Ignite Creation Date:
2024-05-05 @ 4:52 PM
Last Modification Date:
2024-10-26 @ 9:25 AM
Study NCT ID:
NCT00339196
Status:
COMPLETED
Last Update Posted:
2011-05-09
First Post:
2006-06-12
Brief Title:
5-azacytidine Valproic Acid and ATRA in AML and High Risk MDS
Sponsor:
Assistance Publique - Hôpitaux de Paris
Organization:
Assistance Publique - Hôpitaux de Paris
Study Overview
Official Title:
Multi Centers Open-trial Phase II Study Evaluating 5-azacytidine Vidaza Valproic Acid Depakine Before Administration of Retinoic Acid Vesanoid in Patients With Acute Myelogenous Leukemia and High Risk Myelodysplasia
Status:
COMPLETED
Status Verified Date:
2007-03
Last Known Status:
None
Delayed Posting:
No
If Stopped, Why?:
Not Stopped
Has Expanded Access:
False
If Expanded Access, NCT#:
N/A
Has Expanded Access, NCT# Status:
N/A
Acronym:
None
Brief Summary:
MULTICENTERS Uncontrolled and open phase II study Evaluation of the effectiveness of a treatment associating 5 AzacytidineValproic acid Retinoic Acid at subjects-reached of syndromes myelodysplasia and acute MYELOID leukaemia Hematological response at 6 months Uncontrolled prospective cohort
Detailed Description:
Chromatin Demethylation Apart from histone acetylation deacetylation promoter hypermethylation is another important and relevant mechanism involved in gene transcription regulation reviewed in Herman 2003 Chromatin remodeling might thus be also targeted using nucleoside analogues such as 5 azacytidine or decitabine which reactivate gene transcription through DNA demethylation Silverman 2001 Recently in in VITRO studies induction of gene expression by 5 AzaC has been obtained in primary AML and MDS cells by DNA methylation dependent and independent mechanisms SCHMELZ 2005
Again AzaC has been demonstrated as capable to induce clinical hematological responses in patients with MDS A controlled study conducted by the US Cancer and Leukemia Group B CALBGhas reported a higher response rate a lower incidence of leukemic transformation and a prolonged survival as compared with supportive care alone in these patients Silverman 2002 Another confirmatory Phase 3 study is ongoing
AzaC in combination with valproic acid in leukemic cell line HL60 and MOLT4 has demonstrated a synergistic activity to induce gene reexpression reactivation of p21 CIP1 and a synergistic effect in terms of growth inhibition induction of apoptosis Yang H 2005
Histone Acetylation Numerous investigator groups have tried to elucidate the molecular mechanisms underlying the ATRA induced differentiation in NB4 cells fresh APL cells APL mice or APL patients Melnick 1999 One of the main issue was to understand the crucial role of the PML RARα fusion protein in the differentiation response to RA It was observed first that therapeutic concentrations of ATRA resulted in the reformation of PML nuclear bodies associated with a cleavage of the PML RARα fusion protein Disappearance of this fusion product which acts as a dominant negative regulator of RA target genes transcription gave an explanation for the rerun of the differentiation process The dominant negative role of PML RARα was secondly explained by the association of the fusion protein to the N-CoR-SMRT-Sin3 corepressor complex leading to histone deacetylase HDAC activities recruitment and to the lack of target genes transcription REDNER 1999 Of interest a similar recruitment of corepressor HDAC activities has been reported in other fusion gene leukemia including PLZF RARα AML1 ETO CBFß MYH11 and TEL AML1 acute leukemia In PML RARα APL cells therapeutic concentrations of ATRA allow the release of corepressor HDAC activities histone acetylation chromatin remodeling and transcription of target genes potentially responsible for terminal granulocytic differentiation REDNER 1999 DILWORK 2001 From this point of view ATRA therapy of APL is the first example of a gene targeted therapy which specifically targets pathogenic genetic abnormalities in a human leukemia
In VITRO and in vivo resistance to ATRA-induced differentiation observed in patients with PLZF RARα leukemia has been related to a more potent recruitment of corepressor HDAC activities in this APL subset as compared to classical PML- RARα APL two corepressor binding sites on PLZF instead of one on PML Very interestingly it has been recently demonstrated that PLZF RARα leukemic cells are not actually completely resistant to differentiation induction especially if appropriate COSTIMULI are given First these cells can differentiate in the presence of higher concentration of ATRA 3 microM instead of 1 microM
