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Burke MJ, Kostadinov R, Sposto R, Gore L, Kelley SM, Rabik C, Trepel JB, Lee MJ, Yuno A, Lee S, Bhojwani D, Jeha S, Chang BH, Sulis ML, Hermiston ML, Gaynon P, Huynh V, Verma A, Gardner R, Heym KM, Dennis RM, Ziegler DS, Laetsch TW, Oesterheld JE, Dubois SG, Pollard JA, Glade-Bender J, Cooper TM, Kaplan JA, Farooqi MS, Yoo B, Guest E, Wayne AS, Brown PA. Decitabine and Vorinostat with Chemotherapy in Relapsed Pediatric Acute Lymphoblastic Leukemia: A TACL Pilot Study. Clin Cancer Res 2020; 26:2297-2307. [PMID: 31969338 PMCID: PMC7477726 DOI: 10.1158/1078-0432.ccr-19-1251] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 09/20/2019] [Accepted: 01/17/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Treatment failure from drug resistance is the primary reason for relapse in acute lymphoblastic leukemia (ALL). Improving outcomes by targeting mechanisms of drug resistance is a potential solution. PATIENTS AND METHODS We report results investigating the epigenetic modulators decitabine and vorinostat with vincristine, dexamethasone, mitoxantrone, and PEG-asparaginase for pediatric patients with relapsed or refractory B-cell ALL (B-ALL). Twenty-three patients, median age 12 years (range, 1-21) were treated in this trial. RESULTS The most common grade 3-4 toxicities included hypokalemia (65%), anemia (78%), febrile neutropenia (57%), hypophosphatemia (43%), leukopenia (61%), hyperbilirubinemia (39%), thrombocytopenia (87%), neutropenia (91%), and hypocalcemia (39%). Three subjects experienced dose-limiting toxicities, which included cholestasis, steatosis, and hyperbilirubinemia (n = 1); seizure, somnolence, and delirium (n = 1); and pneumonitis, hypoxia, and hyperbilirubinemia (n = 1). Infectious complications were common with 17 of 23 (74%) subjects experiencing grade ≥3 infections including invasive fungal infections in 35% (8/23). Nine subjects (39%) achieved a complete response (CR + CR without platelet recovery + CR without neutrophil recovery) and five had stable disease (22%). Nine (39%) subjects were not evaluable for response, primarily due to treatment-related toxicities. Correlative pharmacodynamics demonstrated potent in vivo modulation of epigenetic marks, and modulation of biologic pathways associated with functional antileukemic effects. CONCLUSIONS Despite encouraging response rates and pharmacodynamics, the combination of decitabine and vorinostat on this intensive chemotherapy backbone was determined not feasible in B-ALL due to the high incidence of significant infectious toxicities. This study is registered at http://www.clinicaltrials.gov as NCT01483690.
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Affiliation(s)
- Michael J Burke
- Division of Pediatric Hematology-Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Rumen Kostadinov
- Division of Pediatric Oncology, Johns Hopkins University, Baltimore, Maryland
| | - Richard Sposto
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, USC Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Lia Gore
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Shannon M Kelley
- Division of Pediatric Oncology, Johns Hopkins University, Baltimore, Maryland
| | - Cara Rabik
- Division of Pediatric Oncology, Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | - Deepa Bhojwani
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, USC Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Sima Jeha
- St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Bill H Chang
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Maria Luisa Sulis
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michelle L Hermiston
- Department of Pediatrics, UCSF Medical Center-Mission Bay, San Francisco, California
| | - Paul Gaynon
- Division of Pediatric Oncology, Johns Hopkins University, Baltimore, Maryland
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Van Huynh
- Department of Pediatrics, Children's Hospital of Orange County, Orange, California
| | - Anupam Verma
- Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Rebecca Gardner
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Kenneth M Heym
- Department of Pediatrics, Cook Children's Medical Center, Fort Worth, Texas
| | - Robyn M Dennis
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - David S Ziegler
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, Australia
| | - Theodore W Laetsch
- Department of Pediatrics, UT Southwestern/Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas
- Pauline Allen Gill Center for Cancer and Blood Disorders, Children's Health, Dallas, Texas
| | - Javier E Oesterheld
- Department of Pediatrics, Carolinas Medical Center/Levine Cancer Institute, Charlotte, North Carolina
| | - Steven G Dubois
- Department of Pediatrics, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Jessica A Pollard
- Department of Pediatrics, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Julia Glade-Bender
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Todd M Cooper
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Joel A Kaplan
- Department of Pediatrics, Carolinas Medical Center/Levine Cancer Institute, Charlotte, North Carolina
| | - Midhat S Farooqi
- Center for Pediatric Genomic Medicine, Children's Mercy Hospital, Kansas City, Missouri
| | - Byunggil Yoo
- Center for Pediatric Genomic Medicine, Children's Mercy Hospital, Kansas City, Missouri
| | - Erin Guest
- Center for Pediatric Genomic Medicine, Children's Mercy Hospital, Kansas City, Missouri
| | - Alan S Wayne
- Division of Pediatric Oncology, Johns Hopkins University, Baltimore, Maryland
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Patrick A Brown
- Division of Pediatric Oncology, Johns Hopkins University, Baltimore, Maryland
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Nair S, Kong ANT. Emerging roles for clinical pharmacometrics in cancer precision medicine. ACTA ACUST UNITED AC 2018; 4:276-283. [PMID: 30345221 DOI: 10.1007/s40495-018-0139-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Purpose of review Although significant progress has been made in cancer research, there exist unmet needs in patient care as reflected by the 'Cancer Moonshot' goals. This review appreciates the potential utility of quantitative pharmacology in cancer precision medicine. Recent findings Precision oncology has received federal funding largely due to 'The Precision Medicine Initiative'. Precision medicine takes into account the inter-individual variability, and allows for tailoring the right medication or the right dose of drug to the best subpopulation of patients who will likely respond to the intervention, thus enhancing therapeutic success and reducing "financial toxicity" to patients, families and caregivers. The National Cancer Institute (NCI) committed US$ 70 million from its fiscal year 2016 budget to advance precision oncology research. Through the 'Critical Path Initiative', pharmacometrics has gained an important role in drug development; however, it is yet to find widespread clinical applicability. Summary Stakeholders including clinicians and pharmacometricians need to work in concert to ensure that benefits of model-based approaches are harnessed to personalize cancer care to the individual needs of the patient via better dosing strategies, companion diagnostics, and predictive biomarkers. In medical oncology, where immediate patient care is the clinician's primary concern, pharmacometric approaches can be tailored to build models that rely on patient data already digitally available in the Electronic Health Record (EHR) to facilitate quick collaboration and avoid additional funding needs. Taken together, we offer a roadmap for the future of precision oncology which is fraught with both challenges and opportunities for pharmacometricians and clinicians alike.
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Affiliation(s)
- Sujit Nair
- Amrita Cancer Discovery Biology Laboratory, Amrita Vishwa Vidyapeetham University, Amritapuri, Clappana P.O., Kollam - 690525, Kerala, India
| | - Ah-Ng Tony Kong
- Center for Cancer Chemoprevention Research and Department of Pharmaceutics, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ-08854, USA
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