Acute Promyelocytic Leukemia 2006 (APL)

A Randomized Trial Assessing the Role of Arsenic Trioxide and/or ATRA During Consolidation Course in Newly Diagnosed Acute Promyelocytic Leukemia (APL)

To assess the role of Arsenic trioxide and/or ATRA during consolidation course in APL. It is hoped that the investigational arms will further increase the event-free survival at 2 years, with reduced toxicity and without increasing the relapse rate by comparison with a classical anthracycline-AraC consolidation regimen.

Study Overview

• Status: Unknown
• Conditions: Leukemia, Promyelocytic, Acute
• Intervention / Treatment: Procedure: Arsenic trioxide; Procedure: ATRA

Detailed Description

Definition: Extended description of the protocol, including information not already contained in other fields, such as comparison(s) studied.

APL is a specific type of acute myeloid leukemia (AML) characterized by its morphology (M3 or M3v in the FAB classification), t(15;17) translocation leading to PML-RARa fusion gene, and by a specific coagulopathy combining D.I.C., fibrinolysis and non specific proteolysis. ATRA can differentiate APL blasts in VITRO and in vivo. The combination of ATRA and anthracycline based chemotherapy yields CR rates greater than 90% in newly diagnosed APL. With early introduction of anthracycline AraC chemotherapy during induction treatment, and maintenance combining continuous 6MP and MTX to intermittent ATRA, the relapse risk in APL therefore now appears to be in the range of 10 to 15%.

Nevertheless, 5 to 10% of the patients do not achieve CR and 10% to 15% still relapse. Another subset of patients (5 to 7% in APL 93 trial including 17% of patients aged greater than 65 years) die in CR, from complications of the consolidation treatment phase, mainly from infection during chemotherapy induced aplasia. Failure to achieve CR with current treatment approaches is almost exclusively due to early death during induction treatment. Causes of death are predominantly bleeding, ATRA syndrome and less often infection. Early deaths predominate in elderly patients and patients with high WBC counts. Reducing the amount of chemotherapy administered to newly diagnosed APL patients diminishes this toxicity. The Spanish PETHEMA group reported results of two successive phase II trials in newly diagnosed APL with ATRA and chemotherapy with intercalating agents (idarubicin and mitoxantrone) without AraC followed by maintenance combining ATRA and low dose chemotherapy (LPA96 and LPA99 trials). Results appeared similar to those of the best arm of APL 93 trial, but with less toxicity and only 2 to 3 % death in CR were seen, including in elderly patients.

Arsenic trioxide (As2O3 or ATO) is an effective agent in relapsing or refractory APL, which induced 85% hematological and 79% molecular CR rates in a pivotal US study. The interest of ATO in the front-line therapy of newly-diagnosed APL has been strongly suggested in three studies which showed high complete remission rate, low incidence of relapse and limited toxicity.

In this study, patients will be stratified based on age (≤ 70 years and > 70 years) and WBC count at diagnosis (WBC<10.000/mm3 and >10.000 /mm3).

-Patients aged 70 years or less with WBC<10.000/mm3.

In this population (about 70 % of APL) the best treatment group of APL2000 trial (ATRA with early introduction of anthracycline-AraC chemotherapy but where Idarubicin will be substituted for Daunorubicin, followed by 2 anthracycline-AraC consolidation courses and maintenance combining continuous chemotherapy and intermittent ATRA) will be compared to the same regimen, but without AraC during consolidation courses which will be replaced by:

• either ATO

• or ATRA It is hoped that the investigational arms will further increase the event-free survival at 2 years, with reduced toxicity and without increasing the relapse rate by comparison with a classical anthracycline-AraC consolidation regimen.

  • Patients aged 70 years or less with WBC>10.000/mm3 Patients ages 70 years or less with initial WBC counts > 10000/mm3 (ie very high counts for APL), which represent about 20% of APL, remain at relatively high risk of relapse even with the current reference treatment. The main objective of the study will be to test the addition of ATO during consolidation courses to our current standard ATRA and chemotherapy regimen. Patients will receive the best treatment group of APL 2000 trial (but where Idarubicin will be substituted for Daunorubicin) with or without ATO during the 2 consolidation cycles.
  • Patients older than 70 years with WBC<10.000 /mm3. Elderly patients with initial WBC ≤ 10000/m3 (about 8% of APL) and no contra indication to this treatment will receive a regimen with reduced cumulative dose of chemotherapy but addition of ATO during consolidation courses and during the first year of maintenance treatment. The main purpose of this non randomized part of the trial is to reduce the early death mortality and death in CR observed in elderly patients, without increasing the relapse rate.
  • Patients older than 70 years with WBC>10.000 /mm3. Elderly patients with initial WBC > 10000/m3 (about 2 to 3% of APL) and no contra indication to intensive regimen will receive the same regimen as those with low WBC but with moderate doses of Aracytine during the induction and during the first consolidation course. The main purpose of this non randomized part of the trial is to reduce the early death mortality and death in CR observed in elderly patients, without increasing the relapse rate.

