocytic leukemia; MDS, myelodysplastic syndrome; MPN, myeloproliferative

neoplasms; MRC, myelodysplasia-related changes; MTD, maximum tolerated dose.




of 30

Table 2 Treatment-Emergent Grade >3 Non-Hematologic Toxicities

Toxicity, n (%)

Alvocidib Dose

<MTD

(<30/60mg/m2)

N=9

Alvocidib Dose at

MTD

(30/60mg/m2)

N=23

Study Total

N=32

Gastrointestinal disorders

Colitis and Enterocolitis 1 (11.1%) 1 (4.3%)0 2 (6.3%)

Diarrhea 3 (33.3%) 11 (47.8%) 14 (43.8%)

Stomatitis 1 (11.1%) 0 (0.0%) 1 (3.1%)

Infections and infestations

Bacteremia/Sepsis 3 (33.3%) 4 (17.4%) 7 (21.9%)

Cellulitis 0 (0.0%) 1 (4.3%) 1 (3.1%)

Clostridium difficile infection 0 (0.0%) 1 (4.3%) 1 (3.1%)

Fungaemia 1 (11.1%) 0 1 (3.1%)

Lung infection and Pneumonia 0 (0.0%) 3 (13.0%) 3 (9.4%)

Renal and urinary disorders

Acute kidney injury and increased blood

creatinine 0 (0.0%) 2 (8.7%) 2 (6.3%)

Hepatobiliary disorders

Aspartate aminotransferase increased 0 (0.0%) 2 (8.7%) 2 (6.3%)

Blood bilirubin increased 0 (0.0%) 1 (4.3%) 1 (3.1%)

Gamma-glutamyltransferase increased 0 (0.0%) 1 (4.3%) 1 (3.1%)

Tumor Lysis Syndrome 1 (11.1%) 10 (43.5%) 11 (34.4%)

Other

Epistaxis 0 (0.0%) 1 (4.3%) 1 (3.1%)

Immune system disorders

Cytokine release syndrome 0 (0.0%) 1 (4.3%) 1 (3.1%)

Metabolism and nutrition disorders

Hyperkalemia 0 (0.0%) 1 (4.3%) 1 (3.1%)

Hypoalbuminemia 0 (0.0%) 1 (4.3%) 1 (3.1%)

Hypocalcemia 2 (22.2%) 3 (13.0%) 5 (15.6%)

Hypokalemia 1 (11.1%) 1 (4.3%) 2 (6.3%)

Hypophosphatemia 2 (22.2%) 0 (0.0%) 2 (6.3%)

Nervous system disorders

Syncope 1 (11.1%) 0 (0.0%) 1 (3.1%)

Skin and subcutaneous tissue

disorders

Rash maculo-papular 0 (0.0%) 1 (4.3%) 1 (3.1%)

Abbreviations: MTD, Maximum tolerated dose. a Toxicity was classified using MedDRA = Medical Dictionary for Regulatory Activities (v19.1)




of 30

Table 3 Clinical Activity – Response Assessments

Response Characteristics Study Total

(N=32)

CR, n (%) 22 (68.8%)

CRi (%) 0 (0.0%)

Overall CR/CRi, n (%) 22 (68.8%)

PR, n (%) 2 (6.3%)

Overall Response Rate (CR+CRi+PR) 24 (75.0%)

Overall CR subgroups, n (%)

Evaluable Study Population, (n=31) 22 (71.0%)

At MTD, (n=23) 15 (65.2%)

Age <60 years, (n=21) 16 (76.2%)

Age >60 years, (n=11) 6 (54.5%)

Secondary AML, (n=6) 3 (50.00%)

AML with MRC, (n=12) 6 (50.0%)

Genomically-defined secondary AML 11 (92%)

ELN-risk, n (%)

Favorable (n=9) 8 (88.9%)

Intermediate (n=7) 5 (71.4%)

Adverse (n=16) 9 (56.3%)

SWOG cytogenetics risk, n (%)

Favorable (n=0) 0 (0.0%)

Intermediate (n=20) 16 (80.0%)

Unfavorable (n=12) 6 (50.0%)

Unknown (n=0) 0 (0.0%)

Abbreviations: CR, complete remission, MRD positive or unknown; CRi, complete remission with incomplete recovery;

ELN, European LeukemiaNet; MRC, myelodysplasia-related changes; MTD, maximum tolerated dose; PR, partial remission;

SWOG, Southwestern Oncology Group.




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FIGURES:

Figure 1 Consort Diagram

Figure 2 Heatmap of Genomic Signatures and Response

A heatmap representing patients with baseline AML mutation achieving CR (green) or No CR

(red). Positive and negative AML mutations are shown in white and grey respectively.

Unknown/not tested mutations are shown in black. One patient who achieved a CR without

detectable MRD was not assessed for the full panel of 15 genes and was excluded from this

analysis.

Figure 3 Clinical Outcomes

Swimmer’s plot of best treatment response and survival for all 32 patients (A). The swim lanes

represent subjects in the study and indicate their progression and survival in the trial along with

response to therapy. The horizontal axis depicts survival in months since the first dose of

alvocidib. Colors of the swim lanes depict best response to treatment (orange – CR (MRD-

negative), blue – CR/CRi, green – PR, grey – no response). Solid black circles (●) on the swim

lanes represent earliest CR/CRi or PR, black triangles (▲) represent allogenic stem cell

transplantation, black circles (○) represent relapse/progression and red stars represent death.

Follow-up data (up to a protocol-specified maximum of 2 years) is still being accrued. Overall

survival (B), event-free survival (C) from Day 1 of treatment up to death, relapse, or no response

to treatment and relapse-free survival (D) defined as time from CR/CRi up to disease relapse or

death, for all patients using Kaplan-Meir estimates. Median OS, and RFS could not be

calculated.




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