Topotecan Hydrochloride and Carboplatin With or Without Veliparib in Treating Advanced Myeloproliferative Disorders and Acute Myeloid Leukemia or Chronic Myelomonocytic Leukemia

PRIMARY OBJECTIVE:

I. To estimate and compare the complete response/complete response with incomplete recovery (CR/CRi) rate of induction therapy with topotecan hydrochloride (topotecan)/carboplatin (T/C) with or without veliparib (V) in myeloproliferative disorder associated leukemias and chronic myelomonocytic leukemia (CMML).

SECONDARY OBJECTIVES:

I. To evaluate and compare the toxicities of T/C/V versus (vs.) T/C. II. To compare the 2-year disease-free survival (DFS) and overall survival (OS) in response to T/C/V vs. T/C.

III. To detect and compare the presence of minimal residual disease (MRD) remaining after T/C/V vs. T/C.

IV. Evaluate predictive biomarkers of response via assessment of pretreatment impaired homologous recombination via assessment of:

IVa. Next generation sequencing (NGS) panel for genes mutated in myeloid malignancies done as standard of care per institution.

IVb. Functional impairment of deoxyribonucleic acid (DNA) damage response via assessment of pretreatment samples for radiation-induced RAD51 foci.

IVc. Topotecan-induced stabilization of topoisomerase I-DNA covalent complexes, which has recently been observed to be a critical predictor of response to combination of a topoisomerase I poison and PARP inhibitor in xenografts.

V. To evaluate veliparib exposure and contribution to response (efficacy and toxicity).

OUTLINE: Patients are randomized to 1 of 2 arms.

ARM A: Patients receive veliparib orally (PO) twice daily (BID) on days 1-21 and topotecan hydrochloride intravenously (IV) continuously over 24 hours and carboplatin IV continuously over 24 hours on days 3-7. Treatment repeats every 28-63 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity.

ARM B: Patients receive topotecan hydrochloride IV continuously over 24 hours and carboplatin IV continuously over 24 hours on days 1-5. Treatment repeats every 28-63 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up for a minimum of 30 days, or longer.

• Carboplatin (Drug), also known as Blastocarb, Carboplat, Carboplatin Hexal, Carboplatino, Carboplatinum, Carbosin, Carbosol, Carbotec, CBDCA, Displata, Ercar, JM-8, JM8, Nealorin, Novoplatinum, Paraplatin, Paraplatin AQ, Paraplatine, Platinwas, Ribocarbo: Given IV
• Topotecan (Drug), also known as Hycamptamine, Topotecan Lactone: Given IV
• Topotecan Hydrochloride (Drug), also known as Evotopin, Hycamptamine, Hycamtin, Nogitecan Hydrochloride, Potactasol, SKF S 104864 A, SKF S-104864-A, SKF S104864A, Topotec, Topotecan HCl, topotecan hydrochloride (oral): Given IV
• Veliparib (Drug), also known as ABT 888, ABT-888, ABT888, PARP-1 inhibitor ABT-888: Given PO

Primary outcomes

• Number of Participants With a Response [Up to 7 months]: Based on published standards for acute leukemias, Complete Response (CR) means less than 5% leukemic blasts in the bone marrow, no blasts in the blood, no longer presence of cytogenetic abnormalities, no longer presence of extramedullary disease, with or without absolute neutrophil count or platelet count recovery; Partial Remission (PR) includes the criteria for Complete Remission except there are 5-25% leukemic blasts in the bone marrow and there is absolute neutrophil count and platelet count recovery; Hematologic Improvement (HI) means the disease has not gotten worse and there is at least a 20% decrease in the leukemic blasts in the bone marrow and/or a decrease in leukemia symptoms. Response = CR, PR, or HI.

