PHASE II TRIAL OF TRIAPINE

Triapine 的 II 期试验

• 批准号: 7604693
• 负责人: JUDITH KARP
• 金额: $ 1.01万
• 依托单位: JOHNS HOPKINS UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2006
• 资助国家: 美国
• 起止时间: 2006-12-01 至 2007-09-16
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7604693
• 关键词: 20q; 3-Aminopyridine-2-carboxaldehyde Thiosemicarbazone; Achievement; Acidosis; Acute; Acute leukemia; Adenine; Adenosine; Adult; Affect; Aggressive-Phase Myeloid Leukemia; Alkylating Agents; Anthracycline Antibiotics; Anthracyclines; Ara-C; Bicarbonates; Biological Assay; Biological Models; Blast Cell; Blast Phase; Cancer cell line; Carbon Dioxide; Cell Count; Cell Line; Cells; Chemosensitization; Child; Chromosomes; Chronic; Chronic Myeloid Leukemia; Chronic Myelomonocytic Leukemia; Chronic Myelomonocytic Leukemia-1; Chronic Myelomonocytic Leukemia-2; Chronic Myeloproliferative Disorder; Chronic Phase; Chronic Phase of Disease; Clinic; Clinical; Clinical Trials; Codon Nucleotides; Combined Modality Therapy; Computer Retrieval of Information on Scientific Projects Database; Continuous Infusion; Count; Creatinine; Cytarabine; Cytogenetics; Cytotoxic agent; DNA; DNA biosynthesis; DNA chemical synthesis; DNA strand break; DNA-Directed DNA Polymerase; Daily; Data; Databases; Demyelinations; Deoxycytidine Kinase; Deoxyribonucleotides; Depth; Disease; Disease remission; Dose; Drug Exposure; Drug Kinetics; Enzyme Activation; Enzymes; Epithelial Cells; Etoposide; Event; Excision; Exhibits; Exposure to; Family; Feedback; Fludarabine/Triapine; Free Radicals; Funding; Generations; Genes; Genetic; Gleevec; Grant; Growth; Hematologic Neoplasms; Hematopoietic; Hemodialysis; Hemorrhagic Thrombocythemia; Heterogeneity; Hour; Hybrids; Hyperbilirubinemia; In Vitro; Incidence; Induction of Apoptosis; Infusion procedures; Institution; Iron; Iron Chelating Agents; Iron Chelation; JAK2 gene; KB Cells; Laboratories; Leukemic Cell; Life; Malignant lymphoid neoplasm; Malignant neoplasm of kidney; Marrow; Methemoglobinemia; Myelogenous; Myeloid Leukemia; Myeloproliferative disease; Myelosuppression; National Cancer Institute; Natural regeneration; Non-Hodgkin' s Lymphoma; Nucleoside Transporter; Nucleosides; Numbers; Oral; Partial Remission; Patient Care; Patients; Personal Communication; Personal Satisfaction; Pharmaceutical Preparations; Pharmacologic Substance; Phase; Phase I Clinical Trials; Phase II Clinical Trials; Phenylalanine; Philadelphia Chromosome Negative Chronic Myelogenous Leukemia; Phosphorylation; Polycythemia Vera; Positioning Attribute; Prevention; Primary Myelofibrosis; Process; Protocols documentation; Rate; Recovery; Refractory; Relapse; Renal carcinoma; Research; Research Personnel; Resistance; Resources; Ribonucleotide Reductase; Ribonucleotide Reductase Inhibitor; Ribonucleotide Reductase Subunit; Ribonucleotides; Risk; Route; Schedule; Sickle Cell Anemia; Solid Neoplasm; Source; Splenomegaly; Standards of Weights and Measures; Stem cells; Sum; System; Testing; Thiosemicarbazones; Time; Toxic effect; Transaminases; Transcript; Treatment Protocols; Triapine; Tumor Cell Line; Tumor Lysis Syndrome; Tyrosine; Tyrosine Kinase Inhibitor; United States National Institutes of Health; Valine; Week; absorption; adenosine deaminase; alpha-aminopyridine; analog; cohort; concept; cytotoxic; cytotoxicity; day; design; fludarabine; gain of function mutation; gemcitabine; hydroxyurea; inhibitor/antagonist; interest; leukemia; nucleoside analog; partial response; peripheral blood; preclinical study; prevent; prototype; repaired; response; ribonucleotide reductase M2; tumor; uptake

This subproject is one of many research subprojects utilizing the resources provided by a Center grant funded by NIH/NCRR. The subproject and investigator (PI) may have received primary funding from another NIH source, and thus could be represented in other CRISP entries. The institution listed is for the Center, which is not necessarily the institution for the investigator. OVERALL OBJECTIVES 1. To determine the efficacy and toxicities of administering Triapine followed by Fludarabine in adults with aggressive myeloproliferative disorders (MPDs), chronic myelogenous leukemia in accelerated phase (CML-AP) or blast crisis (CML-BC), and aggressive chronic myelomonocytic leukemia (CMML) 2. To obtain preliminary descriptive data regarding effects of Triapine and its interaction with Fludarabine on circulating leukemic cell genetics. 