Omacetaxine for Consolidation and Maintenance in Patients Age ≥ 55 With AML in First Remission: A Pilot Study
Phase: PHASE2
Conditions: Acute Myelogenous Leukemia (AML)
Sponsor: Emory University

Protocol #: Winship2176-11  
Protocol Version:  6.0 Dated, 01/14/2017 
 
 
 
 
 
 
Omacetaxine for Consolidation and 
Maintenance in Patients Age > 55 with AML 
in First Remission: a Pilot Study 
 
 
Winship Cancer Institute of Emory University 
1365C Clifton Rd, Building C 
Atlanta, GA 30322 
 
Principal Investigator:  
Martha Arellano 
Co-Principal Investigator: Hanna Jean Khoury 
Sub-investigators: 
Zhengjia Chen 
 
Manila Gaddh 
 
Leonard Heffner 
 
Amelia Langston 
 
Morgan McLemore 
 
Elliott Winton  
 
Protocol #:  
Winship 2176-11 
 
Protocol Version: 6.0 
Protocol Date: January 14, 2017      
 
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Protocol #: Winship2176-11  
Protocol Version:  6.0 Dated, 01/14/2017 
 
 
 
 
TABLE OF CONTENTS 
 
 
 
 
 
 
 
 
 
 
 
  Page 
Synopsis  -----------------------------------------------------------------------------------------    
3 
1. 
Background -----------------------------------------------------------------------------    
5 
1.1    Acute Myelogenous Leukemia (AML) in older Adults -------------------------   
5 
1.2    Role of High Dose Ara-C (HiDAC) in AML Induction---------------------  
6  
1.3    Consolidation Therapy for Older Patients with AML-----------------------   
6 
            1.4    Role of Maintenance Chemotherapy in AML--------------------------------   
7 
1.5    Omacetaxine for AML and MDS ---------------------------------------------    
7 
1.6    Rationale for the study ----------------------------------------------------------   
8 
2. 
Study Objectives -----------------------------------------------------------------------    
8 
3. 
Research Design and Methods --------------------------------------------------------   
9 
            3.1  
Patient Selection ---------------------------------------------------------------   
9 
 
 
3.1.1 Inclusion Criteria -------------------------------------------------------   
9 
 
 
3.1.2 Exclusion Criteria -------------------------------------------------------   
9 
 
3.2  
Patient Enrollment and Registration ----------------------------------------   
10 
 
3.3 
Specific Methods and Protocol Description -------------------------------   
10 
 
 
3.3.1 Plan of Treatment -------------------------------------------------------  
10 
 
 
3.3.2 Patient Evaluations and Definition of Response --------------------  
12 
 
 
3.3.3 Safety Assessment and Study Tests ----------------------------------   
13 
 
 
3.3.4 Dose Modifications and Stopping Rules-----------------------------   
13 
 
 
3.3.5 Correlative Studies-------------------------------------------------------  
14 
 
3.4 
Study Drugs 
 
 
3.4.1    Omacetaxine------------------------------------------------------------ 
15  
4. 
Data Collection --------------------------------------------------------------------------  
16 
5.  
Adverse Event Reporting and Safety Monitoring ----------------------------------   
16 
 
5.1.  
Data Safety Monitoring Plan  -------------------------------------------------   
17 
6. 
Statistical Considerations --------------------------------------------------------------   
18 
7. 
References --------------------------------------------------------------------------------  
19 
 
Appendix A:  The World Health Organization Classification of Myeloid Neoplasms---  21 
Appendix B:  ECOG Performance Status-------------------------------------------------------  22  
Appendix C:  Eligibility Check List and Registration Documents -------------------------   23 
Appendix D:  Evaluations During Induction---------------------------------------------------   24 
Appendix E:   Evaluations During Consolidation----------------------------------------------  25 
Appendix F:   Evaluations During Maintenance-------------------------------------26 
Appendix G:   Comorbidity Scoring-----------------------------------------------------------  
27 
Appendix H:   Quality of Life Questionnaire --------------------------------------------------  28 
Appendix I:   Response Criteria------------------------------------------------------------------  31 
Appendix J:  Omacetaxine Investigator’s Brochure (see embedded document)---------- 32 
 
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Apenndix K:  Omacetaxine Package Insert and Injection Worksheet (see embedded document) 
-------------------------------------------------------------------------- 
33 
Appendix L: Instructions for Omacetaxine Injection (see embedded document) -------- 34 
 
Appendix M: SAE Reporting and AE Log-------------------------------------------------         35 
 
SYNOPSIS 
 
Title: 
• Pilot Study of Omacetaxine for Consolidation and Maintenance for Patients Age > 55 with 
AML in First Remission. 
 
Objectives: 
Primary Objectives: 
• To assess the safety and tolerability of delivering omacetaxine for consolidation in adult 
patients age 55 and older with acute myelogenous leukemia (AML) in first complete 
remission following induction chemotherapy.  
• To assess the safety and tolerability of delivering omacetaxine for maintenance in adult 
patients age 55 and older with acute myelogenous leukemia (AML) in first complete 
remission following 3 consolidation courses with omacetaxine.  
Secondary Objectives: 
• To assess the duration of remission. 
• To evaluate disease-free survival (DFS). 
• To evaluate overall survival (OS). 
• To assess for minimal residual disease (MRD) by WT-1 PCR during consolidation and 
maintenance therapy with omacetaxine. 
Treatment Plan: 
The induction time will be the screening period for the study. Those who achieve 
remission and are willing and able to proceed with OMA consolidation/maintenance will 
continue onto the investigational part of the study. 
Screening:  Patients will receive one to two induction courses according to investigator 
discretion, with a 3+7 regimen (cytarabine/Ara-C and anthracycline) followed by up to one 
course of dose-adjusted high dose cytarabine.  Each induction course consists of: 
• Ara-C 100mg /m2/dose  by continuous infusion daily for 7 days. 
• An anthracycline; either daunorubicin , idarubicin or mitoxantrone at standard 
doses daily for 3 days, starting on day 1. 
 
 
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The second induction will consist of dose-adjusted  high dose Ara-C alone (1-1.5grm/m2 Q12 
hrs on day 1, 3, and 5, per standard of care).  The timing for initiation of the second induction 
depends upon results of marrow done 14-21 days after the first induction according to standard 
of care practice. 
• Patients who do not achieve remission at the conclusion of 2 inductions will be 
considered screen failures and offered alternative therapies. 
 
Consolidation:  
• Omacetaxine 1.25 mg/m² sub-cutaneously twice daily for 5 consecutive days 
every 28 (± 8) days for a total of 3 cycles.  
 
 
Maintenance: 
• Subjects in continuous remission after 3 cycles of consolidation with omacetaxine will 
receive maintenance omacetaxine 1.25mg/m2 twice daily for 3days, every 28 days, for up 
to 6 cycles.  
 
Sample size and patient selection:  
• Screening: 45 patients with newly diagnosed, untreated AML eligible for induction 
chemotherapy. Patients who received 1-2 cycles of hypomethylating therapy for 
cytoreduction are also eligible. 
 
• Consolidation/maintenance: 15 patients in first complete remission after 2 inductions.  
 
Assessment of response:  
• Bone marrow biopsy and aspirate will be obtained at day 14-21 of the 1st cycle, and at day 
28 or at count recovery, whichever occurs first.  
 
• Prior to each consolidation cycle, responses will be evaluated with a complete blood count 
(CBC) and bone marrow aspiration/biopsy to document continued remission.  
 
• Bone marrow aspirate to confirm continuous remission will be obtained every 3 months 
during maintenance, and as clinically indicated thereafter. 
 
Statistical Methods:  
• This study is an open label, pilot study. Continuous data will be described using descriptive 
statistics (n, mean, median, minimum, and maximum) while discrete data will be described 
using frequency counts and percentages.  
 
Time line: 2-3 years, based on previous accrual in the target population. 
 
