Manuscript bioRxiv preprint doi: https://doi.org/10.1101/124263; this version postedClick June here14, 2017. to download The copyright Manuscript holder for this Decitabine preprint (which _ClinicEpigen_4- was not certified by peer review) is the author/funder, who has granted bioRxiv a3-17_CG1_FINAL.docx license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. Click here to view linked References 1 2 3 4 5 1 A multicenter, randomized study of decitabine as 6 7 8 2 epigenetic priming with induction chemotherapy in 9 10 11 3 children with AML 12 13 14 4 15 5 Lia Gore,1 Timothy J. Triche, Jr.,2 Jason E. Farrar,3 Daniel Wai,4 Christophe Legendre,5 16 17 6 Gerald C Gooden,2,5 Winnie S. Liang,5 John Carpten,5 David Lee,6 Frank Alvaro,7 18 19 1 8 9 10 11 20 7 Margaret E. Macy, Carola Arndt, Philip Barnette, Todd Cooper, Laura Martin, Aru 21 22 8 Narendran,12 Jessica Pollard,13 Soheil Meshinchi,14 Jessica Boklan,15 Robert J 23 24 9 Arceci*,4,6,15 and Bodour Salhia*,2,5 25 26 10 27 11 28 12 Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora CO1; Jane 29 13 Anne Nohl Division of Hematology, Keck Medicine of USC and Norris Comprehensive Cancer 30 14 Center, Los Angeles, CA2; Arkansas Children’s Research Institute and University of Arkansas for 31 15 Medical Sciences, Little Rock, AR3; Ron Matricaria Institute of Molecular Medicine, Phoenix, AZ4; 32 16 Translational Genomics Research Institute, Phoenix, AZ5; Sidney Kimmel Comprehensive 33 17 Cancer Center at Johns Hopkins’ University, Baltimore MD6; John Hunter Hospital, New South 34 18 Wales, Australia7; Mayo Clinic, Rochester MN8; Primary Children’s Medical Center and the 35 19 University of Utah, Salt Lake City UT9; Children’s Healthcare of Atlanta, Atlanta GA10; Nationwide 36 20 Children’s Hospital, Columbus OH11; Alberta Children’s Hospital and University of Calgary, 37 21 Calgary, AB, Canada12; Seattle Children’s Hospital13 Seattle, WA and Fred Hutchinson Cancer 38 22 Research Center14, Seattle WA; Phoenix Children’s Hospital, Phoenix, AZ15 39 23 40 24 41 [email protected], [email protected], 42 25 [email protected], [email protected], 43 26 [email protected], [email protected], [email protected], [email protected], 44 27 [email protected], [email protected], 45 28 [email protected], [email protected], [email protected], 46 29 [email protected], [email protected], [email protected], 47 30 [email protected], [email protected], [email protected], [email protected], 48 31 [email protected] 49 32 50 33 *These authors contributed equally to this work. 51 34 52 35 Corresponding Author: Lia Gore, MD 53 36 Center for Cancer and Blood Disorders 54 37 Children’s Hospital Colorado 55 38 13123 East 16th Av, Box B115 56 57 39 Aurora CO 80045 58 40 Tel: 720-777-6458 59 41 Fax: 720-777-7339 60 42 [email protected] 61 62 1 63 64 65 bioRxiv preprint doi: https://doi.org/10.1101/124263; this version posted June 14, 2017. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 1 2 3 4 43 5 ABSTRACT 6 7 8 44 Background: Decitabine is a deoxycytidine nucleoside derivative inhibitor of DNA- 9 10 45 methyltransferases, which has been studied extensively and is approved for 11 12 13 46 myelodysplastic syndrome in adults but with less focus in children. Accordingly, we 14 15 47 conducted a phase 1 multicenter, randomized, open-label study to evaluate decitabine 16 17 48 pre-treatment before standard induction therapy in children with newly diagnosed AML to 18 19 49 assess safety and tolerability and explore a number of biologic endpoints. 20 21 22 23 50 Results: Twenty-four patients were fully assessable for all study objectives per protocol 24 25 51 (10 in Arm A, 14 in Arm B). All patients experienced neutropenia and thrombocytopenia. 26 27 52 The most common grade 3 and 4 non-hematologic adverse events observed were 28 29 53 gastrointestinal toxicities and hypophosphatemia. Plasma decitabine PK were similar to 30 31 32 54 previously reported adult data. Overall CR/CRi was similar for the two arms. MRD 33 34 55 negativity at end-induction was 85% in Arm A versus 67% in Arm B patients. DNA 35 36 56 methylation measured in peripheral blood over the course of treatment tracked with blast 37 38 57 clearance and matched marrow aspirates at day 0 and day 21. Unlike end-point marrow 39 40 58 analyses, promoter methylation in blood identified an apparent reversal of response in 41 42 43 59 the lone treatment failure, one week prior to the patient’s marrow aspirate confirming 44 45 60 non-response. Decitabine-induced effects of end-induction marrows in Arm A were 46 47 61 reflected by changes in DNA methylation and gene expression comparison with matched 48 49 62 paired marrow diagnostic aspirates. 