Paediatric Strategy Forum for medicinal product development for acute myeloid leukaemia in children and adolescents: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration

Purpose:

The current standard-of-care for front-line therapy for acute myeloid leukaemia (AML) results in short-term and long-term toxicity, but still approximately 40% of children relapse. Therefore, there is a major need to accelerate the evaluation of innovative medicines, yet drug development continues to be adult-focused. Furthermore, the large number of competing agents in rare patient populations requires coordinated prioritisation, within the global regulatory framework and cooperative group initiatives.

Methods:

The fourth multi-stakeholder Paediatric Strategy Forum focused on AML in children and adolescents.

Results:

CD123 is a high priority target and the paediatric development should be accelerated as a proof-of-concept. Efforts must be coordinated, however, as there are a limited number of studies that can be delivered. Studies of FLT3 inhibitors in agreed paediatric investigation plans present challenges to be completed because they require enrolment of a larger number of patients than actually exist. A consensus was developed by industry and academia of optimised clinical trials. For AML with rare mutations that are more frequent in adolescents than in children, adult trials should enrol adolescents and when scientifically justified, efficacy data could be extrapolated. Methodologies and definitions of minimal residual disease need to be standardised internationally and validated as a new response criterion. Industry supported, academic sponsored platform trials could identify products to be further developed. The Leukaemia and Lymphoma Society PedAL/EUpAL initiative has the potential to be a major advance in the field.

Conclusion:

These initiatives continue to accelerate drug development for children with AML and ultimately improve clinical outcomes.

Phase 3 (COSMIC-312) study of cabozantinib (C) in combination with atezolizumab (A) versus sorafenib (S) in patients (pts) with advanced hepatocellular carcinoma (aHCC) who have not received previous systemic anticancer therapy

TPS4157

Background: C inhibits tyrosine kinases involved in tumor growth, angiogenesis, and immune regulation, including MET, VEGFR, and TAM kinases (Tyro3, AXL, MER). C is approved for treatment of aHCC after prior S based on improved overall survival (OS) vs placebo in the phase 3 CELESTIAL trial (Abou-Alfa NEJM 2018). Standard of care for first-line treatment of aHCC is tyrosine kinase inhibition with S or lenvatinib, and phase 3 trials of immune checkpoint inhibitors (ICIs) in first- and second- line aHCC are ongoing. C may promote an immune-permissive tumor environment, which could enhance response to ICIs. C is being evaluated in combination with the anti-PD-L1 antibody A in multiple tumor types including HCC in a phase 1 study; and dose, preliminary clinical activity, and safety have been established in aRCC (Agarwal Ann Oncol 2018). A in combination with bevacizumab, an anti-VEGF antibody, has shown preliminary clinical activity in first-line aHCC (Pishvaian Ann Oncol 2018). Here, we present the study design of a phase 3 trial of C+A vs S in pts with aHCC who have not received prior systemic therapy. Methods: This international, randomized, open-label phase 3 trial (NCT03755791) is evaluating the efficacy and safety of C+A vs S as first-line treatment for aHCC. Eligibility criteria include age ≥18 years, BCLC stage B or C, Child-Pugh A, ECOG PS 0 or 1, and measurable disease per RECIST 1.1. Patients are randomized 6:3:1 to an experimental arm of C (40 mg qd) + A (1200 mg infusion q3w), a control arm of S (400 mg bid), and an exploratory arm of C monotherapy (60 mg qd). 640 pts are planned at ~200 sites globally. Randomization is stratified by disease etiology (HBV [with or without HCV], HCV [without HBV], or other), region (Asia, other), and the presence of extrahepatic disease and/or macrovascular invasion (yes, no). OS and progression-free survival are coprimary endpoints and objective response rate is a secondary endpoint. Additional endpoints include safety, pharmacokinetics, and correlation of biomarker analyses with clinical outcomes. Enrollment in COSMIC-312 is ongoing. Clinical trial information: NCT03755791.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Abstract B179: Final results of a phase 1 study of cabozantinib (Cabo) in Japanese patients (pts) with expansion cohorts in non-small cell lung cancer (NSCLC) with defined molecular alterations

Background: Cabo inhibits tyrosine kinases including MET, VEGF receptors, AXL, and RET. The primary objective of this phase 1 study was to establish the recommended phase 2 dose (RP2D) of Cabo in Japanese pts; secondary objectives included assessment of safety, pharmacokinetics, and preliminary evidence of anti-tumor activity. Results from the dose escalation (DE) portion of the study have been previously reported. The final results of the study are presented, including data from expansion cohorts (ECs) in NSCLC with defined molecular alterations involving known driver oncogenes.

Methods: Pts with advanced solid malignancies were enrolled in successive cohorts to receive escalating doses of Cabo orally once daily in a 3+3 design using capsule or tablet formulations. The RP2D was previously determined to be 60 mg qd tablet. Based on responses observed in pts with NSCLC, 3 molecularly defined NSCLC ECs were planned at the RP2D: EC1) pts with mutant EGFR and previous treatment with an EGFR inhibitor, EC2) pts with KRAS mutations, and EC3) pts with rearranged ALK (and previous treatment with an ALK inhibitor), RET, or ROS1. Tumor assessments per RECIST were performed on study day 29, and every 8 weeks thereafter until discontinuation of study treatment.

