Sequential Treatment With Ponatinib and Blinatumomab vs Chemotherapy and Imatinib in Newly Diagnosed Adult Ph+ ALL

Sponsor

Gruppo Italiano Malattie EMatologiche dell'Adulto (Other)

Overall Status

Recruiting

CT.gov ID

NCT04722848

Collaborator

(none)

236

Enrollment

Locations

Arms

71.8

Anticipated Duration (Months)

15.7

Patients Per Site

0.2

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

This is a randomised, open-label, multicenter, phase III study for adult de novo Ph+ ALL patients based on the combination of Ponatinib with Blinatumomab. The control arm will be represented by a chemotherapeutic scheme combined with Imatinib for patients aged 18-65 and by Imatinib plus age-adjusted chemotherapy for elderly patients (>65 years old).

Patients will be randomized 2:1 to receive the experimental or control arm. If patients in the control arm do not achieve a CHR and/or MRD negativity, after the sixth consolidation cycle (week 20), a crossover to receive Blinatumomab is planned. Likewise, if patients in the control arm develop an ABL1 mutation at any time of treatment, they will switch to experimental arm. HLA typing will be performed immediately after diagnosis in both arms for patients aged up to 65 years.

After the 2 cycles of Blinatumomab in the experimental arm and after consolidation in the control arm, patients aged 18-65 will be stratified for transplant allocation.

Condition or Disease	Intervention/Treatment	Phase
Acute Lymphoblastic Leukemia (Philadelphia Chromosome Positive) ALL, Adult Philadelphia-Positive ALL	Drug: Ponatinib + Blinatumomab Drug: Chemotherapy + Imatinib	Phase 3

Detailed Description

This is a randomised, open-label, multicenter, phase III study for adult de novo Ph+ ALL patients (≥18 years, no upper age-limit) based on the combination of the pan-TKI Ponatinib, with the bispecific monoclonal antibody Blinatumomab. The control arm will be represented by a chemotherapeutic scheme combined with Imatinib for patients aged 18-65 and by Imatinib plus age-adjusted chemotherapy for elderly patients (>65 years old).

Patients (≥18 years, no upper age limit) will be randomized 2:1 to receive the experimental or control arm. If patients in the control arm do not achieve a CHR and/or MRD negativity, after the sixth consolidation cycle (week 20), a crossover to receive Blinatumomab is planned. Likewise, if patients in the control arm develop an ABL1 mutation at any time of treatment, they will switch to experimental arm. HLA typing will be performed immediately after diagnosis in both arms for patients aged up to 65 years.

After the 2 cycles of Blinatumomab in the experimental arm and after consolidation in the control arm, patients aged 18-65 will be stratified for transplant allocation.

Study Design

Study Type:

Interventional

Anticipated Enrollment :

236 participants

Allocation:

Randomized

Intervention Model:

Parallel Assignment

Masking:

None (Open Label)

Primary Purpose:

Treatment

Official Title:

Newly Diagnosed Adult Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia (Ph+ ALL). Sequential Treatment With Ponatinib and the Bispecific Monoclonal Antibody Blinatumomab vs Chemotherapy and Imatinib

Actual Study Start Date :

Sep 8, 2021

Anticipated Primary Completion Date :

Sep 1, 2027

Anticipated Study Completion Date :

Sep 1, 2027

Arms and Interventions

Arm	Intervention/Treatment
Experimental: Ponatinib+Blinatumomab patients will receive induction with ponatinib followed by at least 2 cycles of blinatumomab	Drug: Ponatinib + Blinatumomab Patients aged 18-65 will receive Ponatinib at the dose of 45 mg/day for the first 22 days and then will reduce the dose to 30 mg (depending on the morphologic and molecular response), whereas patients older than 65 years will start Ponatinib at 30 mg/day, in order to avoid TAEs. Patients will continue treatment with Ponatinib up to day 70 (10 weeks of treatment), except for disease progression, intolerable toxicity, or withdrawal from study. Thereafter: Patients will receive Blinatumomab (minimum 2 cycles, up to a maximum of 5). Patients not achieving a CHR after 2 cycles of Blinatumomab will go off-study. After the 2 cycles of Blinatumomab patients aged 18-65 will be stratified for transplant allocation
Active Comparator: Chemotherapy+Imatinib patients will receive a combination of imatinib and chemotherapy.	Drug: Chemotherapy + Imatinib patients aged 18-65 will receive chemotherapeutic scheme combined with Imatinib. Elderly patients will receive Imatinib plus mild chemotherapy.

Arm

Intervention/Treatment

Experimental: Ponatinib+Blinatumomab

patients will receive induction with ponatinib followed by at least 2 cycles of blinatumomab

Drug: Ponatinib + Blinatumomab

Patients aged 18-65 will receive Ponatinib at the dose of 45 mg/day for the first 22 days and then will reduce the dose to 30 mg (depending on the morphologic and molecular response), whereas patients older than 65 years will start Ponatinib at 30 mg/day, in order to avoid TAEs. Patients will continue treatment with Ponatinib up to day 70 (10 weeks of treatment), except for disease progression, intolerable toxicity, or withdrawal from study. Thereafter: Patients will receive Blinatumomab (minimum 2 cycles, up to a maximum of 5). Patients not achieving a CHR after 2 cycles of Blinatumomab will go off-study. After the 2 cycles of Blinatumomab patients aged 18-65 will be stratified for transplant allocation

Active Comparator: Chemotherapy+Imatinib

patients will receive a combination of imatinib and chemotherapy.