Secondly the addition of a HDAC inhibitor trichostatin A restores the ATRA sensitivity at 1 microM KITAMURY 2000
Thirdly G CSF signaling may force these cells to undergo terminal differentiation JANSEN 2001
HDAC inhibitors have also been shown as able to induce remission in transgenic models of therapy resistant acute promyelocytic leukemia He 2001
The sensitivity of HL60 cells which do not display any chromosomal rearrangement involving the RARα locus to RA induced differentiation may be related to these observations One may hypothesize that some unknown COSTIMULI including chromatin remodeling events contribute to the RA sensitivity of HL60 cells
From a therapeutic point of view these observations lead to evaluate non targeted transcriptional therapies combining ATRA with non targeted HDAC inhibitors andor cAMP inducers in non APL leukemias Among the known HDAC inhibitors trichostatin A trapoxin A butyrate oxamflatin depsipeptide and MS 275 sodium phenylbutyrate has been successfully administered in combination with ATRA to a patient with clinically ATRA resistant APL WARRELL 1998 This case report represents the first example of a targeted transcriptional therapy in a human leukemia It has recently been demonstrated that valproic acid VPA belongs to the HDAC inhibitor family PHIEL 2001 Valproic acid is a short chained fatty acid widely used as an anticonvulsant and mood stabilizer
The characteristic delay in response to VPA and its teratogenic potential had led for a long time to the proposal that it acts through modulation of gene expression It has also been reported that VPA can activate AP1-dependent transcription ASGHARI 1998 Chen 1999 1 Yuan 2001 and upregulate bcl 2 Chen 1999 2 VPA was also recently demonstrated as capable to induce differentiation of F9 teratocarcinoma cells which are known to be also capable to differentiate in the presence of RA or cAMP WERLING 2001 Finally VPA might sensitize neoplastic cells to pro apoptotic stimuli through an inhibition of glutathione GSH reductase an enzyme required for maintaining high cellular levels of reduced GSH Moog 1996 or an inhibition of the NF-κB pathway ICHIYAMA 2000 Interestingly it was also shown that lithium chloride another mood stabilizer acts synergistically with ATRA to induce terminal differentiation of WEHI-3B leukemia cells As observed with the combination of ATRA and G CSF this observed synergism appeared to be related to the prevention of RAR protein loss usually observed under ATRA exposure Finch 2000
Of interest VPA as single agent or administered in combination with ATRA has been recently demonstrated as capable to induce clinical hematological responses in patients treated for myelodysplastic syndromes KUENDGEN 2004 In this study a pretreatment with VA seemed to be required for further positive effects of ATRA
Retinoic Acid
Retinoids represent a large group of compounds structurally related to vitamin A retinol They act through binding to and activating specific nuclear receptors which bind the DNA Retinoic acid RA the natural acidic derivative of retinol is a key differentiating factor involved in specific phases of the embryonic development differentiation of the visual system and of interest here hemopoietic granulocytic maturation CORNIC 1994 In VITRO RA was demonstrated as capable to induce granulocytic differentiation of the HL60 cell line This cell line was established in 1977 from a patient with AML The cells largely resemble promyelocytes but can be induced to differentiate terminally Some reagents including RA cause HL60 cells to differentiate to granulocyte-like cells others to monocytemacrophage-like cells The HL60 cell genome contains an amplified c-myc proto-oncogene and c-myc mRNA levels decline rapidly following induction of differentiation BIRNIE 1988
