Venetoclax and Azacitidine for the Treatment of Acute Myeloid Leukemia in the Post-Transplant Setting

Inclusion Criteria

• COHORTS 1 AND 2 (MAINTENANCE COHORT)
• Patients 18 to 75 years of age
• English and non-English speaking patients are eligible
• Disease diagnosis with one of the hematological malignancies listed below and who are in morphological remission after allogeneic stem cell transplantation with peripheral blood stem cell (PBSC)s or bone marrow. * AML if they had at least one of the following disease characteristics: ** Therapy related AML ** Cytogenetics and molecular features consistent with adverse risk group by European LeukemiaNet classification for AML ** Primary induction failure defined as absence of complete remission after two different lines of anti-leukemia therapy following diagnosis ** Presence of minimal residual disease by multi-color flow cytometry or cytogenetics or molecular studies at the time of HSCT ** Presence of active disease defined as bone marrow blast count > 5% at the time of HSCT ** Patients transplanted beyond first remission OF * Biphenotypic or bilineage leukemia (including a myeloid component) OR mixed phenotype acute leukemia (MPAL) OR * Patients with acute lymphoblastic leukemia; B cell or T cell in original
• Patients in morphological remission with no detectable minimal residual disease (MRD) after transplant
• Patients who are in remission with no detectable minimal residual disease (MRD) after allogeneic stem cell transplant should have: * Adequate engraftment within 14 days prior to starting study drug: * Absolute neutrophil count (ANC) >= 1.0 x 10^9/L without daily use of myeloid growth factor (granulocyte colony-stimulating factor [G-CSF]) for at least 7 days; and * Platelet >= 30 x 10^9/L without platelet transfusion within 1 week * Be able to start the drug therapy between 42 to 100 days following HSCT
• Use of one of the conditioning regimens as part of allogeneic stem cell transplant listed below: * Reduced intensity regimen with fludarabine/melphalan (100-140 mg/m^2) with or without total body irradiation (TBI) with post-transplant Cytoxan OR * Myeloablative regimens including: ** Busulfan (area under the curve [AUC] at or greater than 4000)/fludarabine with post-transplant Cytoxan or total body irradiation (TBI)/etoposide with any graft versus host disease (GVHD) regimen OR ** Total body irradiation (TBI)/etoposide with any graft versus host disease (GVHD) regimen
• Patients on clinical trials investigating different conditioning regimens (with the above described backbone) with investigational agents will be allowed to enroll.
• Eastern Cooperative Oncology Group (ECOG) performance status of 0, 1, or 2.
• Serum creatinine =< 1.5 mg/dL or creatinine clearance greater or equal than 40 cc/min as defined by the Cockcroft-Gault equation.
• Serum bilirubin =< 1.5 x upper limit of normal (ULN).
• Aspartate transaminase (AST) or alanine transaminase (ALT) =< 2.5 x ULN.
• Alkaline phosphatase =< 2.5 x UL.
• Capable of understanding the investigational nature, potential risks and benefits of the study, and able to provide valid informed consent.
• Negative serum or urine pregnancy test for women with reproductive potential. The only subjects who will be exempt from this criterion are postmenopausal women (defined as women who have been amenorrheic for > 12 months) or subjects who have been surgically sterilized or otherwise proven sterile.
• COHORTS 3 AND 4 (MRD POSITIVE COHORT)
• Patients 18 to 75 years of age.
• English and non-English speaking patients are eligible.
• Disease diagnosis with one of the hematological malignancies listed below and who are in morphological remission after allogeneic stem cell transplantation with PBSCs or bone marrow. * AML OR * Biphenotypic or bilineage leukemia (including a myeloid component) or mixed phenotype acute leukemia (MPAL) OR * Patients with acute lymphoblastic leukemia; B cell or T cell in original.
• Persistence or reappearance of MRD by flow cytometry or cytogenetic or molecular testing while being in morphological remission after allogeneic stem cell transplantation * When MRD is detected by flow cytometry, disease level at or above the sensitivity level of the test will be required ** MRD level at or above 0.01% for B cell ALL and T cell ALL ** MRD level at or above 0.1% for AML and mixed phenotype acute leukemia * When MRD is detected by cytogenetics, disease level at or above the sensitivity level of the test will be required ** The limited of detection is about 0.25% for males and 0.44% for females * When MRD is detected by molecular testing, disease level at or above the sensitivity level of the test will be required ** The limited of detection is 0.01%
• Use of one of the conditioning regimens as part of allogeneic stem cell transplant listed below: * Reduced intensity regimen with fludarabine/melphalan (100-140 mg/m^2) with or without total-body irradiation (TBI) with post-transplant Cytoxan * Myeloablative regimens including: ** Busulfan (AUC at or greater than 4000)/fludarabine with post-transplant Cytoxan or total body irradiation (TBI)/etoposide with any graft versus host disease (GVHD) regimen OR ** Total body irradiation (TBI)/etoposide with any graft versus host disease (GVHD) regimen.
• Patients on clinical trials investigating different conditioning regimens (with the above described backbone) with investigational agents will be allowed to enroll
• ECOG performance status of 0, 1, or 2
• Serum creatinine =< 1.5 mg/dL or creatinine clearance greater or equal than 40 cc/min as defined by the Cockcroft-Gault equation
• Serum bilirubin =< 1.5 x upper limit of normal (ULN)
• Aspartate transaminase (AST) or alanine transaminase (ALT) =< 2.5 x ULN
• Alkaline phosphatase =< 2.5 x UL
• Capable of understanding the investigational nature, potential risks and benefits of the study, and able to provide valid informed consent
• Negative serum or urine pregnancy test for women with reproductive potential. The only subjects who will be exempt from this criterion are postmenopausal women (defined as women who have been amenorrheic for > 12 months) or subjects who have been surgically sterilized or otherwise proven sterile
• Disease diagnosis with one of the hematological malignancies listed below and who are in morphological remission after allogeneic stem cell transplantation with peripheral blood stem cell (PBSC)s or bone marrow * AML OR * Biphenotypic or bilineage leukemia (including a myeloid component) or mixed phenotype acute leukemia (MPAL) OR * Patients with acute lymphoblastic leukemia; B cell or T cell in original

Exclusion Criteria

• Active acute GVHD grade II or higher
• Active chronic GVHD that is extensive
• Uncontrolled GVHD
• Concurrent use of systemic immune suppressive other than calcineurin inhibitors, sirolimus and steroids
• Active uncontrolled systemic fungal, bacterial or viral infection
• Active bleeding
• Symptomatic or uncontrolled arrhythmias
• Significant active cardiac disease within the previous 6 months, including: * New York Heart Association (NYHA) class III or IV congestive heart failure. Unstable angina or angina requiring surgical or medical intervention and/or * Myocardial infarction
• Known active viral infection with human immunodeficiency virus (HIV), hepatitis B virus (HBV) or hepatitis C virus (HCV)
• Prior history of malignancies, other than leukemia, unless the subject has been free of the disease for >= 1 year. However, subjects with the following history/concurrent conditions are allowed: * Basal or squamous cell carcinoma of the skin * Carcinoma in situ of the cervix * Carcinoma in situ of the breast * Incidental histologic finding of prostate cancer (T1a or T1b using the tumor, node, metastasis [TNM] clinical staging system)
• Patients with cognitive impairments and/or any serious unstable pre-existing medical condition or psychiatric disorder that can interfere with safety or with obtaining informed consent or compliance with study procedures