 
 
 
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1. BACKGROUND: 
1.1 
Acute Myelogenous Leukemia (AML) in older Adults 
Outcomes of older patients with AML are poor due to chemotherapy-related toxicity and 
inherent resistant disease.  Despite advances in supportive care, there has been no significant 
progress in the outcomes of these patients. In patients age > 55, standard anti-leukemic 
induction chemotherapy (anthracycline + cytarabine 100-200 mg/m2/d for 7 -10 days) yields 
complete remission (CR) rates ranging from 38-48% with average early mortality of 30% 
(Table 1).   
Table 1. Safety and efficacy of induction chemotherapy in patients with AML > 55. 
Study Group 
Patients 
CR (%) 
Early death 
(%) 
AMLCG1 
511 
39-42 
27-34 
BMRC2 
636 
46-48 
30-52 
CALGB3 
556 
41-47 
31-54 
SECSG4 
111 
53 
20 
EORTC-LCG-
HOVON5 
489 
38-47 
6-15 
 
Induction with single agent chemotherapy results in comparable CR rates and overall lower 
early mortality rates (Table 2), but effects on relapse-free and overall survivals  do not seem to 
have improved using these agents.  
Table 2. Safety and efficacy of induction with single agent chemotherapy in AML. patients > 
55. 
Treatment  
Patients 
CR (%) 
Early death 
(%) 
Clofarabine6 
112 
38 
10 
Decitabine7 
55 
24 
4 
Laromustine8 
104 
32 
18 
Low dose Ara-C 9 
102 
18 
26 
  
Trials for older AML patients randomizing standard remission induction (i.e., anthracycline-
containing) chemotherapy versus either palliative therapy10 or less intensive chemotherapy 
(low dose Ara-C, LDAC) 11 have demonstrated a survival advantage for those patients who 
received the intensive induction regimen. In the study performed by Tilly et al in patients > 65 
years old, 87 patients were randomized to receive either LDAC 10 mg/m2 SC every 12 hours 
for 21 days or standard chemotherapy induction with rubidazone (a daunorubicin-derived 
agent) 100 mg/m2 IV for 4 days plus cytarabine 200 mg/m2 IV for 7 days. The combination 
chemotherapy arm was associated with a higher CR rate (52% versus 32%), and a trend toward 
improved survival (12.8 months versus 8.8 months); albeit at the cost of 31% early death rate 
vs. 10% for the lower dose arm.  
 
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Based on data from these 2 randomized trials, anti-AML induction chemotherapy 
appears to be the best approach to induce remission in carefully selected, older fit 
patients with newly diagnosed AML. 
 
1.2     Role of High Dose Ara-C (HiDAC) in the AML induction regimen. 
High dose cytarabine (HiDAC, doses > 1.5 g/m2/d) administered during induction results in 
improved recurrence-free and overall survival in younger AML patients < 60,12 but is 
associated with increased toxicities in older patients 13,14. We have recently reported on the 
safety and efficacy of modified HiDAC induction for newly diagnosed patients > 60 with 
AML (Arellano et al. ASCO 2010). HiDAC induction was well-tolerated, associated with high 
CR rates (69%), and comparable early mortality to standard dose cytarabine induction (19%). 
In our series, 37/59 (63%) patients were able to receive the 2 planned inductions. Of the 41/59 
(69%) that achieved remission, 6, 11, and 10 patients received 1, 2, and 3 consolidations with 
HiDAC, respectively.  However, despite high initial CR rate (69%) and the delivery of 
standard consolidation in 80%, the median relapse-free survival was 11 months, and 
most patients died from relapsed leukemia.  Therefore, exploring alternative consolidation 
regimens is desirable. Since the current study opened, we have learned that prospectively, our 
patients did not tolerate the 2 consecutive cycles of modified HiDAC/daunorubicin due to 
cardiac toxicity, and have amended the protocol to limit induction to only 1 cycle of standard  
infusional cytarabine 100mg/m2 over 24hrs. daily x 7 days and an anthracycline (daunorubicin, 
idarubicin, or mitoxantrone at standard doses). At count recovery or sooner if residual 
leukemia is present at the end of induction, 1 cycle of dose-adjusted high dose cytarabine can 
be administered (1-1.5gm/m2 IV Q12hrs. on days 1,3, and 5, per standard of care).   
 
1.3 
Consolidation Therapy for Older Patients with AML. 
The optimal consolidation regimen for older adults with AML in remission is unknown. The 
Cancer and Leukemia Group B (CALGB) defined repeated cycles of high dose cytarabine 
(3g/m2 IV every 12hrs on days 1, 3, and 5, repeated every 28 days) as the standard 
consolidation regimen for younger patients with AML in remission, based on a randomized 
trial comparing four courses of cytarabine at one of three doses: 100 mg/m2 of body-surface 
area per day for five days by continuous infusion, 400 mg/m2 per day for five days by 
continuous infusion, or 3 g/m2 in a 3-hour infusion every 12 hours (twice daily) on days 1, 3, 
and 5 15. The benefit of the high dose cytarabine consolidation predominantly extended to 
younger patients with core binding factor AML, although those with normal cytogenetics 
derived a lesser benefit16. The trial, however did not show a benefit for patients age > 60, and 
only 29% of patients age > 60 received the intended cycles of high dose cytarabine. More 
recently, the German-Austrian AML Study Group carried out a clinical trial randomizing 
patients age 61 and older in fist remission from AML after 2 cycles of induction and one 
consolidation, to either a second intensive consolidation (idarubicin 12mg/m2 IV days 1-3 and 
etoposide 100mg/m2 IV on days 1-5) or a 1-year oral maintenance therapy (idarubicin 5mg po 
on days 1, 4, 7, 10, and 13; etoposide 100mg po on days 1 and 13; repeated on day 29 for 12 
courses). Analysis according to second randomization on an intention-to-treat basis revealed a 
statistically significant lower cumulative incidence of relapse (P= 0.005) in patients assigned to 
the intensive second consolidation compared to those assigned to the oral therapy. This 
translated into a statistically significant better survival (P= 0.04) with estimated median 
 
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survival times from second randomization of 22.3 and 14.3 months in the intensive vs. oral 
arm, respectively. However, this trial concluded that while a second intensive consolidation 
was beneficial, it could only be extended to the fraction of patients who could be randomized 
after remission17.  Thus better, more tolerable consolidation regimens are needed for older 
patients with AML who achieve remission. 
 
 
1.4      Role of maintenance chemotherapy in AML 
The role of maintenance therapy in AML is undefined. Several trials have shown no difference 
in survival between AML patients in first complete remission who receive protracted 
maintenance regimens vs. no maintenance or transplantation. Maintenance chemotherapy is 
therefore not part of standard AML therapy at the present time. A Cancer and Leukemia Group 
B (CALGB) study showed that patients who received maintenance therapy for 8 months versus 
3 years had no significant differences in relapse rate or overall survival 3. Another study 
showed that maintenance chemotherapy after intensive early consolidation treatment did not 
prolong survival 18. Low–dose cytarabine maintenance therapy may prolong disease–free 
survival but does not improve survival in older patients with AML 5. A Japanese study 
comparing three cycles of consolidation with maintenance to four cycles of consolidation 
without maintenance19 found no statistical difference in the disease-free or overall survival 
rates between the two arms. A limitation may be that no studies have examined identical 
consolidation regimens followed by a randomization to maintenance or no maintenance 
chemotherapy. In this study, we are investigating the safety and tolerability of an active 
and well-tolerated agent for maintenance therapy in older patients with AML. 
 