Recurrent alterations of the gene coding for the RA alpha receptor RARα located on the chromosome 17q12 are associated with some acute myeloid leukemia AML subsets The most common RARα gene alteration is the reciprocal t1517 chromosomal translocation observed in the vast majority of acute promyelocytic leukemia APL corresponding to the AML-M3 subset of the French-American-British FAB classification This translocation fuses the RARα gene to the PML gene located on the chromosome 15q21 resulting in PML- RARα fusion products Variant translocations fusing the RARα gene with other partners including PLZF on chromosome 11 NPM on chromosome 5 NuMA on chromosome 11 and STAT5 on chromosome 17 have been rarely or occasionally reported The causal role of the RARα fusion proteins at least PML- RARα and PLZF- RARα in APL has been demonstrated in murine models KOGAN 1999 It has been shown that these fusion proteins may act as a dominant transcriptional repressor in APL cells Melnick 1999
The NB4 cell line was established in 1991 from a patient with APL LANOTTE 1991 This cell line has been widely used to study the biology of this disease Conversely to HL60 NB4 is carrying the t1517 translocation As in HL60 cells RA is capable to induce granulocytic differentiation of NB4 cells leading to cell death through terminal induction of apoptosis These differentiating effects have been confirmed in vivo using different murine models of APL KOGAN 1999 He 1999
Based on these pre-clinical observations oral all-trans RA ATRA has been successfully administered to APL patients In patients with relapsing APL front-line therapy with ATRA 45 mgm2day induces in vivo differentiation of leukemic promyelocytes into abnormal granulocytes still carrying the PML- RARα fusion resulting in approximately 90 hematological remission and 20 molecular remission rates as assessed by specific PML- RARα RT-PCR negativation Huang 1988 CASTAIGNE 1990 DEGOS1995 This represented the first example of a differentiation therapy in a human leukemia Unfortunately such beneficial effects have not been observed in patients with other AML subtypes when treated with ATRA using similar dosage and schedule Following these results obtained in relapsing APL patients ATRA was then evaluated in combination with chemotherapy during front-line treatment of newly-diagnosed APL patients Several controlled trials have established the ATRA-chemotherapy combination as the current standard therapy for newly-diagnosed APL Apparently the best results are obtained when ATRA and chemotherapeutic agents are administered simultaneously
Other therapeutic interventions might be considered to increase the RA sensitivity in RA-resistant cells Actually explanations for the RA resistance include RA-induced increased expression of cytochrome P450 isoforms CYPs RA-induced increased expression of cytoplasmic RA-binding proteins type II CRABP-II overexpression of P-glycoprotein P-gp and acquired mutations of the ligand-binding region of the RARα gene Agents interacting with ATRA metabolism such as HIV-1 protease inhibitors indinavir ritonavir saquinavir which inhibit CYPs and P-gp and compete with ATRA for CRABP-I binding could enhance the induction of differentiation in RA-resistant cells IKEZOE 2000
Again AzaC has been demonstrated as capable to induce clinical hematological responses in patients with MDS A controlled study conducted by the US Cancer and Leukemia Group B CALBGhas reported a higher response rate a lower incidence of leukemic transformation and a prolonged survival as compared with supportive care alone in these patients Silverman 2002 Another confirmatory Phase 3 study is ongoing
AzaC in combination with valproic acid in leukemic cell line HL60 and MOLT4 has demonstrated a synergistic activity to induce gene reexpression reactivation of p21 CIP1 and a synergistic effect in terms of growth inhibition induction of apoptosis Yang H 2005
Histone Acetylation Numerous investigator groups have tried to elucidate the molecular mechanisms underlying the ATRA induced differentiation in NB4 cells fresh APL cells APL mice or APL patients Melnick 1999 One of the main issue was to understand the crucial role of the PML RARα fusion protein in the differentiation response to RA It was observed first that therapeutic concentrations of ATRA resulted in the reformation of PML nuclear bodies associated with a cleavage of the PML RARα fusion protein Disappearance of this fusion product which acts as a dominant negative regulator of RA target genes transcription gave an explanation for the rerun of the differentiation process The dominant negative role of PML RARα was secondly explained