Drug: Chemotherapy + Imatinib

patients aged 18-65 will receive chemotherapeutic scheme combined with Imatinib. Elderly patients will receive Imatinib plus mild chemotherapy.

Outcome Measures

Primary Outcome Measures

Number of patients who are event-free [at 5 months]
event-free survival rate

Eligibility Criteria

Criteria

Ages Eligible for Study:

18 Years and Older

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

Inclusion Criteria:

Signed written informed consent according to ICH/EU/GCP and national local laws.
Newly diagnosed adult B-precursor Ph+ ALL patients.
WHO performance status less or equal to 2.
Age greater or equal to18 years, with no upper age limit.
Renal and hepatic function as defined below:

AST (GOT), ALT (GPT), and AP <2 x upper limit of normal (ULN).
Total bilirubin <1.5 x ULN.
Creatinine clearance equal or greater than 50 mL/min.

Pancreatic function as defined below:

Serum amylase less or equal to 1.5 x ULN and serum lipase less or equal to1.5 x ULN.

Normal cardiac function.
No evidence of CNS leukemia at blinatumomab start.
Negative HIV test, negative hepatitis B (HBsAg) and hepatitis C virus (anti-HCV) test.
Negative pregnancy test in women of childbearing potential.
Bone marrow specimen from primary diagnosis available.

Exclusion Criteria:

History of or current relevant CNS pathology (ongoing grade ≥2 epilepsy, seizure, paresis, aphasia, clinically relevant apoplexia, severe brain injuries, dementia, Parkinson's disease, organic brain syndrome, psychosis).
Impaired cardiac function, including any one of the following:

LVEF <45% as determined by MUGA scan or echocardiogram.
Complete left bundle branch block.
Use of a cardiac pacemaker.
ST depression of >1mm in 2 or more leads and/or T wave inversions in 2 or more contiguous leads.
Congenital long QT syndrome.
History of or presence of significant ventricular or atrial arrhythmia.
Clinically significant resting bradycardia (<50 beats per minute).
QTc >450 msec on screening ECG (using the QTcF formula).
Right bundle branch block plus left anterior hemiblock, bifascicular block.
Myocardial infarction within 3 months prior to starting Ponatinib.
Angina pectoris.

Other clinically significant vascular and heart disease (e.g., congestive heart failure, uncontrolled hypertension, history of labile hypertension, or history of poor compliance with an antihypertensive regimen).
Impairment of gastrointestinal (GI) function or GI disease that may significantly alter the absorption of Ponatinib (e.g., ulcerative diseases, uncontrolled nausea, vomiting, diarrhea, malabsorption syndrome, or small bowel resection).
Uncontrolled hypertriglyceridemia (triglycerides >450 mg/dL).
Taking medications that are known to be associated with Torsades de Pointes and medications or herbal supplements that are known to be strong inhibitors of CYP3A4 within at least 14 days before the first dose of ponatinib.
History of or current autoimmune disease.
Systemic cancer chemotherapy within 2 weeks prior to study.
Known hypersensitivity to immunoglobulins or to any other component of the study drug formulation.
Active malignancy other than ALL with the exception of basal cell or squamous cell carcinoma of the skin, or carcinoma "in situ" of the cervix.
Active infection, any other concurrent disease or medical condition that are deemed to interfere with the conduct of the study as judged by the investigator.
Nursing women or women of childbearing potential not willing to use an effective form of contraception during participation in the study and at least 3 months thereafter or male patients not willing to ensure effective contraception during participation in the study and at least three months thereafter.

Contacts and Locations

Locations

	Site	City	Country
1	Area Vasta N. 5 Ascoli Piceno - S. Benedetto Del Tronto, Presidio Ospedaliero Av5 Osp. Gen. Prov.Le "C.G.Mazzoni" - Uoc Ematologia	Ascoli Piceno	Italy
2	Irccs Oncologico Istituto Tumori Giovanni Paolo Ii - Bari - Uo Ematologia	Bari	Italy
3	Asst Papa Giovanni Xxiii - Ospedale Di Bergamo - Sc Ematologia	Bergamo	Italy
4	As Dell'Alto Adige, Ospedale Centrale Di Bolzano - Ematologia E Centro Trapianto Midollo Osseo	Bolzano	Italy
5	Asst Degli Spedali Civili Di Brescia - Uo Ematologia	Brescia	Italy
6	Aulss 3 Serenissima, Ospedale Dell'Angelo - Mestre - Uo Ematologia	Mestre	Italy
7	Aou Di Modena - Sc Ematologia	Modena	Italy
8	Asl Salerno, Presidio Ospedaliero Tortora Pagani - Ematologia	Pagani	Italy
9	Ao Di Perugia, Ospedale S. Maria Della Misericordia - Ematologia E Trapianto Midollo Osseo	Perugia	Italy
10	Ao Ospedali Riuniti Marche Nord - Ospedale San Salvatore - Pesaro - Uoc Ematologia E Centro Trapianti	Pesaro	Italy
11	Asl Di Piacenza, Ospedale "Guglielmo Da Saliceto" - Ematologia E Centro Trapianti	Piacenza	Italy
12	Università Degli Studi Di Roma "Sapienza" - Dipartimento Di Medicina Traslazionale E Di Precisione - U.O.C. Ematologia	Roma	Italy
13	Ente Ecclesiastico Casa Sollievo Della Sofferenza - San Giovanni Rotondo - Ematologia	San Giovanni Rotondo	Italy
14	Aou Senese - Uoc Ematologia E Trapianti	Siena	Italy
15	Asui Di Udine - Presidio Ospedaliero "Santa Maria Della Misericordia" - Clinica Ematologica	Udine	Italy