1.5      Omacetaxine for AML and MDS 
Omacetaxine, an alkaloid agent derived from the bark of the Chinese evergreen tree, 
Cephalotaxus harringtonia, has activity in AML as single agent and in combination with other 
active agents. The mechanism of action of omacetaxine differs from conventional 
chemotherapy, primarily by inhibiting protein synthesis and does not appear to share cross-
resistance with other anti-leukemic agents. In heavily pre-treated relapsed AML patients, using 
single agent omacetaxine showed 3-50% responses 20, 21 and 39 -83% used in combination for 
newly diagnosed AML22-23 .  The activity in older AML patients was 39-47% (advanced MDS 
and RAEB-t) 24.  Wu et al. reported on 32 patients (25 with advanced MDS and 7 with t-AML) 
who enrolled in a study to evaluate the efficacy and toxicity of the low-dose cytarabine and 
omacetaxine in combination with granulocyte colony-stimulating factor (G-CSF) (CHG 
protocol) in patients with advanced myelodysplastic syndromes (MDS) or MDS-transformed 
into acute myeloid leukemia (t-AML). All the patients received the CHG regimen comprising 
low-dose cytarabine (25 mg/day by intravenous continuous infusion on days 1-14), 
omacetaxine (1 mg/day, by intravenous continuous infusion on days 1-14), and G-CSF (300 
mcg/day by subcutaneous injection on days 0-14. The overall response rate was 71.9% after 
the administration of one course of the CHG regimen. Of the 32 patients, 15 (46.9%) achieved 
complete remission (CR) and 8 (25%) achieved partial remission (PR). Among the 7 AML 
patients, 5 achieved CR and 2 achieved a PR. This regimen was followed by a post-remission 
therapy that included conventional chemotherapy, when CR was achieved. The median overall 
survival (OS) was 18.2 months. There were no statistically significant differences for CR, PR, 
and OS when the patients were grouped by age, % marrow blasts, and karyotypes. No 
 
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treatment-related deaths were observed. Myelosuppression was mild to moderate, and no 
severe non-hematological toxicity was observed24. 
Between 04/2007 and 04/2009, we enrolled 9 patients with advanced phase CML and the 
T315I mutation on the CGX635-CML-202 clinical trial and observed acceptable tolerability at 
a dose of 1.25 mg/m² sub-cutaneously twice daily for 14 consecutive days. The regimen was 
administered every 28 (±3) days on an outpatient basis. The treatment with omacetaxine was 
very well tolerated in patients up to age 79, and the drug was administered for a median 
duration of 4.5 months (range, 2-28). Data from ChemGenex shows that the median number of 
cycles administered on this study was 4, and the median days the drug was given per cycle was 
11 days.  
The anti-leukemic activity as well as the tolerability of omacetaxine at the 1.25mg/m2 dose 
makes this drug an attractive alternative for consolidation and maintenance in older 
AML patients. 
 
1.6      Rationale for the study 
The outcome of older patients with AML is dismal with standard anti-leukemic chemotherapy, 
and only a minority of those patients can proceed with curative allogeneic stem cell 
transplantation. Despite good initial responses (CR 50-70%) with anti-leukemic induction 
chemotherapy, half of all patients will relapse within a year and 80% would have relapsed by 2 
years. Therefore, alternative consolidations are needed. Given that omacetaxine is an active 
anti-leukemic agent that is well tolerated, we propose to conduct a prospective pilot study 
exploring safety and tolerability of omacetaxine to treat minimal residual disease in the form of 
consolidation and maintenance for patients age 55 and older with newly diagnosed AML in 
first complete remission. This trial is a necessary step for an efficacy phase II trial. 
 
 
2. STUDY OBJECTIVES  
Primary Objectives: 
• To assess the safety and tolerability of delivering omacetaxine for consolidation in adult 
patients age 55 and older with acute myelogenous leukemia (AML) in first complete 
remission following induction chemotherapy.  
• To assess the safety and tolerability of delivering omacetaxine for maintenance in adult 
patients age 55 and older with acute myelogenous leukemia (AML) in first complete 
remission following 3 consolidation courses with omacetaxine.  
Secondary Objectives: 
• To assess the duration of remission. 
• To evaluate disease-free survival (DFS). 
• To evaluate overall survival (OS). 
• To assess for minimal residual disease (MRD) during consolidation and maintenance 
therapy with omacetaxine. 
 
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3. RESEARCH DESIGN AND METHODS:  
3.1 Patient Selection: 
3.1.1 Inclusion Criteria:  
1. Diagnosis of AML including de novo, secondary, or with an antecedent hematologic 
disorder [AHD] according to the World Health Organization (WHO) criteria25 
(Appendix A). 
2. Age > 55 years. 
3. Patient eligible for standard induction chemotherapy based on ECOG PS and vital 
organ function at the discretion of the treating physician. 
4. Patients who received 1-2 cycles of hypomethylating therapy (decitabine azacitidine) 
are eligible. 
5. Provide signed written informed consent. 
6. Be able to comply with study procedures and follow-up examinations. 
7. Be non-fertile or not pregnant or lactating & agree to use birth control during the study 
through the end of last treatment visit. 
8. Adequate renal and hepatic function at the time of second registration: 
a. Total bilirubin < 1.5 x institutional Upper Limit of Normal (ULN); and 
b. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) < 2.5 x 
ULN; and 
c. Serum creatinine < 1.2 times the upper limit of normal. 
9. ECOG performance < 2 (Appendix B) at the time of second registration: 
10. Patients with a history of carcinoma in remission, on no therapy or on hormonal 
therapy for the adjuvant treatment of breast carcinoma or prostate carcinoma are 
included in the study.  
 
3.1.2  Exclusion Criteria: 
1. Diagnosis of acute promyelocytic leukemia (APL, French-American-British [FAB] 
classification M3 or WHO classification of APL with t (15;17)(q22;q12), (PML/RARa 
and variants). 
2. Prior treatment with omacetaxine  
3. Relapsed or refractory AML. 
4. Investigational agent received within 30 days prior to the first dose of study drug. If 
received any investigational agent prior to this time point, drug-related toxicities must 
have recovered to Grade 2 or less prior to first dose of study drug. 
5. Psychiatric disorders that would interfere with consent, study participation, or follow-
up. 
6. Systemic fungal, bacterial, viral, or other infection not controlled (defined as exhibiting 
ongoing signs/symptoms related to the infection and without improvement, despite 
appropriate antibiotics or other treatment). 
7. Any other severe concurrent disease, or have a history of serious organ dysfunction or 
disease involving the heart, kidney, liver, or other organ system that may place the 
patient at undue risk to undergo the proposed therapy. This includes uncontrolled 
hypertension and uncontrolled diabetes, as cases of life threatening hyperglycemia have 
been reported (using continuous infusion at higher doses of omacetaxine). 
8. Active carcinoma requiring systemic chemotherapy or radiation therapy. 
 
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3.2. Patient Enrollment and Registration: 
Patients will be pre-screened in the hospital (Emory University Hospital) or the out patient 
clinic at the Winship Cancer Institute of Emory University. All patients of age 55 and older 
with newly diagnosed AML deemed eligible for induction chemotherapy by the judgment of 
the treating hematologist will be offered to participate in the study. The primary leukemia 
physician (co-investigator) will discuss the study and counsel patient and family. The 
objectives of the study, procedures, alternative therapies and potential risks and benefits of 
participation will be explained. Eligible patients will sign a consent form approved by the 
Emory University Institutional Review Board (IRB). Protocol registration/screening 
procedures and eligibility checklist will be completed at the time of enrollment (Appendix C) 
will be completed. The protocol registration form, eligibility checklist and signed IRB-
approved consent form will be collected and stored in a specifically designed clinical research 
area.  
 
3.3 Specific Methods and Protocol Description:  
 
3.3.1 Plan of Treatment:  
Patients meeting inclusion criteria will start therapy as detailed below and as summarized in 
the Figure: 
       
 
 
 
 
 
 
 
 
 
 
 
 
A. Induction: 
Induction consists of 1 to 2 courses consisting of the following agents:  
Cycle #1: Cytarabine at 100mgm2/dose via continuous infusion daily for 7 days, starting on 
day 1. 
Daunorubicin, idarubicin, or mitoxantrone at standard dosing  daily for 3 days, starting on day 
1.  
Cycle #2: Cytarabine 1- 1.5gm/m2/dose IV twice daily on days 1, 3 and 5. 
• 
Study specific evaluations during induction (See Appendix D) 
 
B. Consolidation: 
AML 55 or > 
Eligible for 
induction 
chemotherapy 
C
O
N
S
E
N
T 
2Inductio
n courses 
Omacetaxine 
consolidations 
x3 
NO CR 
CR 
Omacetaxine 
maintenance 
 X6 
R
E
G
I
S
T
E
R 
Off stufy 
Bone marrow aspirate 
Screening period 
 
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• Omacetaxine 1.25 mg/m² sub-cutaneously twice daily for 5 consecutive days 
every 28 (± 8) days for 3 cycles, provided that prior to the next planned 
treatment cycle, the patient’s absolute neutrophil count (ANC) recovers to > 1 x 
109/L and the platelet count recovers to > 100 x 109/L.  Patients with history of 
or suspected MDS prior to AML who fail to recover their ANC and platelets 
after induction chemotherapy, may start omacetaxine upon recovery to baseline 
pre-AML ANC and platelet count. Omacetaxine can be administered at 
Emory/Winship Cancer Institute or by self- injection at home. 
• Evaluations during consolidation ( see Appendix E) 
 
