A Phase 1 Study of the DOT1L Inhibitor, Pinometostat (EPZ-5676), in Adults with Relapsed or Refractory Leukemia: Safety, Clinical Activity, Exposure and Target Inhibition
Authors: Stein Eytan M. , Garcia-Manero Guillermo , Rizzieri David A. , Tibes Raoul , Berdeja Jesus G. , Jongen-Lavrencic Mojca , Altman Jessica K. , Dohner Hartmut , Thomson Blythe , Blakemore Stephen J. , Daigle Scott , Fine Greg , Waters Nigel J. , Krivstov Andrei V , Koche Richard , Armstrong Scott A. , Ho Peter T , Lowenberg Bob , Tallman Martin S 
Published: October 2019

Abstract
Introduction: Aberrant fusion proteins involving the MLL histone methyltransferase (HMT) result in recruitment of another HMT, DOT1L, to a multi-protein complex. This leads to abnormal methylation of Histone H3 lysine 79 (H3K79) at MLL target genes and enhanced expression of leukemogenic genes such as HOXA9 and MEIS1 ( Krivstov, 2007). Pinometostat is a small molecule inhibitor of DOT1L with sub-nanomolar affinity and >37,000 fold selectivity against non-MLL HMTs. Pinometostat treatment of MLL-rearranged cells and xenografts reduced histone H3K79 methylation, decreased MLL target gene expression, and induced selective leukemia cell kill (Daigle, 2013). We report the safety, activity, pharmacokinetics (PK) and pharmacodynamics (PD) in the phase 1 trial of pinometostat in adult patients (pts) with relapsed/refractory (R/R) leukemia.
Methods: This open label dose escalation/expansion study of pinometostat enrolled pts >18 years (yrs) with R/R leukemia (NCT01684150). In the dose-escalation phase, pts with AML, ALL, mixed lineage leukemia (MLL), myelodysplastic syndrome, myeloproliferative neoplasm or chronic myeloid leukemia were eligible. Eligibility in the two expansion cohorts: 90 mg/m2 (n = 17) and 54 mg/m2 (n = 6), was restricted to pts with MLL-r or MLL-partial tandem duplication (MLL-PTD). Pinometostat was given via continuous intravenous infusion (CIV) for 21 of 28 day cycles in the dose escalation phase and CIV for 28 of 28 day cycles in the expansion phases, until disease progression or unacceptable toxicity. All pts underwent serial collection of PK and peripheral blood mononuclear cells (PBMC) for PD. Leukemic blasts were isolated from PBMCs using flow cytometry and quantified for dimethylation of H3K79 (H3K79-me2) by ChIP-Seq.
Results: As of 28-June-2015, 49 pts have enrolled in the dose escalation and expansion phases. Pts receiving 21/28 day infusions: 12 (n=1), 24 (n=5), 36 (n=4), 54 (n=6) and 80 mg/m2/day (n=3). Pts receiving 28/28 day infusions: 54 (n=6) and 90 mg/m2/day (n=24).
Table 1. Patient Characteristics n (%) Median age, yrs (range) 51 (19 - 81) Sex (M / F) 27/22 Diagnosis MLL-r* 29 (59) AML MLL-PTD** 5 (9) MLL-wt 7 (14) ALL MLL-r* 5 (10) MLL-wt 1 (2) MLL MLL-r 1 (2) CMML MLL-r 1 (2) # of prior therapeutic regimens 1 - 2 29 (59) 3 - 4 18 (36) >4 2 (4) Prior allogeneic hematopoietic cell transplant 20 (41) * centrally confirmed by karyotype/FISH ** centrally confirmed by NGS (next generation sequencing)
Adverse events (AEs) reported in >15% of pts regardless of attribution were: nausea, constipation, vomiting, abdominal pain, diarrhea, hypocalcemia, hypokalemia, hypomagnesemia, fatigue, fever, peripheral edema, mucositis, febrile neutropenia, leukocytosis, anemia, cough, dyspnea, and pneumonia. Grade ≥3 non-hematologic related toxicities include: hypophosphatemia (n=1), decreased ejection fraction (n=3), or elevated transaminases (n=1). Nine patients had leukocytosis (absolute monocyte and neutrophil 50% above baseline and above upper limit of normal) or differentiation. The median days of pinometostat treatment was 35 days (range 3-189 days). To date, objective responses observed are morphologic CR (1 pt), cytogenetic CR (MLL negative by FISH) (1 pt), PR (1 pt) and resolution of leukemia cutis (3 pts). Dose proportional PK was observed with rapid attainment of steady-state plasma concentrations (Css) on Day 1 of treatment. Plasma Css correlated with inhibition of global H3K79-me2 in PBMCs. H3K79-me2 ChIP-Seq demonstrated pinometostat induced reductions in methylation at MLL -r target genes HOXA9 and MEIS1 (median inhibition = 61%: range = 13-91%) in all 9 pts analyzed to date from the 90 mg/m2 expansion cohort. Inhibition of H3K79-me2 in leukemic blasts is consistent with DOT1L suppression. PK-PD relationships in both expansion cohorts using both free and total plasma Css are being explored.
Conclusions: Pinometostat administered as a CIV to adults with R/R leukemia has an acceptable safety profile. Clinical activity as demonstrated by both marrow responses and resolution of leukemia cutis were observed. In addition, analysis of H3K79-me2 by ChIP-Seq demonstrated PD reductions in the methylation of MLL-r target genes following pinometostat exposure, as expected from DOT1L inhibition. Relationships between PK exposure, reductions in pinometostat induced H3K79-me2 levels and clinical response are being interrogated.

Disclosures
Stein: Seattle Genetics: Consultancy; Agios Pharmaceuticals: Consultancy. Rizzieri:Teva: Other: ad board, Speakers Bureau; Celgene: Other: ad board, Speakers Bureau. Berdeja:Novartis: Research Funding; Takeda: Research Funding; BMS: Research Funding; Curis: Research Funding; MEI: Research Funding; Abbvie: Research Funding; Onyx: Research Funding; Array: Research Funding; Janssen: Research Funding; Celgene: Research Funding; Acetylon: Research Funding. Altman:Novartis: Other: Advisory board; Spectrum: Other: Advisory board; Ariad: Other: Advisory board; Seattle Genetics: Other: Advisory board; BMS: Other: Advisory board; Astellas: Other: Participation in an advisory board December 2013. Thomson:Epizyme, Inc: Employment. Blakemore:Epizyme: Employment. Daigle:Epizyme, Inc: Employment. Fine:Epizyme: Employment. Waters:Epizyme, Inc: Employment. Armstrong:Epizyme, Inc: Consultancy. Ho:Epizyme, Inc: Employment.