50 51 52 53 63 Conclusions: This first-in-pediatrics trial demonstrates that decitabine prior to standard 54 55 64 combination chemotherapy is feasible and well tolerated in children with newly 56 57 65 diagnosed AML. Pre-treatment with decitabine may represent a newer therapeutic 58 59 66 option for pediatric AML, especially as it appears to induce important epigenetic 60 61 62 2 63 64 65 bioRxiv preprint doi: https://doi.org/10.1101/124263; this version posted June 14, 2017. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 1 2 3 4 67 alterations. The novel biological correlates studied in this trial offer a clinically relevant 5 6 68 window into disease progression and remission. Additional studies are needed to 7 8 9 69 definitively assess whether decitabine can enhance durability responses in children with 10 11 70 AML. This trial was registered at www.clinicaltrials.gov as NCT01177540. 12 13 14 71 AML, epigenetics, pediatrics, pharmacokinetics, pharmacodynamics, 15 Keywords: 16 17 72 promoter methylation, repeat element transcription 18 19 20 73 21 22 23 24 74 BACKGROUND 25 26 27 28 75 Attaining complete response/remission (CR) is currently considered the essential 29 30 76 first step in the effective treatment of acute myelogenous leukemia (AML). Historically, 31 32 77 the most widely used induction therapy included seven days of cytarabine plus three 33 34 78 days of anthracycline (known as “7+3”). With this approach, 75-80% of children with 35 36 79 37 AML achieve CR (1-3). Subsequently, the addition of a third agent such as etoposide to 38 39 80 7+3 (ADE) along with expanded supportive care measures, has led to higher remission 40 41 81 induction rates of approximately 85%. Of patients who do not attain remission, 42 43 82 approximately one-half have resistant leukemia and a substantial proportion will die from 44 45 83 complications of the disease or treatment. Thus, there is a need to develop new 46 47 48 84 treatment strategies to improve outcomes for these patients. 49 50 85 Pediatric tumors have been shown to have lower mutation burdens than adult 51 52 86 tumors and many of these mutations occur in the plethora of known epigenetic 53 54 87 complexes (4). In addition, significant aberrant DNA methylation is also observed in 55 56 57 88 pediatric cancers such as AML including in patients with the poorest risk sub-types (5). 58 59 89 These studies argue for the importance of identifying novel epigenetic therapies that 60 61 62 3 63 64 65 bioRxiv preprint doi: https://doi.org/10.1101/124263; this version posted June 14, 2017. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 1 2 3 4 90 target both histone and/or DNA methylation modifications. Specifically, reversal of 5 6 91 7 promoter DNA hypermethylation and associated gene silencing is an attractive 8 9 92 therapeutic approach in adult cancers. The DNA methylation inhibitors decitabine and 10 11 93 azacitidine are efficacious for hematological neoplasms at lower, less toxic, doses (6). 12 13 94 Experimentally, high doses induce rapid DNA damage and cytotoxicity, which do not 14 15 95 explain the prolonged response observed in adult patients (6). Studies have consistently 16 17 18 96 shown that transient low doses of DNA demethylating agents exert durable anti-tumor 19 20 97 effects on hematological and epithelial tumor cells (6). Moreover, studies have 21 22 98 demonstrated that DNA hypomethylating agents can sensitize resistant cancer cells to 23 24 99 cytotoxic agents in vitro and in vivo (7-15) and can enhance chemosensitivity of human 25 26 27 100 leukemia cells to cytarabine (16). Therefore, pretreatment with a DNA hypomethylating 28 29 101 agent may increase the efficacy of pediatric AML induction therapy (17). However, to 30 31 102 date there are no studies to demonstrate the safety, tolerability, or any signal of efficacy 32 33 103 of decitabine in combination with conventional multi-agent chemotherapy for AML in 34 35 104 36 children.