C. Maintenance: 
• Patients in continuous remission after 3 cycles of consolidation will receive 
maintenance omacetaxine 1.25mg/m2 twice daily for 3 days, every 28 days for 
up to 6 cycles, provided that prior to the next planned treatment cycle, the 
patient’s absolute neutrophil count (ANC) recovers to > 1 x 109/L and the 
platelet count recovers to > 100 x 109/L. .  Patients with history of MDS prior to 
AML who fail to recover their ANC and platelets after induction chemotherapy, 
may start omacetaxine upon recovery to baseline pre-AML ANC and platelet 
count. Omacetaxine can be administered at Emory/Winship Cancer Institute or 
by self- injection at home. 
• Evaluations during maintenance ( see Appendix F) 
 
D. Supportive Care (these guidelines are not protocol requirements as these as standard 
of care practices):   
• Standard anti-microbial prophylaxis will be instituted for every patient enrolled in 
this study. Suggestions include: anti-viral (acyclovir or valacyclovir), anti-
bacterial (fluoroquinolone, doxycycline, or standard alternative) and anti-fungal 
(azole  or micafungin) prophylaxis will be initiated at the onset of neutropenia  
according to our institutional standard. Patients experiencing fever will be 
treated according to institutional practice, with blood cultures, imaging of 
suspected areas of infection, and empiric antibiotics targeted at the suspected 
cause of fever.  
• Steroids may be used empirically to prevent a systemic inflammatory response 
syndrome (SIRS) during the first 5 days of both induction cycles, at the 
discretion of the treating physician. 
• Hydroxyurea will be used to reduce the WBC to < 30,000, or a level considered 
safe by the treating physician, prior to initiating induction therapy. Patients may 
undergo leukapheresis if deemed necessary by the treating physician in patients 
believed to be experiencing leukostasis, based on clinical suspicion. 
• Tumor lysis prophylaxis utilizing intra venous fluids and allopurinol (300mg/ day 
po) or rasburicase (variable dose) will be instituted per standard of care. 
• Hematopoietic growth factors may be used at the discretion of the treating 
physician to accelerate count recovery after induction therapy in patients who 
have clearance of AML at day 14-21. 
 
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• Disseminated intra-vascular coagulation (DIC) will be treated based on our 
institutional practice, with transfusion of fresh frozen plasma, cryoprecipitate, 
and platelets, to prevent and/or treat bleeding complications. 
• Patients with diabetes should have their blood glucose monitored and controlled 
due to the risk of life-threatening hyperglycemia with omacetaxine. 
 
3.3.2  Patient Evaluations and Definition of Response: 
• All patients will undergo standard of care pre-treatment testing that includes 
echocardiogram and baseline laboratory testing according to standard of care.  
• A comorbidity score will be determined for all patients at diagnosis and at start of 
consolidation (using the co-morbidities listed in Appendix G). 
• A Quality of Life Questionnaire (appendix H) will be obtained at baseline, start of 
consolidation and prior to each subsequent course of consolidation and 
maintenance. Data from these questionnaires will be reported descriptively. 
• Disease status will be assessed by a bone marrow aspirate and biopsy upon count 
recovery following the induction, monthly during consolidation and quarterly 
(every 3 months) during maintenance therapy.  Response to therapy will be 
classified according to criteria published by the International Working Group on 
Myeloid Malignancies 25 (Appendix I) and defined as follows: 
• Complete Remission (CR): Normocellular marrow with < 5% blasts, 
absence of auer rods and of any unique phenotype identical to what was 
found in the pretreatment specimen, with ANC > 1 x 10 9/L and platelet 
count > 100 x 109/L, and transfusion independence, as well as no residual 
evidence of extramedullary AML. 
• Complete Response with incomplete blood count recovery (CRi): Meets 
criteria for CR above, except for residual neutropenia (ANC < 1 x 109/L) or 
thrombocytopenia (platelets < 100x109/L)  
• Complete Response with incomplete platelet recovery (CRp): Meets 
criteria for CR above, but platelets are < 100x109/L. 
• Cytogenetic Complete Remission (CRc): Disappearance of cytogenetic 
abnormalities thought to be associated with the AML. 
• Molecular Complete Remission (CRm): Disappearance of molecular 
abnormalities thought to be related to the AML. 
• Treatment failure:  
• Resistant disease: Patient survives > 7 days post-chemotherapy and 
has persistent AML in blood or bone marrow. 
• Aplasia: Patient survives > 7 days post-chemotherapy, but dies 
while cytopenic, with an aplastic bone marrow. 
• Morphologic relapse: Reappearance of blasts post-chemotherapy in 
peripheral blood or bone marrow. 
• Molecular/cytogenetic relapse: Reappearance of molecular or cytogenetic 
abnormality. 
• Clearance of Leukemia at the day 14 marrow: < 5% blasts in a 
hypocellular marrow (<15% cellularity). 
 
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• Overall survival (OS): Time from entry onto trial until death from any 
cause. 
• Relapse free survival (RFS): Time from Remission (CR, CRi, CRp) until 
disease relapse or death from any cause. 
• Event free survival (EFS): Time from entry onto trial to treatment 
failure/relapsed disease, or death from any cause. 
• Remission duration: Time from date of CR (or CRp, CRi) until disease 
relapse.  
 
3.3.3  Safety Assessment and Study Tests:  
Toxicities will be monitored by history, physical examination, and laboratory monitoring 
(CBC, serum chemistries to include renal and liver function tests) weekly during consolidation 
and monthly during maintenance according to standard of care (Appendices D-F). Toxicity 
will be assessed according to the NCI Common Toxicity Criteria Version 4.0 (available at the 
NCI web site http://ctep.cancer.gov/reporting/ctc.html). Adverse events will be monitored on 
an ongoing basis. No AEs will be collected during the screening period (the time from 
diagnosis to completion of the standard of care inductions). 
 
3.3.4 Dose Modifications and Stopping Rules: 
A. Omacetaxine  
• Hematological toxicity: 
• The following table summarizes dose adjustments for hematological toxicity 
during consolidation and maintenance with Omacetaxine and are based on 
time to count recovery to < grade 2 hematological toxicity. Hematologic 
toxicity only refers to WBC/neutrophils and platelets and not 
hemoglobin/hematocrit, given that anemia is expected and may not resolve 
after chemotherapy regardless of AML-status. Dose-reductions and delays 
do not apply to anemia. 
 
Time to resolution to 
< grade 2 hematologic 
toxicity 
(days) 
 
 
Action 1 
Action 2: 
Hematologic toxicity after 1st dose 
reduction 
<  36 
 
No dose reduction 
No dose reduction 
> 36 and < 50  
20% dose reduction, i.e. omacetaxine 1.25 mg/m² sub-
cutaneously twice daily for 4 days during consolidation, or 
1.25mg/m2 twice daily for 3 days during maintenance  
Additional 25%  dose reduction, i.e. 
omacetaxine 1.25 mg/m² sub-cutaneously 
twice daily for 3 days during consolidation, 
or 1.25mg/m2 twice daily for 2 days during 
maintenance  
 
 
> 50 
Perform bone marrow aspirate and biopsy. If relapse – patient 
will be taken off study. If hypoplastic marrow (cellularity < 
10%), reassess after 2 weeks.  
 If recovery achieved within 2 weeks post-marrow 
assessment, resume omacetaxine after 60%  dose reduction; 
i.e. omacetaxine 1.25 mg/m² sub-cutaneously twice daily for 
3 days during consolidation, or 1.25mg/m2 twice daily for 2 
days during maintenance 
If no recovery 2 weeks post-marrow assessment,  patient will 
be taken off study. 
 
