Selective inhibition of FLT3 by gilteritinib in relapsed or refractory acute myeloid leukaemia: a multicentre, first-in-human, open-label, phase 1-2 study.

BackgroundInternal tandem duplication mutations in FLT3 are common in acute myeloid leukaemia and are associated with rapid relapse and short overall survival. The clinical benefit of FLT3 inhibitors in patients with acute myeloid leukaemia has been limited by rapid generation of resistance mutations, particularly in codon Asp835 (D835). We aimed to assess the highly selective oral FLT3 inhibitor gilteritinib in patients with relapsed or refractory acute myeloid leukaemia.MethodsIn this phase 1-2 trial, we enrolled patients aged 18 years or older with acute myeloid leukaemia who either were refractory to induction therapy or had relapsed after achieving remission with previous treatment. Patients were enrolled into one of seven dose-escalation or dose-expansion cohorts assigned to receive once-daily doses of oral gilteritinib (20 mg, 40 mg, 80 mg, 120 mg, 200 mg, 300 mg, or 450 mg). Cohort expansion was based on safety and tolerability, FLT3 inhibition in correlative assays, and antileukaemic activity. Although the presence of an FLT3 mutation was not an inclusion criterion, we required ten or more patients with locally confirmed FLT3 mutations (FLT3mut+) to be enrolled in expansion cohorts at each dose level. On the basis of emerging findings, we further expanded the 120 mg and 200 mg dose cohorts to include FLT3mut+ patients only. The primary endpoints were the safety, tolerability, and pharmacokinetics of gilteritinib. Safety and tolerability were assessed in the safety analysis set (all patients who received at least one dose of gilteritinib). Responses were assessed in the full analysis set (all patients who received at least one dose of study drug and who had at least one datapoint post-treatment). Pharmacokinetics were assessed in a subset of the safety analysis set for which sufficient data for concentrations of gilteritinib in plasma were available to enable derivation of one or more pharmacokinetic variables. This study is registered with ClinicalTrials.gov, number NCT02014558, and is ongoing.FindingsBetween Oct 15, 2013, and Aug 27, 2015, 252 adults with relapsed or refractory acute myeloid leukaemia received oral gilteritinib once daily in one of seven dose-escalation (n=23) or dose-expansion (n=229) cohorts. Gilteritinib was well tolerated; the maximum tolerated dose was established as 300 mg/day when two of three patients enrolled in the 450 mg dose-escalation cohort had two dose-limiting toxicities (grade 3 diarrhoea and grade 3 elevated aspartate aminotransferase). The most common grade 3-4 adverse events irrespective of relation to treatment were febrile neutropenia (97 [39%] of 252), anaemia (61 [24%]), thrombocytopenia (33 [13%]), sepsis (28 [11%]), and pneumonia (27 [11%]). Commonly reported treatment-related adverse events were diarrhoea (92 [37%] of 252]), anaemia (86 [34%]), fatigue (83 [33%]), elevated aspartate aminotransferase (65 [26%]), and increased alanine aminotransferase (47 [19%]). Serious adverse events occurring in 5% or more of patients were febrile neutropenia (98 [39%] of 252; five related to treatment), progressive disease (43 [17%]), sepsis (36 [14%]; two related to treatment), pneumonia (27 [11%]), acute renal failure (25 [10%]; five related to treatment), pyrexia (21 [8%]; three related to treatment), bacteraemia (14 [6%]; one related to treatment), and respiratory failure (14 [6%]). 95 people died in the safety analysis set, of which seven deaths were judged possibly or probably related to treatment (pulmonary embolism [200 mg/day], respiratory failure [120 mg/day], haemoptysis [80 mg/day], intracranial haemorrhage [20 mg/day], ventricular fibrillation [120 mg/day], septic shock [80 mg/day], and neutropenia [120 mg/day]). An exposure-related increase in inhibition of FLT3 phosphorylation was noted with increasing concentrations in plasma of gilteritinib. In-vivo inhibition of FLT3 phosphorylation occurred at all dose levels. At least 90% of FLT3 phosphorylation inhibition was seen by day 8 in most patients receiving a daily dose of 80 mg or higher. 100 (40%) of 249 patients in the full analysis set achieved a response, with 19 (8%) achieving complete remission, ten (4%) complete remission with incomplete platelet recovery, 46 (18%) complete remission with incomplete haematological recovery, and 25 (10%) partial remission INTERPRETATION: Gilteritinib had a favourable safety profile and showed consistent FLT3 inhibition in patients with relapsed or refractory acute myeloid leukaemia. These findings confirm that FLT3 is a high-value target for treatment of relapsed or refractory acute myeloid leukaemia; based on activity data, gilteritinib at 120 mg/day is being tested in phase 3 trials.FundingAstellas Pharma, National Cancer Institute (Leukemia Specialized Program of Research Excellence grant), Associazione Italiana Ricerca sul Cancro

Dilepton Production in Nucleon-Nucleon Reactions With and Without Hadronic Inelasticities

We calculate elementary proton-proton and neutron-proton bremsstrahlung and their contribution to the $e^+e^-$ invariant mass distribution. At 4.9 GeV, the proton-proton contribution is larger than neutron-proton, but it is small compared to recent data. We then make a first calculation of bremsstrahlung in nucleon-nucleon reactions with multi-hadron final states. Again at 4.9 GeV, the many-body bremsstrahlung is larger than simple nucleon-nucleon bremsstrahlung by more than an order of magnitude in the low-mass region. When the bremsstrahlung contributions are summed with Dalitz decay of the $\eta$, radiative decay of the $\Delta$ and from two-pion annihilation, the result matches recent high statistics proton-proton data from the Dilepton Spectrometer collaboration.Comment: 1+17 pages plus 11 PostScript figures uuencoded and appended, McGill/93-9, TPI-MINN-93/18-

