Pre-Screening for Low Methyl Guanine Methyltransferase (MGMT) Expression Results in High Response Rates to Temozolomide (TMZ) Therapy in AML and MDS Patients.
Authors: Brandwein Joseph , Kassis Jeannine , Leber Brian , Howson-Jan Kang , Minden Mark D. , Galarneau Andre , Pouliot Jean-Francois 
Published: October 2019

Abstract
Abstract 422

Introduction:
Many patients with acute myeloid leukemia (AML) and high-risk myelodysplasia (MDS) are not suitable candidates for standard induction therapy, and newer treatment approaches are needed. TMZ anti-tumor activity is attributed to methylation of DNA, leading to the formation of O6-methylguanine that eventually leads to apoptosis. Expression of MethylGuanine DNA MethylTransferase (MGMT) restores normal guanine, decreasing DNA alkylation and thus anti-tumor activity of TMZ. Brandwein et al. (Leukemia 2007;21:821–4) previously demonstrated that response to TMZ in AML patients could be correlated with low MGMT expression. Thus MGMT expression prescreening could be used to identify patients more likely to respond to TMZ and provide an alternative for patients who are not candidates for standard induction therapy.

Methods:
We conducted a prospective multicenter study of patients with previously untreated AML and high risk MDS who were not candidates for standard induction therapy. Patient selection was based on MGMT expression as determined by Western blot in bone marrow or peripheral blood. Screening was performed by comparing the expression ratio between MGMT and b-actin protein levels. Patients with a ratio <0.25 were eligible to receive TMZ therapy 200 mg/m2/day × 7 days. Patients achieving a complete response (CR) could receive up to 12 monthly cycles of temozolomide 200 mg/m2/day × 5 days. Partial responders received a modified schedule of temozolomide 100 mg/m2/day × 21 days.

Results:
MGMT expression was tested in 188 patients; median age was 75 years old (range 46–94 years);62% were male. Primary diagnoses were AML (86%) and MDS (14%). Low or weak MGMT expression was detected in 46% of patient that were therefore potential candidates for TMZ therapy. Responses were evaluated in 42 patients, and were divided into 4 categories: Complete (CR/CRp), Morphologic Leukemia-Free State (MLFS), Partial (PR) Minimal (MR). Response was observed in 74% of cases including 29% CR, 10% MLFS, 19% PR and 17% MR. Prognostic factors associated with a higher response rate to temozolomide included MDS presentation, ECOG PS 0 and favorable/standard cytogenetic risk group. Induction and post-remission cycles were well-tolerated and most patients could be successfully treated on an outpatient basis.
Patient who reached CR/CRp had a significantly longer median survival (>18 months) compared to those who reached MLFS, PR and MR (5.6 months). Median duration of therapy for patients reaching CR/CRp was 255 days and a majority (80%) became transfusion independent. Grade 3 and 4 toxicities were rare with the most common being fatigue (17%) and diarrhea (6%).

Discussion:
Pre-selection of patients based on MGMT expression level was associated with a higher response rate to TMZ as compared to previously reported unselected patients. Complete response was associated with increased survival and treatment had a favorable toxicity profile even in frail elderly patients. Targeted therapy with TMZ is feasible in patients with low MGMT expression and represents a new option for AML and MDS patients who are not candidate for standard induction therapy.

Disclosures:
Brandwein: Merck: Research Funding. Off Label Use: Temozolomide therapy for AML and MDS. Kassis:Merck: Research Funding. Leber:Merck: Research Funding. Howson-Jan:Merck: Research Funding. Minden:Merck: Research Funding. Galarneau:Merck: Employment. Pouliot:Merck: Employment.