 
No further dose reduction. Patient will be 
taken off study 
 
 
 
• Non-hematological toxicity: 
 
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o Patient with grade III-IV non-hematological toxicity (deemed at least “possibly” 
related to omacetaxine) will have study drug held until toxicity has recovered to 
grade 1 or less. Treatment may resume after 20% dose reduction.  
 
o Patient who develop grade II non-hematological toxicity that is related to 
omacetaxine will have study drug held at treating physician’s discretion, until 
toxicity has recovered to grade 1 or less. Treatment will resume after 20% dose 
reduction.  
 
o If grade III-IV non-hematological toxicity recurs after dose-reduction, the patient 
will discontinue protocol therapy.  
 
o If grade III-IV non-hematological toxicity does not resolve to grade 1 or less by day 
36 of therapy with omacetaxine, then patient will be taken off study.  
 
B. Cytarabine 
The following guidelines are not protocol requirements given that patients are 
receiving Institutional standard induction.  
Doses of cytarabine can be reduced during the second induction in cases of 
decrease in the calculated creatinine clearance > 20% but less than 50%.  HiDAC 
will be discontinued and patient taken off study if neurotoxicity occurs at any time 
during HiDAC therapy.  
  
C. Daunorubicin, Idarubicin, or mitoxantrone 
The following guidelines are not protocol requirements given that patients are 
receiving Institutional standard induction.  
• Drug will be withheld and patients will be withdrawn from the study, if they 
experience a clinically significant decrease in left ventricular ejection 
fraction, leading to a diagnosis of symptomatic congestive heart failure. 
• Adjustments for hepatic and renal dysfunction will conform to 
recommendation from the package inserts and standard practice. 
 
D. Stopping Rules 
• Omacetaxine will be discontinued in cases of  
• Delay in recovery of ANC to > 1,000/mcL and platelets to > 
100,000/mcL or to baseline ANC and platelets (for patients with 
history of underlying MDS) after 50 days. 
• Grade III-IV irreversible non-hematological toxicity attributable to 
omacetaxine 
• Recurrence of grades III-IV non-hematological toxicities after dose-
reduction. 
• Recurrent leukemia. 
• Patient’s or treating physician’s request. 
 
3.3.5. Correlative studies 
 
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Blood and marrow aspirates (and biopsies when indicated) will be obtained at diagnosis, prior 
to each cycle of consolidation and every 3 months during maintenance therapy. 
• Monitoring MRD using WT1 transcript during consolidation and 
maintenance therapy with omacetaxine.  
• Tissue acquisition for future studies of AML among older adults. 
• In cases where a marrow was obtained at Emory to establish the AML 
diagnosis, prior to enrolling on the study, study marrow can be waived if 
sufficient circulating blasts are present in the peripheral blood.  
• In cases where the presence of disseminated intravascular coagulation (DIC) 
due to AML places the patient at risk of bleeding, marrow collection can be 
waived and instead peripheral blood collection will suffice for baseline 
collection. 
 
 
3.4.  Study Drugs: 
3.4.1 Omacetaxine: 
Generic Name: Omacetaxine,  Homoharringtonine, NSC-141633 
Chemical Name: Cephalotaxine,4-methyl-2-hydroxy-2-(4-hydroxy-4-methylpentyl) 
butanedioate ester 
Formula: C29 H39 N O9 
Molecular Weight: 545.6 g/mo 
 
 
Drug description: 
Omacetaxine is a cephalotaxine ester alkaloid derived from the plant Cephalotaxus fortunei. 
Cephalotaxines have the empirical composition C18H21NO4 and contain a 
methylenedioxypheno group, a secondary hydroxyl group, double bond and a vinyl methoxyl 
group. A variety of esters of cephalotaxine are known, and the two which have been 
investigated clinically are harringtonine, ester-2 and homoharringtonine, ester-3. Omacetaxine 
differs from harringtonine in having a methylene group inserted in the side chain. There are no 
known drug incompatibilities. A summary of chemistry, manufacturing, pharmacokinetics and 
toxicology is supplied in the Investigator’s Drug Brochure. 
 
 
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Mechanism of action: 
Omacetaxine inhibits protein synthesis and induces differentiation and apoptosis. 
 Details are in the investigator’s brochure. Kinetic studies of the effects of the 
agent on L-1210 cells showed a marked inhibition of thymidine incorporation, 
damage to tumor cells in G phase and S phase, block of the progression of cells in G2 phase 
into M phase and block of the traverse of the leukemic cells in G1 
into S phase. 
 
4. DATA COLLECTION: 
Data will be entered onto specific case report forms, and will be managed by designated data 
managers and stored in the WCI database. Data will be then recorded on electronic spread 
sheets for statistical analyses. 
 
5. ADVERSE EVENT REPORTING AND SAFETY MONITORING 
Collection of adverse events information will be managed directly between the Study 
Coordinator and PI. A MedWatch Form Form will be completed for every SAE and those 
which meet FDA reporting requirements will be submitted to the FDA. A data and safety 
monitoring report will be filed with the IRB at least once per year in order to protect patients 
from any harm that might result from their participation in this study. See Appendix L for 
serious adverse events reporting and adverse events log. 
 
Definition of Adverse Events (AE): An AE is defined as any untoward medical occurrence in a 
patient after administration of the study drug.  An AE does not necessarily have a causal 
relationship with the use of the study drug.  An AE can therefore be any unintended sign 
(including an abnormal laboratory finding), symptom, or disease temporally associated with 
the use of the study drug, whether or not related to the study drug.   
Definition of Serious Adverse Events (SAE): A serious adverse event (SAE) is any medical 
complication that results in one of the following outcomes: death, urgent medical intervention 
to prevent death or disability, inpatient hospitalization for more than 24 hours or prolongation 
of hospitalization because of complications that could be caused by the study drugs, new 
persistent or significant disability or incapacity, or exacerbation of a pre-existing significant 
disability or incapacity.   
 
Progression or relapse of AML are not considered AEs or SAEs and will be tracked as 
outcomes in the Case Report forms. 
 
Expedited Reports of SAE's and Unexpected SAE's:  The PI will immediately notify Teva 
Pharmaceuticals of any SAE occuring after the second registration. SAEs (during OMA 
consolidation/maintenance).  SAEs will be sent to the Teva Pharmacovigilance safety mailbox 
at us.clinops.sae@tevapharm.com or Fax #215-619-3825. The PI will review each report to 
determine whether the SAE is expected or unexpected, based on information available in the 
study drugs label, and the study consent document approved by the IRB. An SAE will be 
defined as “unexpected” only if it is not listed in any of these documents and it is not expected 
based on the patient’s medical history. The PI/ study coordinator team will notify the IRB 
 
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immediately of any deaths possibly, probably or definitely associated with the study drug or 
procedures, and will notify the FDA of any unexpected fatal or life-threatening event within 7 
days.  All unanticipated problems involving risks to participants or others (UPs) will be 
reported to the IRB within 10 calendar days. Death from progression of AML is not an SAE. 
The Study Coordinator is responsible for filing SAE reports, patient evaluation forms, and 
medical records in the study file for each patient, and forwarding all SAE reports to the PI. At 
3-month intervals, the Study Coordinator will prepare summaries of all AE information, 
compiled from SAE reports, patient questionnaires, and review of available medical records for 
each patient. Summary reports tabulating the occurrence of all AEs will be forwarded to the PI. 
The PI is responsible for reviewing all SAE reports to determine whether the SAE is expected 
or unexpected.  The PI is responsible for following the reporting requirements  of the IRB, and 
the FDA. The PI is responsible for filing a semi annual  or annual report to the IRB according 
to the IRB requirements. The PI is responsible for responding to inquiries from the IRB. 
5.1 Data Safety Monitoring Plan.  
Patient safety, study efficacy and compliance will be reviewed at the (Leukemia Working 
Group) meetings. The Data and Safety Monitoring Committee (DSMC) of the Winship Cancer 
Institute will provide oversight for the conduct of this study.  The DSMC functions 
independently within Winship Cancer Institute to conduct internal monitoring functions to 
ensure that research being conducted by Winship Cancer Institute Investigators produces high-
quality scientific data in a manner consistent with good clinical practice (GCP) and appropriate 
regulations that govern clinical research.    Depending on the risk level of the protocol, the 
DSMC review may occur every 6 months or annually.  For studies deemed High Risk, initial 
study monitoring will occur within 6 months from the date of the first subject accrued, with 2 
of the first 5 subjects being reviewed.  For studies deemed Moderate Risk, initial study 
monitoring will occur within 1 year from the date of the first subject accrued, with 2 of the first 
5 subjects being reviewed.  Subsequent monitoring will occur in routine intervals per the 
Winship Data and Safety Monitoring Plan (DSMP)..   
 
