Tretinoin + Arsenic Trioxide (+/- Gemtuzumab) for Leukemia

Recruiting at 4 trial locations

Overseen by Farhad Ravandi-Kashani

Age: Any Age

Sex: Any

Travel: May Be Covered

Time Reimbursement: Varies

Trial Phase: Phase 2

Recruiting

Sponsor: M.D. Anderson Cancer Center

Disqualifiers: QTcF interval > 480ms, High creatinine, High bilirubin, High ALT/AST

No Placebo Group

Prior Safety Data

Trial Summary

What is the purpose of this trial?

This study is evaluating whether a combination of drugs may help treat acute promyelocytic leukemia.

Will I have to stop taking my current medications?

The trial information does not specify whether you need to stop taking your current medications. It's best to discuss this with the trial coordinators or your doctor.

What data supports the effectiveness of the drug arsenic trioxide in treating leukemia?

Arsenic trioxide has shown to be highly effective in treating acute promyelocytic leukemia (APL), achieving complete remission in over 80% of patients with relapsed disease and improving event-free survival when used as part of consolidation therapy. It has also been studied in other types of leukemia, showing some effectiveness when combined with other drugs. ^{1 2 3 4 5}

Is the combination of Tretinoin and Arsenic Trioxide safe for treating leukemia?

The combination of Tretinoin (all-trans retinoic acid) and Arsenic Trioxide has been used to treat acute promyelocytic leukemia and is generally well tolerated. Common side effects include fatigue, rash, fluid retention, and changes in heart rhythm, but serious side effects are rare. Studies have shown that this treatment can be safe when used at recommended doses. ^{1 6 7 8 9}

What makes the drug combination of Tretinoin and Arsenic Trioxide unique for treating leukemia?

This drug combination is unique because Arsenic Trioxide is highly effective in treating acute promyelocytic leukemia (APL), especially in relapsed cases, and when combined with Tretinoin, it can improve event-free and overall survival rates. Additionally, this combination can achieve complete molecular remission even in patients with resistant forms of the disease, offering a novel approach compared to traditional chemotherapy. ^{1 2 3 4 10}

Research Team

Farhad Ravandi-Kashani

Principal Investigator

M.D. Anderson Cancer Center

Eligibility Criteria

This trial is for patients with a new diagnosis of acute promyelocytic leukemia (APL) confirmed by specific genetic tests. Participants must understand the study and agree to sign consent forms. Those who have started emergency APL treatment can join, and women of childbearing age need negative pregnancy tests before and during the study. Contraception use is required for all sexually active participants.

Inclusion Criteria

Ability to understand and the willingness to sign a written informed consent document indicating that they are aware of the investigational nature of the study

I started emergency treatment for APL, including ATRA, ATO, or idarubicin.

I agree to use two effective birth control methods during the study.

Exclusion Criteria

Patients with alanine aminotransferase (ALT)/aspartate aminotransferase (AST) > 3 times upper limit of normal unless felt to be related the underlying leukemia by the treating physician or hemolysis or Gilbert's disease

Fridericia corrected QT (QTcF) interval on the electrocardiogram (EKG) greater than 480 milliseconds

Patients with creatinine > 2.5 times upper limit of normal unless felt to be related the underlying leukemia by the treating physician or hemolysis or Gilbert's disease

Trial Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Induction

Patients receive tretinoin orally twice daily, arsenic trioxide intravenously over 1-2 hours daily, and gemtuzumab ozogamicin intravenously over 2 hours once at weeks 1-4

4 weeks

Consolidation

Patients achieving complete response receive arsenic trioxide IV 5 days per week during weeks 1-4, 9-12, 17-20, and 25-28 and tretinoin PO BID for 2 weeks on and 2 weeks off. Treatment repeats every 8 weeks for up to 4 courses

32 weeks

Follow-up

Participants are monitored for safety and effectiveness after treatment

Up to 2 years

Treatment Details

Interventions

• Arsenic Trioxide (Arsenic-containing Agent)
• Gemtuzumab Ozogamicin (Monoclonal Antibodies)
• Tretinoin (Retinoid)

Trial Overview The trial is testing how well tretinoin and arsenic trioxide work together, with or without an additional drug called gemtuzumab ozogamicin, in treating newly diagnosed APL patients. The goal is to see if adding gemtuzumab ozogamicin can kill more cancer cells without harming normal cells.

