Acute Myeloid Leukemia (AML), Myelodysplastic Syndromes (MDS)
Conditions
Keywords
Acute myeloid leukemia, Myelodysplastic Syndromes, mitoxantrone hydrochloride liposome, Cytarabine, Granulocyte Colony-Stimulating Factor, Venetoclax, Randomized Controlled Trial
Brief summary
This study aims to evaluate the efficacy and safety of mitoxantrone hydrochloride liposome, subcutaneous cytarabine and G-CSF combined with venetoclax (CMG+Ven) versus azacitidine combined with venetoclax (VA) in the treatment of adult myelodysplastic syndrome IB2 (MDS-IB2) and newly diagnosed secondary or elderly AML.
Detailed description
Patients with secondary AML (S-AML) and elderly AML have an extremely poor prognosis due to advanced age, multiple comorbidities, and unfavorable cytogenetic abnormalities. Traditional intensive chemotherapy is associated with low remission rates and substantial toxicity. Myelodysplastic syndrome with excess blasts-2 (MDS-IB2) carries a very high risk of transformation to AML, and its management is similar to that of AML. Although venetoclax, a BCL-2 targeted agent, combined with azacitidine (VA regimen) has revolutionized the treatment paradigm for AML patients unfit for intensive chemotherapy, the VA regimen provides insufficient depth of remission in patients eligible for chemotherapy and is difficult to administer at full dosage and full course, highlighting an urgent need for optimization. Mitoxantrone hydrochloride liposome is an improved formulation of conventional mitoxantrone. Through liposomal encapsulation and polyethylene glycol modification, it exhibits a prolonged half-life and enhanced tumor targeting, while significantly reducing cardiac toxicity and other non-hematologic toxicities. Our center's previous exploratory study demonstrated that mitoxantrone hydrochloride liposome combined with cytarabine, G-CSF, and venetoclax (CMG+Ven) achieved a composite complete remission (CRc) rate of 72.6% and an MRD-negative rate of 75.6% in patients with newly diagnosed secondary or elderly AML. Furthermore, compared with the VA regimen, CMG+Ven significantly increased the MRD-negative rate and shortened hospital stay, showing promising clinical potential. Therefore, the investigators designed a prospective, multicenter, randomized controlled trial. The study plans to enroll 168 adult patients with clinically confirmed MDS-IB2 and newly diagnosed secondary or elderly AML. Participants will be randomly assigned in a 1:1 ratio to receive one of the following induction treatments: 1) mitoxantrone hydrochloride liposome, subcutaneous cytarabine, and G-CSF combined with venetoclax (CMG+VEN), or 2) azacitidine combined with venetoclax (VA). The primary endpoint is the composite complete remission (CRc) rate following induction therapy.
Interventions
DRUGMitoxantrone Hydrochloride Liposome
Mitoxantrone Hydrochloride Liposome: 15 mg/m², administered by intravenous drip (ivgtt) on day 1
DRUGCytarabine
Cytarabine: 10 mg/m², administered subcutaneously (H) every 12 hours (q12h) on days 1-7
G-CSF: 5 μg/kg, administered subcutaneously (H) starting from day 0, and discontinued when WBC ≥ 20×10\^9/L
DRUGVenetoclax
Venetoclax: 100 mg on day 2, 200 mg on day 3, and 400 mg on days 4-10, administered orally (po)
DRUGazacitidine
Azacitidine: 75 mg/m\^2, administered subcutaneously (H) on days 1-7.
Sponsors
Ruijin Hospital
CSPC Zhongnuo Pharmaceutical (Shijiazhuang) Co., Ltd.
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to 75 Years
Healthy volunteers
No
Inclusion criteria
* 1\. The patient fully understands the study, voluntarily participates, and signs the Informed Consent Form (ICF). 2\. Age: 18-75 years inclusive. 3. Patients with clinically confirmed adult AML or MDS-IB2 (according to WHO 2022 criteria or ICC 2022 criteria). AML patients must meet any of the following: 1. Therapy-related AML 2. Prior history of MDS 3. Presence of MDS-related genetic/chromosomal abnormalities 4. Prior history of CMML 5. Age ≥ 60 years 6. Prior history of antecedent MPN (including ET, PV, and MF) with bone marrow fibrosis ≤ grade 2 (on a 0-3 grade scale) 4. For elderly AML patients, comprehensive assessment must show they belong to the Fit population: ECOG \< 3, CCI ≤ 0, and MMSE and SPPB assessment results meeting the Fit population criteria. 5\. Liver and kidney function: ALT and AST ≤ 2.5 × ULN (≤ 5 × ULN for patients with liver infiltration); total bilirubin ≤ 1.5 × ULN (≤ 3 × ULN for patients with liver infiltration); serum creatinine ≤ 1.5 × ULN. 6\. Expected survival ≥ 3 months. 7. Prior MDS-related therapy (excluding blood transfusions) must be completed at least 2 weeks before the start of study treatment. In cases of rapidly proliferative disease, hydroxyurea is permitted up to 24 hours before the start of study treatment. Toxicities from prior MDS therapy must have recovered to Grade 2 or lower before the start of study treatment.