Data quality will be monitored on an ongoing basis by random checks of CRFs following the 
Leukemia Working Group meetings. Co-investigators and staff will be trained on the conduct 
of the protocol and any additional training based on protocol amendments at the 
Hematology/Leukemia multi-disciplinary meetings, which meets regularly. Recording, 
grading, and reporting of adverse events will be carried out contemporaneously with each 
patient’s clinic visit and will abide by the guidelines provided by the Winship Cancer Institute 
Clinical Trials Office.  Deviations will be added to the Deviation Log, which is updated and 
reviewed at the Leukemia Working Group meetings. 
 
The Principal investigator is responsible for sending a yearly IND summary report, which 
includes an update and status of the study and a tabulation of the AEs/ SAEs, as well as  status 
of the study subjects, to the FDA. The PI is also responsible for collecting, reviewing, 
analyzing and reporting to the FDA and other investigators any potential serious risks that 
qualify for reporting under the FDA’s IND Safety Reporting regulations at 21 CFR §312.32, 
.64 and 21 CFR § 320.31.  In addition, the Sponsor-Investigator must copy the Emory IRB on 
 
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any such reports and include an analysis of whether the Sponsor-Investigator believes the event 
constitutes an Unanticipated Problem Involving Risks to Subjects or Others.  
 
6. STATISTICAL CONSIDERATIONS: 
Safety: Target omacetaxine dose is the dose that can be delivered to 70% patients without  
dose limiting toxicity (DLT) as defined above (section 3.3.4). Safety analysis will be 
conducted through continuous monitoring of AE/SAE. If 2 of the first 3 patients experience 
DLT, we stop the trial. After that, we stop the trial if there is evidence that the target 
probability of DLT exceeds 30% and the probability of falsely stopping the trial is 10% or less. 
The following table gives the minimum number of DLTs in order to stop the trial and the 
probability of falsely terminating the trial if in fact the probability of DLT is 30% calculated 
using the binomial distribution. For example, if after enrolling 6 patients, 4 or more 
experienced DLT, then we stop the trial and conclude that the target probability of DLT is 
more than 30%. The probability of incorrectly stopping the trial is 0.07. 
To be considered safe, the upper limit of the one-sided 95% CI of DLT among 15 patients must 
not be greater than 30%.  
Number of Patients 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
Number o DLTs to Stop Trial 
> 1 
> 1 
> 3 
> 3 
>  4 
> 4 
> 4 
> 5 
> 5 
> 6 
> 6 
> 6 
> 7 
Probability of falsely terminating the 
trial 
 
0.08 
0.03 
0.07 
0.03 
0.06 
0.10 
0.05 
0.08 
0.04 
0.07 
0.10 
0.05 
 
Feasibility: Feasibility is defined as delivery of 9 cycles of therapy for at least 2/3 of the 
patients. The proportion of patients with full treatment delivery will be estimated with an exact 
95% confidence interval. 
Futility: Based on our previous data showing a median relapse-free survival of 13.8 months, 
we will consider our consolidation/maintenance regimen futile if > 80% of those entering in 
CR relapse during consolidation/maintenance.  
Kaplan-Meier curves will be used to estimate the distribution of time to relapse, relapse free 
survival, and overall survival. 
Analysis of survival outcomes (OS, EFS, RFS) for patients who undergo transplantation in CR 
will include censoring and no censoring at the time of transplantation.   
 
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References: 
1. 
Buchner T, Urbanitz D, Hiddemann W, et al. Intensified induction and consolidation with or without 
maintenance chemotherapy for acute myeloid leukemia (AML): two multicenter studies of the German AML 
Cooperative Group. J Clin Oncol. 1985;3:1583-1589. 
2. 
Rees JK, Gray RG, Swirsky D, Hayhoe FG. Principal results of the Medical Research Council's 8th acute 
myeloid leukaemia trial. Lancet. 1986;2:1236-1241. 
3. 
Preisler H, Davis RB, Kirshner J, et al. Comparison of three remission induction regimens and two 
postinduction strategies for the treatment of acute nonlymphocytic leukemia: a cancer and leukemia group B 
study. Blood. 1987;69:1441-1449. 
4. 
Vogler WR, Velez-Garcia E, Weiner RS, et al. A phase III trial comparing idarubicin and daunorubicin 
in combination with cytarabine in acute myelogenous leukemia: a Southeastern Cancer Study Group Study. J Clin 
Oncol. 1992;10:1103-1111. 
5. 
Lowenberg B, Suciu S, Archimbaud E, et al. Mitoxantrone versus daunorubicin in induction-
consolidation chemotherapy--the value of low-dose cytarabine for maintenance of remission, and an assessment 
of prognostic factors in acute myeloid leukemia in the elderly: final report. European Organization for the 
Research and Treatment of Cancer and the Dutch-Belgian Hemato-Oncology Cooperative Hovon Group. J Clin 
Oncol. 1998;16:872-881. 
6. 
Kantarjian HM, Erba HP, Claxton D, et al. Phase II study of clofarabine monotherapy in previously 
untreated older adults with acute myeloid leukemia and unfavorable prognostic factors. J Clin Oncol. 
2010;28:549-555. 
7. 
Cashen AF, Schiller GJ, O'Donnell MR, DiPersio JF. Multicenter, phase II study of decitabine for the 
first-line treatment of older patients with acute myeloid leukemia. J Clin Oncol. 2010;28:556-561. 
8. 
Giles F, Rizzieri D, Karp J, et al. Cloretazine (VNP40101M), a novel sulfonylhydrazine alkylating agent, 
in patients age 60 years or older with previously untreated acute myeloid leukemia. J Clin Oncol. 2007;25:25-31. 
9. 
Burnett AK, Milligan D, Prentice AG, et al. A comparison of low-dose cytarabine and hydroxyurea with 
or without all-trans retinoic acid for acute myeloid leukemia and high-risk myelodysplastic syndrome in patients 
not considered fit for intensive treatment. Cancer. 2007;109:1114-1124. 
10. 
Lowenberg B, Suciu S, Archimbaud E, et al. Use of recombinant GM-CSF during and after remission 
induction chemotherapy in patients aged 61 years and older with acute myeloid leukemia: final report of AML-11, 
a phase III randomized study of the Leukemia Cooperative Group of European Organisation for the Research and 
Treatment of Cancer and the Dutch Belgian Hemato-Oncology Cooperative Group. Blood. 1997;90:2952-2961. 
11. 
Tilly H, Castaigne S, Bordessoule D, et al. Low-dose cytarabine versus intensive chemotherapy in the 
treatment of acute nonlymphocytic leukemia in the elderly. J Clin Oncol. 1990;8:272-279. 
12. 
Kern W, Estey EH. High-dose cytosine arabinoside in the treatment of acute myeloid leukemia: Review 
of three randomized trials. Cancer. 2006;107:116-124. 
13. 
Giles FJ, Borthakur G, Ravandi F, et al. The haematopoietic cell transplantation comorbidity index score 
is predictive of early death and survival in patients over 60 years of age receiving induction therapy for acute 
myeloid leukaemia. Br J Haematol. 2007;136:624-627. 
14. 
Lazarus HM, Vogler WR, Burns CP, Winton EF. High-dose cytosine arabinoside and daunorubicin as 
primary therapy in elderly patients with acute myelogenous leukemia. A phase I-II study of the Southeastern 
Cancer Study Group. Cancer. 1989;63:1055-1059. 
15. 
Mayer RJ, Davis RB, Schiffer CA, et al. Intensive postremission chemotherapy in adults with acute 
myeloid leukemia. Cancer and Leukemia Group B. N Engl J Med. 1994;331:896-903. 
16. 
Bloomfield CD, Lawrence D, Byrd JC, et al. Frequency of prolonged remission duration after high-dose 
cytarabine intensification in acute myeloid leukemia varies by cytogenetic subtype. Cancer Res. 1998;58:4173-
4179. 
17. 
Schlenk RF, Frohling S, Hartmann F, et al. Intensive consolidation versus oral maintenance therapy in 
patients 61 years or older with acute myeloid leukemia in first remission: results of second randomization of the 
AML HD98-B treatment Trial. Leukemia. 2006;20:748-750. 
18. 
Sauter C, Berchtold W, Fopp M, et al. Acute myelogenous leukaemia: maintenance chemotherapy after 
early consolidation treatment does not prolong survival. Lancet. 1984;1:379-382. 
19. 
Miyawaki S, Sakamaki H, Ohtake S, et al. A randomized, postremission comparison of four courses of 
standard-dose consolidation therapy without maintenance therapy versus three courses of standard-dose 
consolidation with maintenance therapy in adults with acute myeloid leukemia: the Japan Adult Leukemia Study 
Group AML 97 Study. Cancer. 2005;104:2726-2734. 
 