• Study Type: Interventional
• Enrollment (Anticipated): 800
• Phase: Phase 3

Contacts and Locations

• Study Contact: Name: Lionel ADES, MD; Phone Number: +33(0)-148 95 70 55; Email: Lionel.ades@avc.aphp.fr

Study Locations

• France
  • Bobigny, France, 93000
    • Recruiting
    • CHU Avicenne
    • Contact: Lionel ADES, MD,PhD; Phone Number: +33(0)- 148 95 70 55; Email: Lionel.ades@avc.aphp.fr
    • Principal Investigator: Lionel ADES, MD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Diagnosis of APL based on morphological grounds, which will have to be confirmed by the presence of t(15;17) and/or PML-RARA rearrangement with characterization of the bcr subtype (PML-RAR characterization).
• Untreated patients.
• No contraindication to intensive chemotherapy (especially well documented cardiac contraindication to idarubicin).
• In female patients: absence of pregnancy and adequate contraceptive methods (due to teratogenetic effects of ATRA in early pregnancy).
• Absence of Hypersensitivity to Arsenic derivatives.
• No QT interval prolongation or complete atria-ventricular block.
• Written informed consent.

Exclusion Criteria:

• Patients already treated.
• Patients with contraindication to intensive chemotherapy, especially well documented cardiac contraindication to Idarubicin.
• In female patients: pregnancy or absence of adequate contraceptive Methods
• QT interval prolongation or complete atria-ventricular block.
• Hypersensitivity to Arsenic derivatives.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: 1; Arsenic trioxide	Procedure: Arsenic trioxide; Arsenic trioxide; Procedure: ATRA; ATRA

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
For Patients aged 70 years or less with WBC<10.000/mm3, The primary end point will be event free survival at 2 years from CR achievement	For Patients aged 70 years or less with WBC<10.000/mm3, The primary end point	during de study
For patients older than 70 years with WBC>10.000 /mm3, The primary end point will be EFS at 2 years from diagnosis	For patients older than 70 years with WBC>10.000 /mm3, The primary end point will be EFS at 2 years from diagnosis	during the study

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
For Patients aged 70 years or less with WBC<10.000/mm3 :	For Patients aged 70 years or less with WBC<10.000/mm3 :	during the study
Relapse (molecular or hematological).	Relapse (molecular or hematological).	during the study
Kinetics of decrease of PML-RARA transcript level during and after consolidation course.	Kinetics of decrease of PML-RARA transcript level during and after consolidation course.	during the study
Survival at 2 years.	Survival at 2 years.	during the study
Side effects of the treatment, including treatment-related mortality and morbidity of consolidation treatment.	Side effects of the treatment, including treatment-related mortality and morbidity of consolidation treatment.	during th study
Days on antibiotics, transfusion requirement and nights spent in Hospital	Days on antibiotics, transfusion requirement and nights spent in Hospital	during the study
For Patients aged 70 years or less with WBC>10.000/mm3	For Patients aged 70 years or less with WBC>10.000/mm3	during the study
event free survival at 2 years from CR achievement	event free survival at 2 years from CR achievement	during the study
Side effects of the treatment, including treatment-related mortality and morbidity of consolidation treatment.	Side effects of the treatment, including treatment-related mortality and morbidity of consolidation treatment.	during the study
For Patients older than 70 years with WBC<10.000 /mm3	For Patients older than 70 years with WBC<10.000 /mm3	during the study
Kinetics of decrease of PML-RARA transcript level during and after consolidation course.	Kinetics of decrease of PML-RARA transcript level during and after	during the study
Relapse and survival at 2 years.	Relapse and survival at 2 years.	during the study
Side effects of the treatment, including mortality and morbidity of consolidation treatment.	Side effects of the treatment, including mortality and morbidity of	during the study
For patients older than 70 years with WBC>10.000 /mm3	For patients older than 70 years with WBC>10.000 /mm3	during the study

Collaborators and Investigators

• Sponsor: Assistance Publique - Hôpitaux de Paris
• Investigators: Principal Investigator: Lionel ADES, MD,PhD, Assistance Publique - Hôpitaux de Paris

Publications and helpful links

General Publications

• Ades L, Thomas X, Bresler AG, Raffoux E, Spertini O, Vey N, Marchand T, Recher C, Pigneux A, Girault S, Deconinck E, Gardin C, Tournilhac O, Lambert JF, Chevallier P, de Botton S, Lejeune J, Dombret H, Chevret S, Fenaux P. Arsenic trioxide is required in the treatment of newly diagnosed acute promyelocytic leukemia. Analysis of a randomized trial (APL 2006) by the French Belgian Swiss APL group. Haematologica. 2018 Dec;103(12):2033-2039. doi: 10.3324/haematol.2018.198614. Epub 2018 Jul 19.

Study record dates

Study Major Dates

• Study Start: October 1, 2006
• Primary Completion (Anticipated): September 1, 2016
• Study Completion (Anticipated): September 1, 2016

Study Registration Dates

• First Submitted: September 18, 2006
• First Submitted That Met QC Criteria: September 19, 2006
• First Posted (Estimate): September 20, 2006

Study Record Updates

• Last Update Posted (Estimate): April 16, 2014
• Last Update Submitted That Met QC Criteria: April 15, 2014
• Last Verified: March 1, 2007

More Information

Terms related to this study

• Keywords: Idarubicin; ATRA; Arsenic trioxide; Acute promyelocytic leukaemia; Patient with a newly acute promyelocytic leukaemia (APL); Unmapped MeSH term
• Additional Relevant MeSH Terms: Neoplasms by Histologic Type; Neoplasms; Leukemia, Myeloid; Leukemia, Myeloid, Acute; Leukemia; Leukemia, Promyelocytic, Acute; Antineoplastic Agents; Arsenic Trioxide
• Other Study ID Numbers: P050604