Clinical Trial of Ceramide nanoLiposomes in AML

项目摘要 急性髓系白血病（AML）是第二种最常见的白血病类型，5年生存率 只有27%。虽然剂量强化诱导和巩固化疗诱导临床完全缓解， 大多数适合治疗的患者缓解，大多数复发，而其他患者发展为难治性 急性髓细胞白血病最近，Bcl-2抑制剂维奈托克，显示出当与 阿糖胞苷（AraC）是治疗复发性和难治性AML的常规药物。根据疗效， 在临床前模型中，我们假设促凋亡生物活性脂质C6-神经酰胺的脂质体递送将 增加这种低剂量AraC/venetoclax标准治疗方案的疗效，并具有有意义的 治疗复发性/难治性AML的临床影响。这一假设将在三个具体目标中加以检验。在 具体目标1，神经酰胺纳米脂质体的1b期（剂量递增）/2a期（剂量扩展）临床试验 (CNL)在与低剂量AraC和维奈托克联合治疗的复发性/难治性AML患者中（IND前 #142902，UVA方案审查委员会批准#5414，CAV试验）。此前提 试验得到CNL已经达到FDA中假定的MTD的事实的支持（IND 109471， NCT 02834611）NCI支持的（U43 CA 186118）实体瘤I期试验，其中CNL已得到良好的- 多名患者表现出稳定的疾病。在具体目标2中，我们研究了潜在的 CNL、AraC和维奈托克在AML中的协同性。我们表明，CNL与AraC的联合给药 和/或维奈托克发挥多种协同功效机制。首先，我们证明，这种方案 增加促凋亡C16-和C18-神经酰胺相对于较少凋亡C24神经酰胺的比率。利用 在体外和体内模型的分子策略，我们将测试的假设，这是介导的 神经酰胺转移酶和确定神经酰胺转移酶如何调节AML存活。其次，我们表明， CNL降低了维奈托克诱导的促生存蛋白的升高。我们将检验这一假设， 在临床前模型中使用分子方法，在具体目标3中，我们表明， C18与C24神经酰胺的比例预测AML患者的无进展生存期，这是第一个应用于 作为癌症的生物标志物。我们将扩展并确认鞘脂代谢物或比例， AML生物学和预后的生物标志物，利用大量的、充分表征的AML样本作为验证 队列。同时还研究来自特定目标1的临床样品以评估CNL功效的生物标志物。 已发表和未发表的观察结果表明，高表达的酶，减少 神经酰胺水平（酸性神经酰胺酶，鞘氨醇激酶，葡萄糖神经酰胺合成酶），并减少促凋亡 神经酰胺（例如C16/C18）导致AML患者的存活率降低。总之，拟议的研究将测试 临床应用，并阐明CNL与AraC/维奈托克协同作用的机制途径， 确定AML中鞘脂代谢失调的预后影响。

PROJECT SUMMARY Acute Myeloid Leukemia (AML) is the 2nd most common type of leukemia diagnosed with a 5-year survival rate of only 27%. Though dose-intensive induction and consolidation chemotherapy induces clinical complete remission in the majority of patients suitable for treatment, most relapse whereas others develop refractory AML. Recently, the Bcl-2 inhibitor, venetoclax, demonstrated improved clinical outcomes when combined with the conventional therapeutic, cytarabine (AraC), in relapsed and refractory AML. Based upon efficacy in preclinical models, we hypothesize that liposomal delivery of the pro-apoptotic bioactive lipid C6-ceramide will augment the efficacy of this low dose AraC/venetoclax standard-of-care regimen and have a meaningful clinical impact in treating relapsed/refractory AML. This hypothesis will be examined in three Specific Aims. In Specific Aim 1, a Phase 1b (dose escalation)/2a (dose-expansion) clinical trial for ceramide nanoLiposomes (CNL) in relapsed/refractory AML patients treated in combination with low dose AraC and venetoclax (pre-IND #142902, UVA Protocol Review Committee Approval #5414, CAV trial) will be conducted. The premise of this trial is supported by the fact that CNL has already reached its putative MTD in an FDA (IND 109471, NCT02834611) NCI-supported (U43 CA186118) Phase 1 trial for solid tumors, where CNL has been well- tolerated with multiple patients exhibiting stable disease. In Specific Aim 2, we examine the underlying cooperativity between CNL, AraC, and venetoclax in AML. We show that co-administration of CNL with AraC and/or venetoclax exerts multiple synergistic mechanisms of efficacy. First, we demonstrate that this regimen increases the ratio of pro-apoptotic C16- and C18-ceramides over less apoptotic C24 ceramides. Utilizing molecular strategies in both in vitro and in vivo models, we will test the hypothesis that this is mediated by ceramide synthases and determine how ceramide synthases regulate AML survival. Second, we show that CNL reduces venetoclax-induced elevation of pro-survival proteins. We will test the hypothesis that this effect is STAT3-dependent using molecular approaches in preclinical models. In Specific Aim 3, we show that the ratio of C18 to C24 ceramides predicts progression-free survival in AML patients, which is the first application of this ratio as a biomarker for cancer. We will extend and confirm sphingolipid metabolites or ratios as biomarkers of AML biology and prognosis utilizing large, well-characterized AML samples as a validation cohort. while also investigating clinical samples from Specific Aim 1 to assess biomarkers of CNL efficacy. Published and unpublished observations demonstrate that high-expression of enzymes that decrease ceramide levels (acid ceramidase, sphingosine kinase, glucosylceramide synthase) and reduce pro-apoptotic ceramides (e.g. C16/C18) leads to lower survival in AML patients. Together, the proposed studies will test the clinical application and unravel the mechanistic pathways of CNL cooperativity with AraC/venetoclax, while ascertaining the prognostic impact of dysregulated sphingolipid metabolism in AML.