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Protocol #: Winship2176-11  
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20. 
Warrell RP, Jr., Coonley CJ, Gee TS. Homoharringtonine: an effective new drug for remission induction 
in refractory nonlymphoblastic leukemia. J Clin Oncol. 1985;3:617-621. 
21. 
Feldman E, Arlin Z, Ahmed T, et al. Homoharringtonine is safe and effective for patients with acute 
myelogenous leukemia. Leukemia. 1992;6:1185-1188. 
22. 
Jin J, Jiang DZ, Mai WY, et al. Homoharringtonine in combination with cytarabine and aclarubicin 
resulted in high complete remission rate after the first induction therapy in patients with de novo acute myeloid 
leukemia. Leukemia. 2006;20:1361-1367. 
23. 
Wang J, Lu S, Yang J, et al. A homoharringtonine-based induction regimen for the treatment of elderly 
patients with acute myeloid leukemia: a single center experience from China. J Hematol Oncol. 2009;2:32. 
24. 
Wu L, Li X, Su J, et al. Effect of low-dose cytarabine, homoharringtonine and granulocyte colony-
stimulating factor priming regimen on patients with advanced myelodysplastic syndrome or acute myeloid 
leukemia transformed from myelodysplastic syndrome. Leuk Lymphoma. 2009;50:1461-1467. 
25. 
Cheson BD, Bennett JM, Kopecky KJ, et al. Revised recommendations of the International Working 
Group for Diagnosis, Standardization of Response Criteria, Treatment Outcomes, and Reporting Standards for 
Therapeutic Trials in Acute Myeloid Leukemia. J Clin Oncol. 2003;21:4642-4649. 
 
 
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APPENDIX A: THE WORLD HEALTH ORGANIZATION (WHO) CLASSIFICATION 
OF THE MYELOID NEOPLASMS 
 
Acute myeloid leukemia with recurrent genetic abnormalities 
• 
Acute myeloid leukemia with t(8;21)(q22;q22), (AML1/ETO) 
• 
Acute myeloid leukemia with abnormal bone marrow eosinophils and 
• 
inv(16)(p13q22) or t(16;16)(p13;q22), (CBF_/MYH11) 
• 
Acute promyelocytic leukemia with t(15;17)(q22;q12), (PML/RAR_) and variants 
• 
Acute myeloid leukemia with 11q23 (MLL) abnormalities 
Acute myeloid leukemia with multilineage dysplasia 
• 
Following MDS or MDS/MPD: 
 Without antecedent MDS or MDS/MPD, but with dysplasia in at least 50% 
of cells in 2 or more myeloid lineages 
Acute myeloid leukemia and myelodysplastic syndromes, therapy related 
• Alkylating agent/radiation–related type 
• Topoisomerase II inhibitor–related type (some may be lymphoid) 
• Others 
Acute myeloid leukemia, not otherwise categorized, classify as: 
 Acute myeloid leukemia, minimally differentiated 
 Acute myeloid leukemia without maturation 
 Acute myeloid leukemia with maturation 
 Acute myelomonocytic leukemia 
 Acute monoblastic/acute monocytic leukemia 
 Acute erythroid leukemia (erythroid/myeloid and pure erythroleukemia) 
 Acute megakaryoblastic leukemia 
 Acute basophilic leukemia 
 Acute panmyelosis with myelofibrosis 
 Myeloid sarcoma 
 
Adapted from Blood. 2002;100:2292-2302 
 
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APPENDIX B: ECOG PERFORMANCE STATUS 
 
 
 
Grade ECOG 
0 
Fully active, able to carry on all pre-disease performance without restriction 
1 
Restricted in physically strenuous activity but ambulatory and able to carry out work 
of a light or sedentary nature, e.g., light house work, office work 
2 
Ambulatory and capable of all selfcare but unable to carry out any work activities. Up 
and about more than 50% of waking hours 
3 
Capable of only limited selfcare, confined to bed or chair more than 50% of waking 
hours 
4 
Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair 
5 
Dead 
 
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APPENDIX C: ELIGIBILITY CHECK LIST AT THE TIME OF SECOND 
REGISTRATION  
Demographics:  
Patient Name: ______________________   UPN:_________ Age (years):  _______________  
 
 
Patient Gender: ο Male ο Female              Ethnicity __________________________________________ 
• 
Date Diagnosis of AML:   
 
 
                 
____ / ___ / ______ 
• 
DOB  
 
 
 
 
 
 
 
____/ ___ / ______ 
• 
Age > 55 years 
 
 
 
 
 
 
 
  Yes 
 No 
• 
Informed consent  
 
 
 
 
 
 
  Yes 
 No  
• 
Stated patient willingness to comply with study procedures  
 
 
  Yes 
 No 
• 
Lack of active, uncontrolled fungal or viral infection                                  
  Yes 
 No 
• 
ECOG performance status  0-2 ______                                                                   
  Yes 
 No 
• 
ECOG PS=___________ 
• 
Adequate hepatic and renal function?             
 
                             
  Yes 
 No 
• 
Total bilirubn < 1.5 x ULN                                                                  
 
  Yes 
 No 
• 
Total bilirbin =_________on ___/___/___   
• 
AST < 2.5 x ULN                                                                             
 
  Yes 
 No 
• 
AST=_________________ on ___/___/___    
• 
ALT < 2.5 x ULN                                                                                
 
  Yes 
 No 
• 
ALT= _________________ on ___/___/___   
• 
Creatinine < 1.2 x ULN                                                                       
 
  Yes 
 No 
• 
Creatinine= ____________ on ___/___/___   
• 
Cytotoxic chemotherapy concluded > 4 weeks prior to enrollment?                       
  Yes 
 No 
(1-2 cycles of hypomethylating agent allowed) 
 
Secondary AML          
 Yes  
  No         If yes, answer the following: 
• 
Name of Antecendent hematological disorder _____________________ 
• 
Type of previous carcinoma if applicable_________________________ 
• 
Prior chemotherapy _________________ concluding on  _____/_____/_____ 
• 
Prior radiation therapy concluding on _____/_____/_____   
Non-Fertile     
 
 Yes  
 No 
 
If not non-fertile:  1.  Method of contracept ion to be used   _______________________ 
 
 
 
 2.  Date if negative pregnancy test:   ___________________________ 
Statement of Eligibility 
This subject is  
 eligible / 
 ineligible for participation in the study based on the 
inclusion/exclusion criteria described in the IRB submission, as approved by the IRB. 
PI/designee signature*: 
Date**: 
Printed name of person assessing eligibility : 
Printed name of person completing this form: 
** This form should be signed by the PI or designee, as described on the delegation of  authority log.  
**Documentation of eligibility determination should be completed prior to registration. 
 