Observation of Two Narrow States Decaying into Ξc+γ\Xi_{c}^{+}\gamma and Ξc0γ\Xi_{c}^{0}\gamma

We report the first observation of two narrow charmed strange baryons decaying to $\Xi_c^+\gamma$ and $\Xi_c^0\gamma$, respectively, using data from the CLEO II detector at CESR. We interpret the observed signals as the $\Xi_c^{+\prime}(c{su})$ and $\Xi_c^{0\prime}(c{sd})$, the symmetric partners of the well-established antisymmetric $\Xi_c^+(c[su])$ and $\Xi_c^0(c[sd])$. The mass differences $M(\Xi_c^{+\prime})-M(\Xi_c^+)$ and $M(\Xi_c^{0\prime})-M(\Xi_c^0)$ are measured to be $107.8\pm 1.7\pm 2.5$ and $107.0\pm 1.4\pm 2.5 MeV/c^2$, respectively.Comment: 11 pages, postscript file also available through http://w4.lns.cornell.edu/public/CLN

Study of Gluon versus Quark Fragmentation in Υ→ggγ\Upsilon\to gg\gamma and e+e−→qqˉγe^{+}e^{-}\to q\bar{q}\gamma Events at \sqrt{s}=10 GeV

Using data collected with the CLEO II detector at the Cornell Electron Storage Ring, we determine the ratio R(chrg) for the mean charged multiplicity observed in Upsilon(1S)->gggamma events, to the mean charged multiplicity observed in e+e- -> qqbar gamma events. We find R(chrg)=1.04+/-0.02+/-0.05 for jet-jet masses less than 7 GeV.Comment: 15 pages, postscript file also available through http://w4.lns.cornell.edu/public/CLN

Peroxiredoxin II Regulates Effector and Secondary Memory CD8+ T cell Responses

Reactive oxygen intermediates (ROI) generated in response to receptor stimulation play an important role in cellular responses. However, the effect of increased H2O2on an antigen-specific CD8+ T cell response was unknown. Following T cell receptor (TCR) stimulation, the expression and oxidation of peroxiredoxin II (PrdxII), a critical antioxidant enzyme, increased in CD8+ T cells. Deletion of PrdxII increased ROI, S phase entry, division, and death during in vitro division. During primary acute viral and bacterial infection, the number of effector CD8+ T cells in PrdxII-deficient mice was increased, while the number of memory cells were similar to those of the wild-type cells. Adoptive transfer of P14 TCR transgenic cells demonstrated that the increased expansion of effector cells was T cell autonomous. After rechallenge, effector CD8+ T cells in mutant animals were more skewed to memory phenotype than cells from wild-type mice, resulting in a larger secondary memory CD8+ T cell pool. During chronic viral infection, increased antigen-specific CD8+ T cells accumulated in the spleens of PrdxII mutant mice, causing mortality. These results demonstrate that PrdxII controls effector CD8+ T cell expansion, secondary memory generation, and immunopathology

Tau Neutrino Helicity from h±h^{\pm} Energy Correlations

We report a measurement of the magnitude of the tau neutrino helicity from tau-pair events taken with the CLEO detector at the CESR electron-positron storage ring. Events in which each tau undergoes the decay tau -> h nu, with h a charged pion or kaon, are analyzed for energy correlations between the daughter hadrons, yielding |xi| = 2*|h_nu| = 1.03 +/- 0.06 +/- 0.04, with the first error statistical and the second systematic.Comment: 11 pages, postscript file also available through http://w4.lns.cornell.edu/public/CLN

Limit on the Two-Photon Production of the Glueball Candidate fJ(2220)f_{J}(2220) at CLEO

We use the CLEO detector at the Cornell electron-positron storage ring, CESR, to search for the two-photon production of the glueball candidate f_J(2220) in its decay to K_s K_s. We present a restrictive upper limit on the product of the two-photon partial width and the K_s K_s branching fraction. We use this limit to calculate a lower limit on the stickiness, which is a measure of the two-gluon coupling relative to the two-photon coupling. This limit on stickiness indicates that the f_J(2220) has substantial glueball content.Comment: 9 page postscript file, postscript file also available through http://w4.lns.cornell.edu/public/CLN

Study of the Decays B0 --> D(*)+D(*)-

The decays B0 --> D*+D*-, B0 --> D*+D- and B0 --> D+D- are studied in 9.7 million Y(4S) --> BBbar decays accumulated with the CLEO detector. We determine Br(B0 --> D*+D*-) = (9.9+4.2-3.3+-1.2)e-4 and limit Br(B0 --> D*+D-) < 6.3e-4 and Br(B0 --> D+D-) < 9.4e-4 at 90% confidence level (CL). We also perform the first angular analysis of the B0 --> D*+D*- decay and determine that the CP-even fraction of the final state is greater than 0.11 at 90% CL. Future measurements of the time dependence of these decays may be useful for the investigation of CP violation in neutral B meson decays.Comment: 21 pages, 5 figures, submitted to Phys. Rev.

Measurement of B(/\c->pKpi)

The /\c->pKpi yield has been measured in a sample of two-jet continuum events containing a both an anticharm tag (Dbar) as well as an antiproton (e+e- -> Dbar pbar X), with the antiproton in the hemisphere opposite the Dbar. Under the hypothesis that such selection criteria tag e+e- -> Dbar pbar (/\c) X events, the /\c->pkpi branching fraction can be determined by measuring the pkpi yield in the same hemisphere as the antiprotons in our Dbar pbar X sample. Combining our results from three independent types of anticharm tags, we obtain B(/\c->pKpi)=(5.0+/-0.5+/-1.2)