2. BACKGROUND 2.1 Triapine (3-Aminopyridine-2-Carboxaldehyde Thiosemicarbazone) Ribonucleotide reductase (RR) converts ribonucleotides into deoxyribonucleotides and is therefore a pivotal enzyme in the processes of DNA synthesis and repair. Inhibition of RR depletes the intracellular pools of deoxyribonucleotides and their triphopshorylated forms (dNTPs). The depletion enhances the intracellular accumulation of nucleoside analogs, in part by diminishing the pools of normal dNTPs and in part due to enhanced transporter function and nucleoside activation enzymes such deoxycytidine kinase (dCK). The accumulation, in turn, enhances the incorporation of triphosphorylated nucleoside analogs into DNA, thereby heightening the cytotoxic effects of those agents. RR is composed of 2 subunits: a regulatory (M1) subunit which is inhibited by nucleoside analogues such as Gemcitabine and Fludarabine, and a catalytic (M2) subunit which requires iron and generation of a tyrosyl free radical for activity.1 The M2 subunit is inhibited by Hydroxyurea (HU)2 and the new thiosemicarbazone derivative Triapine (3-aminopyridine-2-carboxaldehyde thiosemicarbazone).3,4 HU has been used clinically for three decades, mainly in the settings of acute and chronic myelogenous leukemias5 including chronic myelomonocytic leukemia6,7, and myeloproliferative disorders such as polycythemia vera and essential thrombocythemia,8,9 and sickle cell anemia.10 This agent effects prompt decreases in peripheral blood leukemic cell counts without inducing severe non-hematologic toxicities. As an oral agent, HU is well-suited to chronic administration and, until the advent of interferon11,12 and more recently the tyrosine kinase inhibitor Gleevec,13 served as a standard of care for patients with chronic myelogenous leukemia (CML) in the chronic phase. The oral route of administration, however, has generated concerns about heterogeneity in absorption leading to interindividual pharmacokinetic variability. This concern may have contributed to lack of application of HU to intensive combination therapies for aggressive hematologic malignancies. In addition, while HU destroys the tyrosine free radical, the drug has not shown strong clinical activity, perhaps because the tyrosine free radical can be regenerated easily with resultant rapid reversal of HUinduced RR inhibition.2 Triapine is a derivative of the ?-heterocyclic carboxaldeyde thiosemicarbazones that are exceedingly potent inhibitors of the RR M2 subunit (100-1000-fold more potent than HU).3,4 The heightened ability of Triapine to inhibit the M2 subunit relates in part because Triapine chelates iron as well as quenching the tyrosyl free radical. The iron chelation prevents regeneration of the radical and therefore exerts a less reversible inhibitory effect.6 Triapine has shown marked cytotoxicity against hematopoietic and epithelial cell lines, including HU-resistant L1210 leukemia.3,14,15 In the National Cancer Institute's panel of 60 tumor cell lines (a 48-hour exposure assay). The mean GI50 (concentration causing 50% growth inhibition) was 1.6 micromolar. The leukemia and renal cancer cell lines were most consistently sensitive to Triapine, with the majority demonstrating a GI50 of 450+ days; and among 15 patients with blasts in peripheral blood, 10 (66%) had ? 80% reduction and 7 (47%) had ? 95% reduction in circulating blasts, although the reduction was short-lived in most patients. In sum, clinical activity with hematologic improvement, reduction in splenomegaly, and/or clearance of marrow blasts was noted in 6/20 (30%) patients with highly refractory AML, CML-Blast Crisis and myeloproliferative disorders.18 This spectrum of activity parallels that defined previously for HU.9-11 A second study explored a 96 hr infusion, initially given every other week, but in the final 3 cohorts given for 2 consecutive weeks. A MTD of 140 mg/m2/d for the first infusion and 160 mg/m2/d for the second infusion was established.17 A 25% incidence of reversible grade 3-4 transaminases at the 160 mg/m2/d dose level precluded additional dose escalation, despite an unclear relationship to drug administration (all 3 events occurred in the first 3 patients treated at this dose, and no intermediate toxicity was observed). Approximately 25-33% of all patients developed reversible grade 2 decrease in bicarbonate, increased creatinine, or hyperbilirubinemia. There was no apparent cumulative toxicity. Although there were no complete or partial responses, 58% of patients with blasts in peripheral blood had 80% reduction, and 37% had ? 