Exclusion criteria
* Patients who meet any of the following criteria will be excluded from the study: 1. Prior anti-cancer treatment history meeting any of the following: 1. Prior treatment with mitoxantrone or mitoxantrone liposome. 2. Prior treatment with venetoclax or hypomethylating agents. 3. Prior treatment with doxorubicin or other anthracyclines, with a cumulative doxorubicin dose \> 360 mg/m\^2 (for other anthracyclines, 1 mg doxorubicin is equivalent to 2 mg daunorubicin or 0.5 mg idarubicin). 4. Received anti-cancer treatment including surgery, chemotherapy, targeted therapy, etc., or participated in another clinical trial with investigational drug within 4 weeks or 5 half-lives before the first dose of study drug. 2. Cardiac function or disease meeting any of the following: 1. Long QTc syndrome or QTc interval \> 480 ms. 2. Complete left bundle branch block, second-degree or third-degree atrioventricular block. 3. Severe, uncontrolled arrhythmia requiring medication. 4. New York Heart Association (NYHA) Class ≥ II. 5. Left ventricular ejection fraction (LVEF) \< 50%. 6. History of myocardial infarction, unstable angina, severe unstable ventricular arrhythmia or any other arrhythmia requiring treatment, clinically significant pericardial disease within 6 months before enrollment, or electrocardiographic evidence of acute ischemia or active conduction system abnormalities. 3. Concurrent uncontrolled malignancy other than adequately controlled non-melanoma skin basal cell carcinoma, carcinoma in situ of breast/cervix, or other malignancies that have been effectively controlled without treatment for \> 6 months and patients receiving long-term non-chemotherapy treatment (e.g., hormone therapy). 4. Uncontrolled systemic disease (e.g., progressive infection, uncontrolled hypertension, diabetes mellitus). 5. Central nervous system (CNS) leukemia. 6. Secondary AML with bone marrow fibrosis ≥ grade 3. 7. Blast crisis of chronic myeloid leukemia (CML). 8. AML with favorable-risk karyotypes: t(8;21)(q22;q22.1) RUNX1::RUNX1T1, inv(16)(p13.1q22) CBFB::MYH11, or acute promyelocytic leukemia (APL). 9. Human immunodeficiency virus (HIV) infection (HIV antibody positive). 10. Active hepatitis B or hepatitis C infection (HBsAg or HBcAb positive with HBV-DNA \> 1×10\^3 copies/mL; HCV antibody positive with HCV-RNA \> 1×10\^3 copies/mL). 11. Known immediate or delayed hypersensitivity reaction to the study drug's class or excipients.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Proportion of Participants With Composite Complete Remission (CRc = CR + CRh + CRI) in Induction Therapy (Assessed via European LeukemiaNet [ELN] 2022 Criteria) | At the end of each cycle (each cycle is 28 days), up to 2 cycles | Number of participants achieving composite complete remission (CRc), defined as complete remission (CR) + complete remission with partial hematologic recovery (CRh) + complete remission with incomplete hematologic recovery (CRI), assessed at the end of each 28-day cycle (up to 2 cycles) using European LeukemiaNet \[ELN\] 2022 criteria. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Proportion of Participants With Objective Response (ORR = CRC + Morphologic Leukemia-Free State [MLFS] + Partial Remission [PR]) in Induction Therapy (Assessed via European LeukemiaNet [ELN] 2022 Criteria) | At the end of each cycle (each cycle is 28 days), up to 2 cycles | Number of participants achieving objective response (ORR), defined as composite complete remission (CRC) + morphologic leukemia-free state (MLFS) + partial remission (PR), assessed at the end of each 28-day cycle (up to 2 cycles) using European LeukemiaNet \[ELN\] 2022 criteria. |
| Proportion of CRc-Achieving Participants With Measurable Residual Disease (MRD) Negativity (Assessed via Flow Cytometry Testing Per ELN 2022 Criteria) | At the end of each cycle (each cycle is 28 days), up to 2 cycles | Number of participants who achieved CRc and had MRD negativity, assessed at the end of each 28-day cycle (up to 2 cycles) using flow cytometry testing per European LeukemiaNet \[ELN\] 2022 criteria. |
| Overall Survival (OS) Time (From Treatment Day 1 to Date of Death From Any Cause) | Up to 1 years after the date of the last enrolled participants | Time from day 1 of treatment to date of death from any cause, measured for all participants in the study, up to 1 year after the last enrolled participant's enrollment date. |
| Relapsed-Free Survival (RFS) Time (From CRc Achievement to Hematologic Relapse or Death From Any Cause) | Up to 1 years after the date of the last enrolled participants | Time from date of achieving CRc to date of hematologic relapse or death from any cause, measured only for participants who achieved CRc, up to 1 year after the last enrolled participant's enrollment date. |
| Event-Free Survival (EFS) Time (From Treatment Day 1 to Treatment Failure, Hematologic Relapse From CRc, or Death From Any Cause [Whichever Occurs First]) | Up to 1 years after the date of the last enrolled participants | Time from day 1 of treatment to date of treatment failure, hematologic relapse from CRc, or death from any cause (whichever occurs first), measured for all participants in the study, up to 1 year after the last enrolled participant's enrollment date. |
| Incidence of Treatment-Emergent Adverse Events (Assessed via Common Terminology Criteria for Adverse Events [CTCAE] v5.0) | From day 1 of treatment to 28 days after the last dose | Number of participants with treatment-emergent adverse events, assessed via Common Terminology Criteria for Adverse Events \[CTCAE\] v5.0, from day 1 of treatment to 28 days after the last dose. |
| Exploratory Biomarker Profiling (Including Genetic Mutations, Gene Expression Profiles, and Molecular Markers in Blood/Bone Marrow) | Baseline, end of each cycle (up to 2 cycles) | Assessment of exploratory biomarkers (including genetic mutations, gene expression profiles, and molecular markers) in blood or bone marrow, to explore association with treatment response/resistance/prognosis in AML, at baseline and end of each 28-day cycle (up to 2 cycles). |
Contacts
CONTACTXiaoqian Xu
PRINCIPAL_INVESTIGATORSujiang Zhang
Ruijin Hospital
Outcome results
None listed