by the association of the fusion protein to the N-CoR-SMRT-Sin3 corepressor complex leading to histone deacetylase HDAC activities recruitment and to the lack of target genes transcription REDNER 1999 Of interest a similar recruitment of corepressor HDAC activities has been reported in other fusion gene leukemia including PLZF RARα AML1 ETO CBFß MYH11 and TEL AML1 acute leukemia In PML RARα APL cells therapeutic concentrations of ATRA allow the release of corepressor HDAC activities histone acetylation chromatin remodeling and transcription of target genes potentially responsible for terminal granulocytic differentiation REDNER 1999 DILWORK 2001 From this point of view ATRA therapy of APL is the first example of a gene targeted therapy which specifically targets pathogenic genetic abnormalities in a human leukemia
In VITRO and in vivo resistance to ATRA-induced differentiation observed in patients with PLZF RARα leukemia has been related to a more potent recruitment of corepressor HDAC activities in this APL subset as compared to classical PML- RARα APL two corepressor binding sites on PLZF instead of one on PML Very interestingly it has been recently demonstrated that PLZF RARα leukemic cells are not actually completely resistant to differentiation induction especially if appropriate COSTIMULI are given First these cells can differentiate in the presence of higher concentration of ATRA 3 microM instead of 1 microM
Secondly the addition of a HDAC inhibitor trichostatin A restores the ATRA sensitivity at 1 microM KITAMURY 2000
Thirdly G CSF signaling may force these cells to undergo terminal differentiation JANSEN 2001
HDAC inhibitors have also been shown as able to induce remission in transgenic models of therapy resistant acute promyelocytic leukemia He 2001
The sensitivity of HL60 cells which do not display any chromosomal rearrangement involving the RARα locus to RA induced differentiation may be related to these observations One may hypothesize that some unknown COSTIMULI including chromatin remodeling events contribute to the RA sensitivity of HL60 cells
From a therapeutic point of view these observations lead to evaluate non targeted transcriptional therapies combining ATRA with non targeted HDAC inhibitors andor cAMP inducers in non APL leukemias Among the known HDAC inhibitors trichostatin A trapoxin A butyrate oxamflatin depsipeptide and MS 275 sodium phenylbutyrate has been successfully administered in combination with ATRA to a patient with clinically ATRA resistant APL WARRELL 1998 This case report represents the first example of a targeted transcriptional therapy in a human leukemia It has recently been demonstrated that valproic acid VPA belongs to the HDAC inhibitor family PHIEL 2001 Valproic acid is a short chained fatty acid widely used as an anticonvulsant and mood stabilizer
The characteristic delay in response to VPA and its teratogenic potential had led for a long time to the proposal that it acts through modulation of gene expression It has also been reported that VPA can activate AP1-dependent transcription ASGHARI 1998 Chen 1999 1 Yuan 2001 and upregulate bcl 2 Chen 1999 2 VPA was also recently demonstrated as capable to induce differentiation of F9 teratocarcinoma cells which are known to be also capable to differentiate in the presence of RA or cAMP WERLING 2001 Finally VPA might sensitize neoplastic cells to pro apoptotic stimuli through an inhibition of glutathione GSH reductase an enzyme required for maintaining high cellular levels of reduced GSH Moog 1996 or an inhibition of the NF-κB pathway ICHIYAMA 2000 Interestingly it was also shown that lithium chloride another mood stabilizer acts synergistically with ATRA to induce terminal differentiation of WEHI-3B leukemia cells As observed with the combination of ATRA and G CSF this observed synergism appeared to be related to the prevention of RAR protein loss usually observed under ATRA exposure Finch 2000
Of interest VPA as single agent or administered in combination with ATRA has been recently demonstrated as capable to induce clinical hematological responses in patients treated for myelodysplastic syndromes KUENDGEN 2004 In this study a pretreatment with VA seemed to be required for further positive effects of ATRA
Retinoic Acid