Results: Forty three total pts were enrolled. Twenty three pts were enrolled in the DE cohorts, including 9 pts with NSCLC. Twenty pts were enrolled in the NSCLC ECs: 15 pts in EC1, 2 pts in EC2, and 3 pts in EC3 (n = 1 ALK+, n = 2 RET+). The median duration of treatment was 28.1 (3-156) weeks (wks) in the DE cohorts, and 13.3 (4-49) wks in the NSCLC ECs. Grade 3-4 AEs experienced by ≥3 pts were gamma glutamyl transferase increase (n = 4), hypertension (n = 3), and lymphopenia (n = 3) in the DE cohorts, and hypertension (n = 6), neutropenia (n = 5), alanine aminotransferase increase (n = 3), hand foot syndrome (n = 3), hypophosphatemia (n = 3), and dyspnea (n = 3) in the ECs. Serious AEs in ≥3 pts were dyspnea (n = 3), lung infection/pneumonia (n = 3), and pleural effusion (n = 3). The final PK analysis demonstrated that Cabo plasma exposures in Japanese pts were approximately 34% higher than reported previously in non-Japanese pts at the 60 mg tablet dose, and were within the range of inter-subject variability (%CV: 34% Japanese; 48% non-Japanese). Objective responses were observed in NSCLC pts: 4/9 NSCLC pts enrolled in the DE cohorts had a confirmed partial response (cPR) (2 pts ALK+, 1 pt RET+, 1 pt EGFR+), and 4/20 pts enrolled in the NSCLC EC cohorts had a cPR (all 4 pts were in EC1 [EGFR+]). Best change in sum of longest diameters (SLD) for all NSCLC pts with measureable disease (n = 28) ranged from 0 - 82% decrease (median = 24% decrease). For pts with a cPR, the time to initial response ranged from 4 - 20 wks and time from response to radiographic progression ranged from 4 - 64 wks.

Conclusions: The RP2D of Cabo in Japanese pts was determined to be 60 mg. The safety and pharmacokinetic profiles are consistent with data from studies in non-Japanese pts. Antitumor activity with Cabo has been observed, including in pts with molecularly-defined NSCLC.

Citation Format: Hiroshi Nokihara, Makoto Nishio, Noboru Yamamoto, Yutaka Fujiwawa, Hidehito Horinouchi, Shintaro Kanda, Asushi Horiike, Fumiyoshi Ohyanagi, Yifah Yaron, Anne Borgman, Tomohide Tamura. Final results of a phase 1 study of cabozantinib (Cabo) in Japanese patients (pts) with expansion cohorts in non-small cell lung cancer (NSCLC) with defined molecular alterations. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2015 Nov 5-9; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl 2):Abstract nr B179.

Gender differences in Parkinson's disease symptom profile

Gender symptom differences were studied in 948 subjects with Parkinson's disease (PD) using a questionnaire covering the most common symptoms associated with PD at debut (SP-1) and at present (SP-2). The symptoms most frequently reported by both genders were: tremor, fumblingness, writing problems, rigidity and fatigue. At SP-1 females reported neck-pain and low back pain more frequently than males. At SP-2 subjects reported an increased number of symptoms. The following symptoms were more frequent among males than females: writing difficulties, fumblingness, gait problems, speech problems, increased flow of saliva, lack of initiative. Sleep problems were common in both sexes with inability to turn in bed and calf muscle cramps in a high percentage. A majority of female subjects find their symptoms (e.g. depression) constantly distressing. Although depression is not one of primary reported symptoms (36%) attention is called for, due to the problem with compliance to treatment regimes. About 30% do not report having tremor and rigidity. This study indicates the usefulness of a symptom profile instrument capable of capturing the many symptoms involved in PD. Such an instrument could be used to detect apparent mistakes in medication and thereby increase the function and quality of life for the individual.

Tourette's disorder with and without obsessive-compulsive disorder in adults: are they different?

Clinical research has documented a bidirectional overlap between Tourette's disorder (TD) and obsessive-compulsive disorder (OCD) from familial-genetic, phenomenological, comorbidity, and natural history perspectives. Patients with Tourette's disorder plus obsessive-compulsive disorder (TD + OCD), a putative subtype, share features of both. The purpose of this exploratory study was to evaluate correlates of patients with TD, OCD, and TD + OCD to determine whether TD + OCD is a subtype of TD, OCD, or an additive form of both. Sixty-one subjects with TD, OCD, or TD + OCD were evaluated with the Structured Clinical Interview for DSM-III-R supplemented with additional modules. The three groups differed in the rates of bipolar disorder (p < .04), social phobia (p < .02), body dysmorphic disorder (p < .002), attention deficit hyperactivity disorder (p < .03), and substance use disorders (p < .04). These findings were accounted for by the elevated rates of the disorders in the TD + OCD group compared with the TD and OCD groups. These finding are most consistent with the hypothesis that TD + OCD is a more severe disorder than TD and OCD and may be more etiologically linked to TD than to OCD. These findings highlight the importance of assessment of the full spectrum of psychiatric comorbidity in patients with TD and OCD.