 
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APPENDIX D: EVALUATIONS DURING INDUCTION 
(DURING INDUCTION) 
 
Test 
Baseline 
Research Samples: 
Peripheral blood 
(20mL), 
 
Bone Marrow 
Aspirate (10mL)* 
X 
 
 
 
 
 
 
Comordity Score 
X 
 
Quality of life 
Questionnaire 
X 
 
 
* Bone marrow aspirate and peripheral blood to be collected for correlative testing at baseline and at all 
subsequent SOC collections during induction.(only peripheral blood will be collected if a bone marrow 
biopsy presents  a risk to the patient)   
 
 
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APPENDIX E: EVALUATIONS DURING CONSOLIDATION 
 
Week  
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
Day 
1 
 
 
 
 
 
 
 
 
 
 
 
H&P 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Medication review 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Physical exam 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
ECOG PS 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
CBC with diff.  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
CP Comp  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Research 
samples: 
Peripheral blood 
(20mL) and  
Bone marrow 
aspirate (10mL) 
X 
 
 
X 
 
 
 
X 
 
 
 
X 
Bone marrow 
aspirate1  
X 
X 
 
X 
 
 
 
X 
 
 
 
X 
Quality of life 
questionnaire 
X 
 
 
X 
 
 
 
X 
 
 
 
X 
Comordity Score 
X 
 
 
 
 
 
 
 
 
 
 
 
 
1. Bone marrow aspirate (biopsy if indicated based on suspicion of relapse) performed monthly during 
consolidation to document continuous remission. Molecular tests and cytogenetics obtained as 
clinically indicated. Research samples are obtained monthly during consolidation. (only peripheral 
blood will be collected if a bone marrow biopsy  presents  a risk to the patient)  
2. *All time points have an up to 3-day window.      
 
 
 
 
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Protocol #: Winship2176-11  
Protocol Version:  6.0 Dated, 01/14/2017 
 
 
APPENDIX F: EVALUATIONS DURING MAINTENANCE 
 
Week  
1 
4 
8 
12 
16 
20 
24 
Day 
1 
 
 
 
 
 
 
H&P 
X 
X 
X 
X 
X 
X 
X 
Medication review 
X 
X 
X 
X 
X 
X 
X 
Physical exam 
X 
X 
X 
X 
X 
X 
X 
ECOG PS 
X 
X 
X 
X 
X 
X 
X 
CBC with diff. 1 
X 
X 
X 
X 
X 
X 
X 
CP Comp  
X 
X 
X 
X 
X 
X 
X 
Research 
samples: 
Peripheral blood 
(20mL) and  
Bone marrow 
aspirate (10mL) 
X 
 
 
X 
 
 
X 
Bone marrow  
aspirate2 
X 
 
 
X 
 
 
X 
Quality of life 
questionnaire 
X 
 
 
X 
 
 
X 
 
1. CBC with differential will be collected weekly during maintenance and if counts remain stable (no 
neutropenia or significant thrombocytopenia), can decrease frequency to every other week. 
2. Bone marrow aspirate (biopsy if indicated) performed every 3 months during maintenance. 
Molecular tests and cytogenetics obtained as clinically indicated. Research samples are obtained 
every 3 months during maintenance. (only peripheral blood will be collected if a bone marrow 
biopsy presents  a risk to the patient) 
3. *All time points have an up to 3-day window.   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
26 

Protocol #: Winship2176-11  
Protocol Version:  6.0 Dated, 01/14/2017 
 
 
 
 
APPENDIX G: COMORBIDITY SCORING  
(Blood. 2005;106: 2912-2919) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
27 

Protocol #: Winship2176-11  
Protocol Version:  6.0 Dated, 01/14/2017 
 
 
 
 
 
APPENDIX H: 
QUALITY OF LIFE QUESTIONNAIRE 
NAME:  ______________________________ DATE:  ____ / ____ / ____ 
 
 
28 

Protocol #: Winship2176-11  
Protocol Version:  6.0 Dated, 01/14/2017 
 
 
 
 
29 

Protocol #: Winship2176-11  
Protocol Version:  6.0 Dated, 01/14/2017 
 
 
 
 
30 

Protocol #: Winship2176-11  
Protocol Version:  6.0 Dated, 01/14/2017 
 
 
 
APPENDIX I: RESPONSE CRITERIA 
 
• Complete Remission (CR): Normocellular marrow with < 5% blasts, absence of 
auer rods and of any unique phenotype identical to what was found in the 
pretreatment specimen, with ANC > 1 x 10 9/L and platelet count > 100 x 109/L, 
and transfusion independence, as well as no residual evidence of extramedullary 
AML. 
• Complete Response with incomplete blood count recovery (CRi): Meets criteria 
for CR above, except for residual neutropenia (ANC < 1 x 109/L) or 
thrombocytopenia (platelets < 100x109/L)  
• Complete Response with incomplete platelet recovery (CRp): Meets criteria for 
CR above, but platelets are < 100x109/L. 
• Cytogenetic Complete Remission (CRc): Disappearance of cytogenetic 
abnormalities thought to be associated with the AML. 
• Molecular 
Complete 
Remission 
(CRm): 
Disappearance 
of 
molecular 
abnormalities thought to be related to the AML. 
• Treatment failure:  
• Resistant disease: Patient survives > 7 days post-chemotherapy and has 
persistent AML in blood or bone marrow. 
• Aplasia: Patient survives > 7 days post-chemotherapy, but dies while cytopenic, 
with an aplastic bone marrow. 
• Morphologic relapse: Reappearance of blasts post-chemotherapy in peripheral 
blood or bone marrow. 
• Molecular/cytogenetic relapse: Reappearance of molecular or cytogenetic 
abnormality. 
• Clearance of Leukemia at the day 14 marrow: < 5% blasts in a hypocellular 
marrow (<15% cellularity). 
• Overall survival (OS): Time from entry onto trial until death from any cause. 
• Relapse free survival (RFS): Time from Remission (CR, CRi, CRp) until disease 
relapse or death from any cause. 
• Event free survival (EFS): Time from entry onto trial to treatment failure/relapsed 
disease, or death from any cause. 
• Remission duration: Time from date of CR (or CRp, CRi) until disease relapse.  
 
31 

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Protocol #: Winship2176-11  
Protocol Version:  6.0 Dated, 01/14/2017 
 
 
 
APPENDIX M:  SAE REPORTING AND AE LOG  
 
 
STUDY TITLE:  
_____________________          PI:    _____________________ 
             CONSENT DATE:  ___________________ ______  
 
 
TREATMENT START DATE: __________________    TREATMENT END DATE: _________________    OFF STUDY DATE: ___________________ 
 
Adverse  
Event 
Start and 
stop dates 
Serious 
 
Grade** 
 
Relationship to 
drug/device 
Anticipated 
Action taken 
with the 
drug/device 
Other 
actions 
taken  
Was the AE 
reported to 
the sponsor?  
Was the AE 
reported to the 
IRB? *** 
PI 
initials 
 
 
 
Start: 
 
___________
Stop: 
 
___________ 
□Yes 
□No     
 
□Mild    
□Moderate 
□Severe        
□Life Threatening   
□Death  
□Not related 
□Possibly     
□Probably 
□Related   
□Unknown   
 
□Yes 
□No     
 
□None 
□Reduced     
□Interrupted 
□Discontinued  
□Other 
 
□Yes 
□No     
Date of report 
 
___________ 
□Yes 
□No     
Date of report 
 
___________ 
 
 
 
 
Start: 
 
___________ 
Stop: 
 
___________ 
□Yes 
□No     
 
□Mild    
□Moderate 
□Severe        
□Life Threatening   
□Death 
□Not related 
□Possibly     
□Probably 
□Related   
□Yes 
□No     
 
□None 
□Reduced     
□Interrupted 
□Discontinued  
 
□Yes 
□No     
Date of report 
 
___________ 
□Yes 
□No     
Date of report 
 
___________ 
 
 
 
 
Start: 
 
___________ 
Stop: 
 
___________ 
□Yes 
□No     
 
□Mild    
□Moderate 
□Severe        
□Life Threatening   
□Death 
□Not related 
□Possibly     
□Probably 
□Related   
□Yes 
□No     
 
□None 
□Reduced     
□Interrupted 
□Discontinued  
 
□Yes 
□No     
Date of report 
 
___________ 
□Yes 
□No     
Date of report 
 
___________ 
 
 
Start: 
 
___________ 
Stop: 
 
___________ 
□Yes 
□No     
 
□Mild    
□Moderate 
□Severe        
□Life Threatening   
□ Death 
□Not related 
□Possibly     
□Probably 
□Related   
□Yes 
□No     
 
□None 
□Reduced     
□Interrupted 
□Discontinued  
 
□Yes 
□No     
Date of report 
 
___________ 
□Yes 
□No     
Date of report 
 
___________ 
 
* 0= not, 1= suspected 
Codes for action taken:   
 0= none,   1= OM dose reduced,    2= OM held,   3= OM restarted,     
4= OM stopped due to this SAE, 5= patient admitted to the hospital,    
6=taken off study 
 
35