Updated Results and Longer Follow-up from the AUGMENT-101 Phase 2 Study of Revumenib in All Patients with Relapsed or Refractory (R/R) KMT2Ar Acute Leukemia
Authors: Aldoss Ibrahim , Issa Ghayas C. , Blachly James S. , Thirman Michael J. , Mannis Gabriel N , Arellano Martha L. , DiPersio John F. , Traer Elie , Zwaan C. Michel , Shukla Neerav , Cuglievan Branko , Grove Carolyn S. , Greenwood Matthew , McMahon Christine M. , Perl Alexander E. , Stone Richard M. , Papayannidis Cristina , Dickens David S. , Heiblig Maël , Žučenka Andrius , Montesinos Pau , Mantzaris Ioannis , Kovacsovics Tibor , Shami Paul J. , Yu Li , Bagley Rebecca G. , McNeer Nicole , Stein Eytan M. 
Published: December 2024

Background: Rearrangements of the lysine methyltransferase 2A (KMT2Ar) gene occur in ≤10% of acute leukemias (ALs) and are associated with a poor prognosis. In patients (pts) with KMT2Ar AL, the menin-KMT2A fusion protein interaction is a key driver of leukemogenesis. Revumenib, an oral, potent, and selective menin inhibitor, demonstrated a high rate of complete remission (CR) or CR with partial hematologic recovery (CR+CRh; 23%) and overall response rate (ORR; 63%) with a tolerable safety profile in pts with R/R KMT2Ar AL in the phase 2 interim analysis of AUGMENT-101 (NCT04065399). The KMT2Ar cohorts met prespecified stopping rules for efficacy, and the data from this analysis (n=57) were the basis for a New Drug Application to the FDA. Here we report longer follow-up and a larger data set, including safety and efficacy results for all pts with KMT2Ar enrolled in the phase 2 study (N=116), representing the largest evaluation of menin inhibition in pts with R/R KMT2Ar AL to date.

Methods: Pts aged ≥30 d with R/R KMT2Ar AL were enrolled and received revumenib 163 mg (95 mg/m2 if body weight &lt;40 kg) every 12 h (q12h) with a strong CYP3A4 inhibitor azole in 28-d continuous cycles. Treatment continued until lack of at least morphological leukemia-free state (MLFS) after 4 cycles, disease progression, or unacceptable adverse events (AEs). Primary objectives were safety and tolerability and rate of CR+CRh. Key secondary endpoints included rate of composite CR (CRc [CR+CRh+CR with incomplete platelet recovery+CR with incomplete count recovery), ORR (CRc+MLFS+partial remission), and duration of response (DoR). The efficacy population included pts with centrally confirmed KMT2Ar and ≥5% baseline bone marrow blasts. Measurable residual disease (MRD) was assessed locally by flow cytometry or PCR at the discretion of investigators.

Results: At the time of the interim analysis (data cutoff [DCO]: July 24, 2023), 13 pts achieved CR+CRh (23%), 6 of whom remained in follow-up with no relapse or death at that time. In this current analysis, with 7 additional mo of follow-up (DCO: February 29, 2024), the updated median duration of CR+CRh in these 13 responders was 13.0 mo (95% CI, 3.4 mo-not reached [NR]); 5 remained in follow-up with no relapse or death, while 1 more pt had relapsed.

A total of 116 pts with R/R KMT2Ar AL received ≥1 dose of revumenib and were included in the safety population. Median age was 35.5 y (range, 0.6-75.0); 28 (24%) pts were &lt;18 y, and 14 (12%) were ≥65 y. A total of 95 (82%) pts had AML, and 21 (18%) had ALL or MPAL; 67 (58%) were female, and 18 (16%) were non-White. Pts were heavily pretreated (median of 2 prior therapies [range, 1-11]), with 51 (44%) receiving ≥3 prior lines, 73 (63%) receiving prior venetoclax, and 59 (51%) underwent prior hematopoietic stem cell transplant (HSCT).

In the efficacy population (n=97), 22 pts (23% [95% CI, 15%-32%]) achieved CR+CRh with a median DoR of 6.4 mo (95% CI, 1.9 mo-NR). CRc rate was 42% (95% CI, 32%-53%); ORR was 64% (95% CI, 54%-73%). Of 18 CR+CRh responders with MRD results available, 11 (61%) achieved MRD negativity; 21/36 (58%) MRD-evaluable CRc responders achieved MRD negativity. Of 62 pts who achieved ORR, 21 (34%) proceeded to HSCT. Nine pts resumed revumenib post HSCT.

In the safety population (N=116), 106 (91%) pts experienced a grade ≥3 treatment-emergent AE (TEAE) and 63 (54%) experienced a grade ≥3 treatment-related AE (TRAE). The most common (≥10%) grade ≥3 TEAEs were febrile neutropenia (45 [39%]), anemia (23 [20%]), platelet count decreased (19 [16%]), differentiation syndrome (17 [15%]; only 1 grade 4, no grade 5), neutrophil count decreased (17 [15%]), white blood cell count decreased (17 [15%]), sepsis (16 [14%]), and QTc prolongation (15 [13%]; all grade 3). Sixteen pts (14%) discontinued treatment due to a TEAE, and 6 (5%) discontinued due to a TRAE. Nineteen (16%) and 4 (3%) pts experienced a TEAE or TRAE leading to death, respectively.

Conclusions: Revumenib monotherapy provides clinically meaningful responses in heavily pretreated pts with R/R KMT2Ar acute leukemias, including high rates of MRD negativity and ability to proceed to HSCT. Continued treatment and follow-up of pts after the interim analysis demonstrate the durability of ongoing response. The safety profile of revumenib with this longer follow-up is consistent with prior reports. This trial represents the largest evaluation of a targeted therapy for pts with R/R KMT2Ar acute leukemias to date.