95% reduction in circulating blasts. Reduction of blast counts was transient in this trial. 2.2 Fludarabine (9-?-D-arabinosyl-2-fluoro-adenine monophosphate) Fludarabine is an analog of adenosine that is resistant to the deaminating effects of adenosine deaminase and has demonstrated remarkable activity in lymphoid malignancies.19 Like the prototype nucleoside analog ara-C, Fludarabine is triphosphorylated and is incorporated into DNA with termination of chain elongation and resultant DNA strand breakage.20 Moreover, Fludarabine inhibits several enzymes critical to DNA synthesis and repair, including DNA polymerases and the M1 subunit of RR.20,21 While Fludarabine exhibits potent single agent activity against chronic lymphoid malignancies, its activity as a single agent against myeloid leukemias including AML is seen only at very high doses ( 100 mg/m2 daily x 5) and is limited by delayed onset of severe, progressive8 demyelination.20,22,23 Nonetheless, Fludarabine can interact synergistically with multiple cytotoxic agents including alkylators, ara-C, etoposide and hydroxyurea.24 At least part of this interaction relates to Fludarabine's RR inhibition with resultant decreases in dNTP levels.20,21,24 Indeed, clinical trials in refractory AML combining Fludarabine and ara-C (with or without anthracycline) in a sequential fashion have demonstrated that the initial administration of Fludarabine augments the rate of ara-C triphopshate (ara-CTP) synthesis and accumulation with resultant potentiation of ara-C cytotoxicity ex vivo21,25,26 and with salutary clinical results in adults and children with poor-risk leukemias.27,28 2.3 Preclinical Studies of Triapine in Combination with Nucleoside Analogues In a number of experimental systems, inhibition of the M1 or M2 subunit of RR can enhance the anti-tumor activity of subsequently administered nucleoside analogues.29-35 Most of the preclinical studies have been conducted with HU and ara-C. The exact mechanisms responsible for additive or synergistic cytotoxicity of an RR inhibitor in combination with a nucleoside analogue are unclear and may differ depending on the cell line, concentration of agents, and sequence of administration. The available data suggest that RR inhibition will cause a decline in concentration of one or more of the dNTPs, and/or arrest of cells in S-phase, which in turn stimulates an increase in nucleoside transporters and/or reduces feedback inhibition on nucleoside analogue activation enzymes such as dCK. Furthermore, reduced cellular dNTP pools provide less competition to phosphorylated nucleoside analogues for incorporation into DNA during synthesis or repair. The end result is greater uptake, phosphorylation, intracellular accumulation, and DNA incorporation of the nucleoside analogues. Of interest, in one model system HU was shown to increase cytarabine cytotoxicity even in a cytarabine-resistant, dCK deficient cell line.30 Triapine, which is more potent than HU and retains its anti-tumor effects in certain HU-resistant tumor cell lines,3,4,14,15 also enhances cellular uptake, DNA incorporation, and cytotoxicity of cytarabine in tumor cell lines (data on file, Vion Pharmaceuticals). In vitro studies demonstrate that, of all nucleosides, dATP levels are most affected by Triapine. This preferential depletion of dATP is similar to the effect noted with HU.36 Depletion of dATP was evident at Triapine doses of 1-2uM, occurred within 30 min of drug exposure and, in the HTB-177 and KB cell lines, persisted for 24 hrs with continuous drug exposure. dATP levels recovered within 4-6 hours after Triapine removal. The effects on intracellular levels of other dNTPs were variable and shortlived. Limited exposure to Triapine for 4-12 hrs followed by 72 hr-exposure to Fludarabine resulted in heightened Fludarabine cytotoxicity in a Fludarabine-resistant KB cell line (Belcourt M., Sznol M., personal communication). 