Participant Groups

Group I: Treatment (tretinoin, arsenic trioxide, gemtuzumab ozogamicin) Experimental Treatment 4 Interventions

INDUCTION: Patients receive tretinoin PO BID, arsenic trioxide IV over 1-2 hours daily, and gemtuzumab ozogamicin IV over 2 hours once at weeks 1-4. CONSOLIDATION: Patients achieving CR receive arsenic trioxide IV 5 days per week during weeks 1-4, 9-12, 17-20, and 25-28 and tretinoin PO BID for 2 weeks on and 2 weeks off. Treatment repeats every 8 weeks for up to 4 courses in the absence of disease progression or unacceptable toxicity.

Who Is Running the Clinical Trial?

M.D. Anderson Cancer Center

Lead Sponsor

Trials

3,107

Recruited

1,813,000+

Dr. Peter WT Pisters

M.D. Anderson Cancer Center

Chief Executive Officer since 2017

MD from University of Western Ontario

Dr. Jeffrey E. Lee

M.D. Anderson Cancer Center

Chief Medical Officer

MD from Stanford University School of Medicine

National Cancer Institute (NCI)

Collaborator

Trials

14,080

Recruited

41,180,000+

Dr. Douglas R. Lowy

National Cancer Institute (NCI)

Chief Executive Officer since 2023

MD from New York University School of Medicine

Dr. Monica Bertagnolli

National Cancer Institute (NCI)

Chief Medical Officer since 2022

MD from Harvard Medical School

Findings from Research

Arsenic trioxide is highly effective in treating acute promyelocytic leukemia (APL), achieving complete remissions in over 80% of relapsed patients and molecular remission in 90% of those who reach complete remission.

Clinical trials indicate that arsenic trioxide not only benefits relapsed APL patients but also shows promise in first-line treatment and consolidation therapy, improving event-free and overall survival rates.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

New data with arsenic trioxide in leukemias and myelodysplastic syndromes. Sekeres, MA.[2019]

Arsenic trioxide (As2O3) combined with all-trans retinoic acid (ATRA) successfully achieved complete molecular remission in a patient with secondary, relapsed, resistant promyelocytic leukemia, despite the patient's severe complications.

The treatment was notable for its lack of significant toxicity, allowing the patient to undergo a bone marrow autograft after reaching complete remission.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Arsenic and all-trans retinoic acid as induction therapy before autograft in a case of relapsed resistant secondary acute promyelocytic leukemia. Galimberti, S., Papineschi, F., Carmignani, A., et al.[2018]

Arsenic trioxide, combined with low-dose ara-C, was tested in a phase I/II trial involving 113 patients (49 with myelodysplastic syndrome and 64 with acute myeloid leukemia), showing that the treatment was generally well tolerated and led to complete remissions in both groups.

This combination therapy demonstrated efficacy even in patients with poor baseline health and unfavorable genetic profiles, highlighting arsenic trioxide's potential as a valuable treatment option for high-risk blood cancers.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Arsenic and old lace: novel approaches in elderly patients with acute myeloid leukemia. Roboz, GJ.[2018]

In a study of 481 patients with untreated acute promyelocytic leukemia (APL), the addition of arsenic trioxide (As(2)O(3)) to standard treatment significantly improved event-free survival at 3 years (80% vs. 63%).

Patients receiving As(2)O(3) also showed better disease-free survival rates (90% vs. 70% at 3 years), indicating that As(2)O(3) is an effective consolidation treatment for newly diagnosed APL.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Arsenic trioxide improves event-free and overall survival for adults with acute promyelocytic leukemia: North American Leukemia Intergroup Study C9710. Powell, BL., Moser, B., Stock, W., et al.[2021]

In a study of 129 adult patients with acute promyelocytic leukemia (APL), maintenance therapy using ATRA, arsenic trioxide, and ascorbic acid (AAA) demonstrated a favorable safety profile with no severe organ toxicities and resulted in high long-term survival rates, with 5-year overall survival at 94%.

The maintenance therapy led to a low relapse rate of 13% over a median follow-up of 100 months, indicating that AAA is effective in maintaining first complete remission (CR1) in APL patients.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Oral arsenic trioxide, all-trans retinoic acid, and ascorbic acid maintenance after first complete remission in acute promyelocytic leukemia: Long-term results and unique prognostic indicators. Gill, HS., Yim, R., Kumana, CR., et al.[2021]

In a study of 20 patients with acute promyelocytic leukemia (APL), the combination of all-trans retinoic acid (ATRA) and arsenic trioxide (As(2)O(3)) resulted in a high complete remission (CR) rate of 94.4%, with 17 out of 18 evaluable patients achieving CR.

