Vorasidenib, a Dual Inhibitor of Mutant IDH1/2, in Recurrent or Progressive Glioma; Results of a First-in-Human Phase I Trial
Ingo K Mellinghoff, Marta Penas-Prado, Katherine B Peters, Howard A Burris 3rd, Elizabeth A Maher, Filip Janku, Gregory M Cote, Macarena I de la Fuente, Jennifer L Clarke, Benjamin M Ellingson, Saewon Chun, Robert J Young, Hua Liu, Sung Choe, Min Lu, Kha Le, Islam Hassan, Lori Steelman, Shuchi S Pandya, Timothy F Cloughesy, Patrick Y Wen, Ingo K Mellinghoff, Marta Penas-Prado, Katherine B Peters, Howard A Burris 3rd, Elizabeth A Maher, Filip Janku, Gregory M Cote, Macarena I de la Fuente, Jennifer L Clarke, Benjamin M Ellingson, Saewon Chun, Robert J Young, Hua Liu, Sung Choe, Min Lu, Kha Le, Islam Hassan, Lori Steelman, Shuchi S Pandya, Timothy F Cloughesy, Patrick Y Wen
Abstract
Purpose: Lower grade gliomas (LGGs) are malignant brain tumors. Current therapy is associated with short- and long-term toxicity. Progression to higher tumor grade is associated with contrast enhancement on MRI. The majority of LGGs harbor mutations in the genes encoding isocitrate dehydrogenase 1 or 2 (IDH1/IDH2). Vorasidenib (AG-881) is a first-in-class, brain-penetrant, dual inhibitor of the mutant IDH1 and mutant IDH2 enzymes.
Patients and methods: We conducted a multicenter, open-label, phase I, dose-escalation study of vorasidenib in 93 patients with mutant IDH1/2 (mIDH1/2) solid tumors, including 52 patients with glioma that had recurred or progressed following standard therapy. Vorasidenib was administered orally, once daily, in 28-day cycles until progression or unacceptable toxicity. Enrollment is complete; this trial is registered with ClinicalTrials.gov, NCT02481154.
Results: Vorasidenib showed a favorable safety profile in the glioma cohort. Dose-limiting toxicities of elevated transaminases occurred at doses ≥100 mg and were reversible. The protocol-defined objective response rate per Response Assessment in Neuro-Oncology criteria for LGG in patients with nonenhancing glioma was 18% (one partial response, three minor responses). The median progression-free survival was 36.8 months [95% confidence interval (CI), 11.2-40.8] for patients with nonenhancing glioma and 3.6 months (95% CI, 1.8-6.5) for patients with enhancing glioma. Exploratory evaluation of tumor volumes in patients with nonenhancing glioma showed sustained tumor shrinkage in multiple patients.
Conclusions: Vorasidenib was well tolerated and showed preliminary antitumor activity in patients with recurrent or progressive nonenhancing mIDH LGG.
©2021 The Authors; Published by the American Association for Cancer Research.
Figures
References
- GBD 2016 Brain and Other CNS Cancer Collaborators. Global, regional, and national burden of brain and other CNS cancer, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 2019;18:376–93.
- Louis DN, Perry A, Reifenberger G, von Deimling A, Figarella-Branger D, Cavenee WK, et al. . The 2016 World Health Organization Classification of Tumors of the Central Nervous System: a summary. Acta Neuropathol 2016;131:803–20.
- Cancer Genome Atlas Research Network, Brat DJ, Verhaak RGW, Aldape KD, Yung WKA, Salama SR, Cooper LAD, et al.. Comprehensive, integrative genomic analysis of diffuse lower-grade gliomas. N Engl J Med 2015;372:2481–98.
- Pallud J, Capelle L, Taillandier L, Fontaine D, Mandonnet E, Guillevin R, et al. . Prognostic significance of imaging contrast enhancement for WHO grade II gliomas. Neuro Oncol 2009;11:176–82.
- van den Bent MJ, Smits M, Kros JM, Chang SM. Diffuse infiltrating oligodendroglioma and astrocytoma. J Clin Oncol 2017;35:2394–401.
- Weller M, van den Bent M, Preusser M, Le Rhun E, Tonn JC, Minniti G, et al. . EANO guidelines on the diagnosis and treatment of diffuse gliomas of adulthood. Nat Rev Clin Oncol 2021;18:170–86.
- Claus EB, Walsh KM, Wiencke JK, Molinaro AM, Wiemels JL, Schildkraut JM, et al. . Survival and low-grade glioma: the emergence of genetic information. Neurosurg Focus 2015;38:E6.
- Hardee ME, Zagzag D. Mechanisms of glioma-associated neovascularization. Am J Pathol 2012;181:1126–41.
- Klein M, Heimans JJ, Aaronson NK, van der Ploeg HM, Grit J, Muller M, et al. . Effect of radiotherapy and other treatment-related factors on mid-term to long-term cognitive sequelae in low-grade gliomas: a comparative study. Lancet 2002;360:1361–8.
- McAleer MF, Brown PD. Neurocognitive function following therapy for low-grade gliomas. Semin Radiat Oncol 2015;25:210–8.
- Dang L, White DW, Gross S, Bennett BD, Bittinger MA, Driggers EM, et al. . Cancer-associated IDH1 mutations produce 2-hydroxyglutarate. Nature 2010;465:966.
- Ward PS, Patel J, Wise DR, Abdel-Wahab O, Bennett BD, Coller HA, et al. . The common feature of leukemia-associated IDH1 and IDH2 mutations is a neomorphic enzyme activity converting alpha-ketoglutarate to 2-hydroxyglutarate. Cancer Cell 2010;17:225–34.
