Ponatinib Is Well Tolerated and Active In Patients With Relapsed/Refractory Philadelphia Positive Acute Lymphoblastic Leukemia (PH+ ALL) and Advanced Phase Of Chronic Myelogenous Leukemia (CML) Harbouring T315I Mutation: The Bologna Experience
Authors: Papayannidis Cristina , De Benedittis Caterina , Soverini Simona , Iacobucci Ilaria , Abbenante Maria Chiara , Sartor Chiara , Bochicchio Maria Teresa , Ferrari Anna , Venturi Claudia , Robustelli Valentina , Luserna Di Rorà Andrea Ghelli , Guadagnuolo Viviana , Ottaviani Emanuela , Testoni Nicoletta , Baldazzi Carmen , Luatti Simona , Parisi Sarah , Paolini Stefania , Clissa Cristina , Conficoni Alberto , Frabetti Federica , Lani Elisa , Piccari Silvia , Di Bartolomeo Paolo , Di Lorenzo Roberto , Fanin Renato , Cimino Giuseppe , Martinelli Giovanni 
Published: October 2019

Abstract

Background
Ponatinib, a potent third generation pan BCR-ABL inhibitor, has recently shown relevant activity against native and mutant forms of BCR-ABL, including the TKI resistant T315I mutant. The aim of this compassionate protocol was to confirm and evaluate the efficacy and the safety of the compound in patients with advanced Ph+ ALL and CML.
Design and Methods
Ponatinib was obtained through a compassionate use named patient program, approved by ARIAD Pharmaceuticals and by the Bologna Ethical Committee. After informed consent was signed, 17 patients (M/F: 8/9) have been treated with Ponatinib (45 mg orally, once daily) between February 2012 and July 2013, including 14 Ph+ ALL (10 p190, 4 p210) and 3 blast phases of CML (2 Myeloid and 1 Lymphoid, p210). The median age of the patients was 64 years (range 23 -77). The median time from diagnosis was 754 days (range 46-2264). All the patients were resistant or intolerant to previous TKIs (median number of previous TKIs: 2; range 1-3). Standard chemotherapy was previously performed in 7/17 patients (41%). Four patients (23%) had previously received allogeneic stem cell transplantation. At the time of enrolment, median Hb, PLTs and WBC values were 10,9 g/dl (range 8.6-13.9), 139000/mmc (range 14000-325000) and 4300/mmc (range 1700-17000), respectively. In 6 out of 17 patients, additional cytogenetic alterations were revealed. Mutational analysis showed the presence of T315I mutation (9 pts), G250E (1 pt), T315I and Y253H (1 pt), T315I and Y253A (1 pt), V299L (1 pt). No mutations were detected in 4 patients.

Results
The median treatment duration was 139 days (range 14-540+). Causes of treatment stop were: progression disease (5 patients), savage allogenic stem cell transplantation (6 patients), drug intolerance (1 patient), consisting in grade III headache.
With a median follow up of 284 days (range 8-540+), a maHR was obtained in 13/17 patients (76%). After one month of treatment, a reduction of BCR-ABL fusion transcript level was observed in 9/15 patients (60%). For two patients the follow up is too short to be evaluable. The level became undetectable in 4 patients (3 presenting with T315I mutation).
After treatment, T315I mutation disappeared in 6 out of the 9 patients who showed this molecular alteration at the beginning of therapy. At the time of this report, 6/17 patients are still on study (35%). Five patients died due to progression disease. As expected, the drug was well tolerated. Non-hematologic adverse events were described in 7/17 patients (grade >III skin rash in 3 patients; grade>II serum lipase increase in 2 patients; grade>II myalgia in 1 patient; grade III headache).

Conclusion
In our experience, the activity of Ponatinib in advanced Ph+ leukemias, mainly in T315I mutated patients, was confirmed. No treatment-related deaths occurred. The understanding of molecular mechanisms responsible for resistance or lack of response to the drug will be necessary in order to identify patients early on who could take advantage of this treatment.

Acknowledgments
Work supported by European LeukemiaNet, AIRC, PRIN 2010-2011, University of Bologna and BolognAIL.

Disclosures:
Soverini: Novartis: Consultancy; Bristol-Myers Squibb: Consultancy; ARIAD: Consultancy. Martinelli:NOVARTIS: Consultancy, Speakers Bureau; BMS: Consultancy, Speakers Bureau; PFIZER: Consultancy; ARIAD: Consultancy.