Secondary outcomes

• The Highest Grade Adverse Event Experienced [Up to 7 months]: Adverse events were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 5.0.
• Number of Participants Without Disease at Study Completion [Up to 7 months]: Study completion was either death or completion of all protocol-specified activities, whichever came first. Participants who came off study due to disease-related death were counted as having disease.
• Duration of Disease-free Survival [Up to 7 months]: Disease-free survival is defined as participants who are still alive and without disease at study completion. Study completion was either death or completion of all protocol-specified activities, whichever came first.
• Number of Participants Still Alive at Study Completion [Up to 7 months]: Study completion was either death or completion of all protocol-specified activities, whichever came first.
• Duration of Overall Survival at the Time of Study Completion [Up to 7 months]: Study completion was either death or completion of all protocol-specified activities, whichever came first. Duration was measured from the date of registration to the participant's study completion date.
• Number of Participants With Minimal Residual Disease (MRD) After Treatment [Up to 7 months]: Minimal residual disease (MRD) refers to a small number of leukemic cells that remain after treatment.
• Distribution of Mutations in Deoxyribonucleic Acid (DNA) Repair Defects Via Assessment in Leukemia Mutation Panel [Baseline]: Will be summarized using descriptive statistics. The association response will be described with appropriate tests for continuously measured biomarkers (t tests, Wilcoxon rank sum tests) and categorical biomarkers (Fisher's exact test). Descriptive analyses will be performed for the whole cohort and also separately for Arms A and B. Differential treatment outcomes for patient subgroups may be explored using appropriate tests for interactions.
• Frequency of Patients With Functional Impairment of DNA Damage Response Via Assessment With RAD51 Assay [Baseline]: Will be reported with exact binomial 95% confidence intervals. The association response will be described with appropriate tests for continuously measured biomarkers (t tests, Wilcoxon rank sum tests) and categorical biomarkers (Fisher's exact test). Descriptive analyses will be performed for the whole cohort and also separately for Arms A and B. Differential treatment outcomes for patient subgroups may be explored using appropriate tests for interactions.
• Topotecan-induced Stabilization of Topoisomerase I-DNA Covalent Complexes [Up to 7 months]: Topotecan-induced stabilization of topoisomerase I-DNA covalent complexes from peripheral blood
• Pharmacokinetic Sampling Studies Measured Using a Validated Liquid Chromatography/Tandem Mass Spectrometric Method in Plasma and Bone Marrow [Pre-treatment, day 1, day 8, day 14, day 15, and day 22 (approximately 24 hours post last dose)]: Plasma trough levels will be obtained weekly through the first cycle to provide a steady-state assessment. Steady-state plasma concentrations will be calculated for each patient. Exploratory correlative studies between veliparib exposure (plasma and bone marrow) with pharmacodynamic (biological endpoints, toxicity and efficacy) will be analyzed using nonparametric statistics. Significance for comparisons will be at the p < 0.05 level.

Sex: All, ages: 18 Years to any

Inclusion Criteria:

* PRE-REGISTRATION ELIGIBILITY CRITERIA
* Newly diagnosed acute myeloid leukemia (AML) associated with antecedent myeloproliferative disorder (polycythemia vera, essential thrombocythemia, myelofibrosis, atypical chronic myeloid leukemia, chronic myelomonocytic leukemia and related undifferentiated myeloproliferative/myelodysplastic disorders)
* Relapsed/refractory AML associated with antecedent myeloproliferative disorder (polycythemia vera, essential thrombocythemia, myelofibrosis, atypical chronic myeloid leukemia, chronic myelomonocytic leukemia and related undifferentiated myeloproliferative/myelodysplastic disorders) who have received two or fewer prior induction chemotherapy courses
* Accelerated phase myeloproliferative disorders per Zeider et al with two or fewer prior therapies

  * For aggressive phase myeloproliferative disorders (MPD) (polycythemia vera, essential thrombocythemia, Philadelphia \[Ph\]-negative chronic myelogenous leukemia), one or more of the following criteria must be met: marrow blasts > 5%, peripheral blood blasts plus progranulocytes > 10%, new onset or increasing myelofibrosis, new onset or > 25% increase in hepatomegaly or splenomegaly, new onset constitutional symptoms (fever, weight loss, splenic pain, bone pain). Zeider et al
  * For chronic myelomonocytic leukemia (CMML), the following criteria must be met: 5-19% bone marrow blasts (aggressive) or >= 20% marrow blasts (transformation)
* Bone marrow and/or peripheral blood specimens will be submitted for correlative studies; patients with a dry tap will still be eligible
* RANDOMIZATION ELIGIBILITY CRITERIA
* Bone marrow aspirate and/or peripheral blood specimens were submitted to the central lab and site has confirmation by the local institution that the patient meets one of the criteria specified above
* Eastern Cooperative Oncology Group (ECOG) performance status =< 2 or Karnofsky >= 60%
* Total bilirubin less than 2.0 mg/dL unless due to Gilbert's syndrome, then less than 5.0 mg/dL
* Aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase \[SGOT\])/alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase \[SGPT\]) less than 5 x institutional upper limit of normal
* Creatinine clearance glomerular filtration rate (GFR) greater than 30 ml/min per modified Cockcroft-Gault formula
* Interval of greater than 4 weeks since allogeneic blood or marrow transplantation (BMT) if performed; and absence of active graft versus host disease (GVHD)
* The effects of veliparib on the developing human fetus are unknown; for this reason and because PARP inhibiting agents as well as topoisomerase inhibitors and platinating agents are known to be teratogenic, women of child-bearing potential must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry, for the duration of study participation, and for 6 months following the last dose of study drug; should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately; men treated or enrolled on this protocol must also agree to use adequate contraception prior to the study, for the duration of study participation, and 4 months after completion of veliparib administration
* Ability to understand and the willingness to sign a written informed consent document