- Lu C, Ward PS, Kapoor GS, Rohle D, Turcan S, Abdel-Wahab O, et al. . IDH mutation impairs histone demethylation and results in a block to cell differentiation. Nature 2012;483:474–8.
- Xu W, Yang H, Liu Y, Yang Y, Wang P, Kim SH, et al. . Oncometabolite 2-hydroxyglutarate is a competitive inhibitor of α-ketoglutarate-dependent dioxygenases. Cancer Cell 2011;19:17–30.
- Rohle D, Popovici-Muller J, Palaskas N, Turcan S, Grommes C, Campos C, et al. . An inhibitor of mutant IDH1 delays growth and promotes differentiation of glioma cells. Science 2013;340:626–30.
- Wang F, Travins J, DeLaBarre B, Penard-Lacronique V, Schalm S, Hansen E, et al. . Targeted inhibition of mutant IDH2 in leukemia cells induces cellular differentiation. Science 2013;340:622–6.
- Saha SK, Parachoniak CA, Ghanta KS, Fitamant J, Ross KN, Najem MS, et al. . Mutant IDH inhibits HNF-4α to block hepatocyte differentiation and promote biliary cancer. Nature 2014;513:110–4.
- DiNardo CD, Stein EM, de Botton S, Roboz GJ, Altman JK, Mims AS, et al. . Durable remissions with ivosidenib in IDH1-mutated relapsed or refractory AML. N Engl J Med 2018;378:2386–98.
- Stein EM, DiNardo CD, Pollyea DA, Fathi AT, Roboz GJ, Altman JK, et al. . Enasidenib in mutant IDH2 relapsed or refractory acute myeloid leukemia. Blood 2017;130:722–31.
- Mellinghoff IK, Ellingson BM, Touat M, Maher E, De La Fuente MI, Holdhoff M, et al. . Ivosidenib in isocitrate dehydrogenase 1-mutated advanced glioma. J Clin Oncol 2020;38:3398–406.
- Konteatis Z, Artin E, Nicolay B, Straley K, Padyana AK, Jin L, et al. . Vorasidenib (AG-881): a first-in-class, brain-penetrant dual inhibitor of mutant IDH1 and 2 for treatment of glioma. ACS Med Chem Lett 2020;11:101–7.
- Nicolay B, Narayanaswamy R, Amatangelo MD, Aguado E, Nagaraja R, Murtie J, et al. . EXTH-34. Combined use of the pan-IDH mutant inhibitor AG-881 with radiation therapy shows added benefit in an orthotopic IDH1 mutant glioma model in vivo. Neuro Oncol 2017;19:vi79.
- Harding JJ, Lowery MA, Shih AH, Schvartzman JM, Hou S, Famulare C, et al. . Isoform switching as a mechanism of acquired resistance to mutant isocitrate dehydrogenase inhibition. Cancer Discov 2018;8:1540–7.
- Wen PY, Macdonald DR, Reardon DA, Cloughesy TF, Sorensen AG, Galanis E, et al. . Updated response assessment criteria for high-grade gliomas: response assessment in neuro-oncology working group. J Clin Oncol 2010;28:1963–72.
- van den Bent MJ, Wefel JS, Schiff D, Taphoorn MJ, Jaeckle K, Junck L, et al. . Response assessment in neuro-oncology (a report of the RANO group): assessment of outcome in trials of diffuse low-grade gliomas. Lancet Oncol 2011;12:583–93.
- Eisenhauer EA, Therasse P, Bogaerts J, Schwartz LH, Sargent D, Ford R, et al. . New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer 2009;45:228–47.
- Okada H, Weller M, Huang R, Finocchiaro G, Gilbert MR, Wick W, et al. . Immunotherapy response assessment in neuro-oncology: a report of the RANO working group. Lancet Oncol 2015;16:e534–42.
- Neuenschwander B, Branson M, Gsponer T. Critical aspects of the Bayesian approach to phase I cancer trials. Stat Med 2008;27:2420–39.
- Mellinghoff I, Cloughesy T, Wen P, Taylor J, Maher E, Arrillaga-Romany I, et al. . ACTR-66. A phase 1, open-label, perioperative study of ivosidenib (AG-120) and vorasidenib (AG-881) in recurrent IDH1 mutant, low-grade glioma: updated results. Neuro Oncol 2019;21:vi28–9.
- Baumert BG, Hegi ME, van den Bent MJ, von Deimling A, Gorlia T, Hoang-Xuan K, et al. . Temozolomide chemotherapy versus radiotherapy in high-risk low-grade glioma (EORTC 22033–26033): a randomised, open-label, phase 3 intergroup study. Lancet Oncol 2016;17:1521–32.
- Houillier C, Wang X, Kaloshi G, Mokhtari K, Guillevin R, Laffaire J, et al. . IDH1 or IDH2 mutations predict longer survival and response to temozolomide in low-grade gliomas. Neurology 2010;75:1560–6.
- Jonsson P, Lin AL, Young RJ, DiStefano NM, Hyman DM, Li BT, et al. . Genomic correlates of disease progression and treatment response in prospectively characterized gliomas. Clin Cancer Res 2019;25:5537–47.
- Johnson BE, Mazor T, Hong C, Barnes M, Aihara K, McLean CY, et al. . Mutational analysis reveals the origin and therapy-driven evolution of recurrent glioma. Science 2014;343:189–93.
Source: PubMed