Retinoids represent a large group of compounds structurally related to vitamin A retinol They act through binding to and activating specific nuclear receptors which bind the DNA Retinoic acid RA the natural acidic derivative of retinol is a key differentiating factor involved in specific phases of the embryonic development differentiation of the visual system and of interest here hemopoietic granulocytic maturation CORNIC 1994 In VITRO RA was demonstrated as capable to induce granulocytic differentiation of the HL60 cell line This cell line was established in 1977 from a patient with AML The cells largely resemble promyelocytes but can be induced to differentiate terminally Some reagents including RA cause HL60 cells to differentiate to granulocyte-like cells others to monocytemacrophage-like cells The HL60 cell genome contains an amplified c-myc proto-oncogene and c-myc mRNA levels decline rapidly following induction of differentiation BIRNIE 1988
Recurrent alterations of the gene coding for the RA alpha receptor RARα located on the chromosome 17q12 are associated with some acute myeloid leukemia AML subsets The most common RARα gene alteration is the reciprocal t1517 chromosomal translocation observed in the vast majority of acute promyelocytic leukemia APL corresponding to the AML-M3 subset of the French-American-British FAB classification This translocation fuses the RARα gene to the PML gene located on the chromosome 15q21 resulting in PML- RARα fusion products Variant translocations fusing the RARα gene with other partners including PLZF on chromosome 11 NPM on chromosome 5 NuMA on chromosome 11 and STAT5 on chromosome 17 have been rarely or occasionally reported The causal role of the RARα fusion proteins at least PML- RARα and PLZF- RARα in APL has been demonstrated in murine models KOGAN 1999 It has been shown that these fusion proteins may act as a dominant transcriptional repressor in APL cells Melnick 1999
The NB4 cell line was established in 1991 from a patient with APL LANOTTE 1991 This cell line has been widely used to study the biology of this disease Conversely to HL60 NB4 is carrying the t1517 translocation As in HL60 cells RA is capable to induce granulocytic differentiation of NB4 cells leading to cell death through terminal induction of apoptosis These differentiating effects have been confirmed in vivo using different murine models of APL KOGAN 1999 He 1999
Based on these pre-clinical observations oral all-trans RA ATRA has been successfully administered to APL patients In patients with relapsing APL front-line therapy with ATRA 45 mgm2day induces in vivo differentiation of leukemic promyelocytes into abnormal granulocytes still carrying the PML- RARα fusion resulting in approximately 90 hematological remission and 20 molecular remission rates as assessed by specific PML- RARα RT-PCR negativation Huang 1988 CASTAIGNE 1990 DEGOS1995 This represented the first example of a differentiation therapy in a human leukemia Unfortunately such beneficial effects have not been observed in patients with other AML subtypes when treated with ATRA using similar dosage and schedule Following these results obtained in relapsing APL patients ATRA was then evaluated in combination with chemotherapy during front-line treatment of newly-diagnosed APL patients Several controlled trials have established the ATRA-chemotherapy combination as the current standard therapy for newly-diagnosed APL Apparently the best results are obtained when ATRA and chemotherapeutic agents are administered simultaneously
Other therapeutic interventions might be considered to increase the RA sensitivity in RA-resistant cells Actually explanations for the RA resistance include RA-induced increased expression of cytochrome P450 isoforms CYPs RA-induced increased expression of cytoplasmic RA-binding proteins type II CRABP-II overexpression of P-glycoprotein P-gp and acquired mutations of the ligand-binding region of the RARα gene Agents interacting with ATRA metabolism such as HIV-1 protease inhibitors indinavir ritonavir saquinavir which inhibit CYPs and P-gp and compete with ATRA for CRABP-I binding could enhance the induction of differentiation in RA-resistant cells IKEZOE 2000
Study Oversight
Has Oversight DMC:
None
Is a FDA Regulated Drug?:
None
Is a FDA Regulated Device?:
None
Is an Unapproved Device?:
None
Is a PPSD?:
None
Is a US Export?:
None
Is an FDA AA801 Violation?:
None