The treatment was well-tolerated, showing no significant side effects, indicating that this combination therapy is both effective and safe for APL patients.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

[Preliminary observation of the combination of arsenic trioxide and all-trans retinoic acid for the treatment of acute promyelocytic leukemia]. Zhao, YZ., Li, HQ., Li, DP., et al.[2018]

Arsenic trioxide (AT) has shown high efficacy in treating acute promyelocytic leukemia (APL), achieving complete remission in 80% to 90% of patients with refractory or relapsed cases, while being well tolerated at a dose of 0.15 mg/kg/d.

Common side effects include fatigue, rash, and QTc-interval prolongation, but ongoing research is exploring its combination with retinoic acid and potential use in other blood cancers and solid tumors.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Arsenicals in hematologic cancers. Novick, SC., Warrell, RP.[2018]

The novel oral formulation ORH-2014 of arsenic trioxide was found to be safe and well-tolerated in a phase 1 study involving 12 patients with advanced hematologic malignancies, with no dose-limiting toxicities and only one instance of grade III QT prolongation that resolved after treatment interruption.

At a dose of 15 mg, ORH-2014 achieved comparable plasma concentrations to the standard intravenous arsenic trioxide, indicating it provides similar therapeutic exposure while being easier to administer, making it a promising candidate for future clinical trials.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Oral arsenic trioxide ORH-2014 pharmacokinetic and safety profile in patients with advanced hematologic disorders. Ravandi, F., Koumenis, I., Johri, A., et al.[2021]

Arsenic trioxide (ATO) showed a complete remission (CR) rate of 97.5% in 41 patients with acute promyelocytic leukemia (APL), which is comparable to the 93.3% CR rate seen with all-trans retinoic acid (ATRA) in 30 patients.

ATO therapy resulted in a significantly shorter median time to complete remission (29 days) compared to ATRA (38.5 days), and ATRA was associated with a high incidence of retinoic acid syndrome (52.9%), suggesting ATO may be a safer and more effective first-line treatment for APL.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

[Comparison of efficacy and adverse effects between arsenic trioxide and all-trans retinoic acid in patients with acute promyelocytic leukemia]. Jiao, L., Wang, SJ., Zhuang, JL., et al.[2018]

Arsenic trioxide is a key treatment for acute promyelocytic leukemia and shows effectiveness against other leukemia types, but its side effects can limit its use, particularly in patients with complex symptoms.

Combining arsenic trioxide with other anticancer drugs, vitamins, and plant products can help reduce side effects and improve treatment outcomes, highlighting the need for careful clinical application to maximize benefits and minimize risks.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

An overview of arsenic trioxide-involved combined treatment algorithms for leukemia: basic concepts and clinical implications. Jiang, Y., Shen, X., Zhi, F., et al.[2023]

References

1. United States pubmed.ncbi.nlm.nih.gov

New data with arsenic trioxide in leukemias and myelodysplastic syndromes. [2019]

2. England pubmed.ncbi.nlm.nih.gov

Arsenic and all-trans retinoic acid as induction therapy before autograft in a case of relapsed resistant secondary acute promyelocytic leukemia. [2018]

3. United States pubmed.ncbi.nlm.nih.gov

Arsenic and old lace: novel approaches in elderly patients with acute myeloid leukemia. [2018]

4. United States pubmed.ncbi.nlm.nih.gov

Arsenic trioxide improves event-free and overall survival for adults with acute promyelocytic leukemia: North American Leukemia Intergroup Study C9710. [2021]

5. United States pubmed.ncbi.nlm.nih.gov

Oral arsenic trioxide, all-trans retinoic acid, and ascorbic acid maintenance after first complete remission in acute promyelocytic leukemia: Long-term results and unique prognostic indicators. [2021]

6. China pubmed.ncbi.nlm.nih.gov

[Preliminary observation of the combination of arsenic trioxide and all-trans retinoic acid for the treatment of acute promyelocytic leukemia]. [2018]

7. United States pubmed.ncbi.nlm.nih.gov

Arsenicals in hematologic cancers. [2018]

8. Italy pubmed.ncbi.nlm.nih.gov

Oral arsenic trioxide ORH-2014 pharmacokinetic and safety profile in patients with advanced hematologic disorders. [2021]

9. China pubmed.ncbi.nlm.nih.gov

[Comparison of efficacy and adverse effects between arsenic trioxide and all-trans retinoic acid in patients with acute promyelocytic leukemia]. [2018]

10. United States pubmed.ncbi.nlm.nih.gov

An overview of arsenic trioxide-involved combined treatment algorithms for leukemia: basic concepts and clinical implications. [2023]