Azacitidine and Lintuzumab in Treating Patients With Previously Untreated Myelodysplastic Syndromes

Phase II Study of 5-azacytidine and Lintuzumab in Myelodysplastic Syndromes (MDS)

RATIONALE: Drugs used in chemotherapy, such as azacitidine, work in different ways to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Monoclonal antibodies, such as lintuzumab, can block cancer growth in different ways. Some block the ability of cancer cells to grow and spread. Others find cancer cells and help kill them or carry cancer-killing substances to them. Giving chemotherapy together with monoclonal antibodies may be a better way to block cancer growth.

PURPOSE: This phase II trial is studying the side effects and how well giving azacitidine together with lintuzumab works in treating patients with previously untreated myelodysplastic syndromes.

OBJECTIVES:

Primary

• To determine the complete response rate of the combination of lintuzumab and azacitidine in patients with myelodysplastic syndromes.

Secondary

• To define the specific toxicities of this regimen.
• To determine the overall response rate.
• To determine the relationship between pretreatment expression of Syk and clinical response.
• To determine whether the investigational agents modulate Syk expression and to correlate drug-induced changes in Syk with response to treatment.
• To provide preliminary data on the biological activity of azacitidine as a demethylating agent (changes in target gene methylation and gene expression, DNMT1 protein expression, global methylation).
• To perform exploratory studies of azacitidine-triphosphate with global DNA methylation.
• To explore the biologic role of microRNA in determining clinical response to this regimen and achievement of the other pharmacodynamic endpoints.

OUTLINE: Patients receive azacitidine IV or subcutaneously once daily on days 1-7 and lintuzumab IV on days 2, 7, 15, and 22 (days 2 and 15 of course 1 only). Treatment repeats every 28 days for 6 courses in the absence of disease progression or unacceptable toxicity. Treatment modifications may apply according to response.

Blood and bone marrow samples are collected periodically for pharmacodynamic studies.

After completion of study treatment, patients are followed up for 5 years.

Eligibility Criteria:

• Age >18 with untreated MDS by FAB or WHO criteria (note: FAB criteria for MDS includes <29% blasts; FAB criteria includes CMML).

• Patients with therapy related disease (t-MDS).

• If the patient has co-morbid medical illness, life expectancy attributed to this must be greater than 6 months.

• Eastern Cooperative Oncology Group (ECOG) performance status <2.

• Must have adequate organ function as defined below:

  • total bilirubin <2.0mg/dL
  • AST(SGOT)/ALT(SGPT) <2.5 X institutional upper limit of normal
  • creatinine <2.0mg/dL
  • NYHA CHF(congestive heart failure)Class II or better

• Women of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence).

• Ability to understand and willingness to sign the written informed consent document.

• CD33 expression is required on at least 25% of left shifted dysplastic myeloid cells, including blasts. This testing will be done on bone marrow aspirate, but for patients whose CD33 expression in this cellular compartment cannot be ascertained, peripheral blood will be allowed to determine this.

Exclusion Criteria:

• Patients who have had chemotherapy or radiotherapy within 6 months (for other cancers) prior to entering the study.
• Patients receiving any other investigational agents or patients that have received other investigational agents within 1 month of enrollment.
• Patients with active central nervous system disease or with granulocytic sarcoma as sole site of disease.
• Patients with history of allergic reactions attributed to compounds of similar chemical or biologic composition to AZA or lintuzumab that are not easily managed are excluded. Patients with hypersensitivity to mannitol are excluded.
• Uncontrolled intercurrent illness including, but not limited to, symptomatic congestive heart failure, unstable angina pectoris, serious cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements. As infection is a common feature of MDS, patients with active infection are permitted to enroll provided that the infection is under control. Myocardial infarction within 6 months prior to enrollment or has New York Heart Association (NYHA) Class III or IV heart failure, uncontrolled angina, severe uncontrolled ventricular arrhythmias, or electrocardiographic evidence of acute ischemia or active conduction system abnormalities.
• Psychiatric conditions that prevent compliance with protocol or consent.
• Pregnant women or women who are breastfeeding are excluded from this study.
• HIV-positive patients on combination antiretroviral therapy are ineligible.
• Patients with serious medical or psychiatric illness likely to interfere with participation in this clinical study.
• Patients with serious medical or psychiatric illness likely to interfere with participation in this clinical study.
• Patients with baseline fibrinogen <100mg/dL, or those with clinically significant disseminated intravascular coagulation, are excluded.
• Patients who require ongoing therapeutic anticoagulation with warfarin, lovenox, or similar agent are excluded. This does not apply to patients on low dose prophylaxis therapy.
• Patients who require ongoing clopidogrel therapy are excluded. In cases where clopidogrel use at screening is subsequently discontinued due to ongoing or future risk of drug and treatment related cytopenias, such patients will be eligible.
• Patients with platelet <10,000/uL who are refractory to platelet transfusion are not eligible (must bump to at least >10,000/uL after transfusion)
• Patients who have previously received lenalidomide or thalidomide are excluded.