Exclusion Criteria:

* Patients who have had chemotherapy or radiotherapy within 4 weeks prior to entering the study with the exception of hydroxyurea for cytoreduction; therapy with tyrosine kinase inhibitors (TKIs) directed against JAK2, BCR-ABL or FLT3 will be allowed to be continued until 24 hours prior to start of therapy on trial
* Patients with active uncontrolled infection; antibiotic therapy for fevers, and continuation of treatment of prior infection are allowed
* Patients who have active central nervous system (CNS) disease are excluded; patients with known active CNS leukemia should be excluded from this clinical trial because of their poor prognosis and because they often develop progressive neurologic dysfunction that would confound the evaluation of neurologic and other adverse events
* Patients who are receiving any other investigational agents; patients who have completed therapy with an investigational agent should be off this therapy for at least 5 half-lives or two weeks, whichever is shorter
* History of allergic reactions attributed to compounds of similar chemical or biologic composition to veliparib, topotecan or carboplatin
* Uncontrolled intercurrent illness including, but not limited to, active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements
* Pregnant women are excluded from this study because veliparib is PARP inhibiting agent with the potential for teratogenic or abortifacient effects; because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with veliparib, breastfeeding should be discontinued if the mother is treated with veliparib; these potential risks may also apply to topotecan and carboplatin used in this study
* Human immunodeficiency virus (HIV)-patients positive patients are not excluded if they have CD4+ cells >= 250/mm\^3 and negligible viral load and are on a stable combination antiretroviral therapy
* History of uncontrolled seizure disorder, including focal or generalized seizure within the past year

Participant flow

Outcome results

• Number of Participants With a Response (Primary), Count of participants, Participants: Arm A (Veliparib, Topotecan Hydrochloride, Carboplatin) 5; Arm B (Topotecan Hydrochloride, Carboplatin) 4
• The Highest Grade Adverse Event Experienced (Secondary), Count of participants, Participants: Arm A (Veliparib, Topotecan Hydrochloride, Carboplatin) 0; Arm B (Topotecan Hydrochloride, Carboplatin) 1
• Number of Participants Without Disease at Study Completion (Secondary), Count of participants, Participants: Arm A (Veliparib, Topotecan Hydrochloride, Carboplatin) 3; Arm B (Topotecan Hydrochloride, Carboplatin) 3
• Duration of Disease-free Survival (Secondary), Median, days: Arm A (Veliparib, Topotecan Hydrochloride, Carboplatin) 120 (37 to 137); Arm B (Topotecan Hydrochloride, Carboplatin) 89 (27 to 137)
• Number of Participants Still Alive at Study Completion (Secondary), Count of participants, Participants: Arm A (Veliparib, Topotecan Hydrochloride, Carboplatin) 5; Arm B (Topotecan Hydrochloride, Carboplatin) 5
• Duration of Overall Survival at the Time of Study Completion (Secondary), Median, Days: Arm A (Veliparib, Topotecan Hydrochloride, Carboplatin) 83 (74 to 295); Arm B (Topotecan Hydrochloride, Carboplatin) 123 (82 to 295)
• Number of Participants With Minimal Residual Disease (MRD) After Treatment (Secondary)
• Distribution of Mutations in Deoxyribonucleic Acid (DNA) Repair Defects Via Assessment in Leukemia Mutation Panel (Secondary)
• Frequency of Patients With Functional Impairment of DNA Damage Response Via Assessment With RAD51 Assay (Secondary)
• Topotecan-induced Stabilization of Topoisomerase I-DNA Covalent Complexes (Secondary)
• Pharmacokinetic Sampling Studies Measured Using a Validated Liquid Chromatography/Tandem Mass Spectrometric Method in Plasma and Bone Marrow (Secondary)

Adverse events

Time frame: Up 7 months

Serious adverse events by term

Other adverse events by term

144 more terms not shown.

• Results publication: Richardson DR, Green SD, Foster MC, Zeidner JF. Secondary AML Emerging After Therapy with Hypomethylating Agents: Outcomes, Prognostic Factors, and Treatment Options. Curr Hematol Malig Rep. 2021 Feb;16(1):97-111. doi: 10.1007/s11899-021-00608-6. Epub 2021 Feb 20. PMID 33609248

• Study Protocol and Statistical Analysis Plan (PDF, 2019-10-24)

• Keith W Pratz, Principal investigator, JHU Sidney Kimmel Comprehensive Cancer Center LAO

NIH grants: UM1CA186691