2.4 Phase I Clinical Trial of Triapine Plus Fludarabine in Refractory Leukemias On the basis of the data delineated above, we designed a Phase I clinical trial to test the combination of Triapine followed by escalating doses of Fludarabine in adults with relapsed and refractory acute leukemias, high-risk MDS or transformed MPDs including CMML (NCI protocol 6255). A total of 24 patients received Triapine 105 mg/m2 over 4hrs followed immediately by Fludarabine (15-30 mg/m2) daily x 5, with cycles repeated every 21-28 days. Of these 24, 13 had refractory AML, 2 had refractory ALL, 4 had aggressive CMML (2 transformed to AML), 2 had MPD transformed to AML, and 3 had aggressive CML. Adverse cytogenetics were documented in 10/15 tested (67%). Tumor lysis syndrome occurred in 6 (severe in 1 with 9 CML-BC requiring hemodialysis), transient methemoglobinemia occurred in 1, and transient acidosis (CO2 10-18, median 14) occurred in 8 days 3-5 of treatment. No DLT was reached. A total of 6/24 (25%) enjoyed some type of clinical response. Complete remission (CR) was achieved in 2 (8%: 1 complete hematologic remission (CHR) from accelerated phase CML, 1 short CR from refractory AML) at Fludarabine dose levels 3 and 4 (25 and 30 mg/m2). An additional 4 patients (17%) had evidence of partial remission or hematologic improvement across all Fludarabine dose levels, including both patients with MPD/AML, 1 CML-BC, and 1 CMML transformed to AML. The combination of Triapine given as a 24 hr continuous infusion at 200 mg/m2 followed by 5 days of gemcitabine has been examined in patients with advanced solid tumors (Vion, data on file). This mode of Triapine administration was associated with greater marrow suppression without non-hematologic toxicities. For this reason, we examined the feasibility and toxicities of Triapine 200 mg/m2/24 hrs beginning Day 1 followed by Fludarabine 30 mg/m2 daily x 5 days. Of 7 patients receiving this regimen, 3 have CMML transformed to AML, 1 has CML-BC, 1 refractory ALL and 2 refractory AML, with 4 of 6 (67%) having adverse cytogenetics. Interestingly, despite the longer infusion time, methemoglobinemia occurred in 2 patients and acidosis occurred in 1 (CO2 16). One pt with transformed CMML has achieved hematologic improvement, without evidence of significant response in the remaining patients. Despite the achievement of deep myelosuppression, this schedule of Triapine followed by Fludarabine was associated with rapid recovery of leukemia beginning day 10-12 of therapy, suggesting inadequate depth and duration of myelosuppression when Fludarabine was given without Triapine for 4 out of the 5 daily doses. 2.5 Aggressive Myeloproliferative Disorders (MPDs) MPDs are a group of disorders that includes agnogenic myeloid metaplasia (AMM), polycythemia vera (PV), essential thrombocythemia (ET), CML, and atypical (Ph negative) CML and CMML, the latter being considered to be hybrid MPD/MDS disorders. While these diseases may have protracted chronic phases, they eventually transform to an acute leukemic phase that is ultimately fatal and for which there is no effective therapy. Recent studies have unraveled a common genetic thread among these MPDs, namely a gain-of-function mutation in the JAK2 gene (located on chromosome 9p) at codon 1849 (G?T) that results in substitution of phenylalanine for valine at position 617.37-39 Further, altered expression of the Dido (deathinducer- obliterator) gene on chromosome 20q, with reduction in one or more of its 3 transcripts, has been detected consistently in hybrid MPD/MDS disorders.40,41 These findings suggest that, while there may be phenotypic heterogeneity among the family of MPDs, there may be genetic homogeneity at a stem cell level, with varying degrees of lineage differentiation in the chronic phases of these diseases that is lost upon transformation to acute leukemia. 2.6 Rationale The concept of RR inhibition by a nucleoside analogue was established in the laboratory more than 2 decades ago29,32,33 and tested in the clinic 10-15 years ago, with provocative results in non-Hodgkin's lymphomas using a sequential administration of HU followed by ara-C.42 While all nucleoside analogues (ara-C being a prototype) act via incorporation into DNA with resultant prevention of DNA strand elongation leading to DNA strand breaks and induction of apoptosis, newer analogues such as gemcitabine and Fludarabine also inhibit the M1 subunit of RR.20,21 10 Taking all of these considerations together, we propose a Phase II clinical trial of Triapine at a fixed dose of 105 mg/m2 given as a 4 hour infusion followed by Fludarabine 30 mg/m2 given over 30 minutes, with the Triapine/Fludarabine sequence administered daily x5 days, in patients with refractory hematologic malignancies. Fludarabine may be of particular interest, not only because of its complementary and mechanistically non-cross-resistant inhibition of RR but also because of the apparent selective effect of Triapine on intracellular dATP levels. Our phase I data support the administration of Triapine over a 4 hr period followed by Fludarabine30 mg/m2 daily for 5 days.