Eprenetapopt (APR-246) and Azacitidine in <i>TP53</i>-Mutant Myelodysplastic Syndromes.

Abstract

Approximately 20% of patients with <i>TP53</i>-mutant myelodysplastic syndromes (MDS) achieve complete remission (CR) with hypomethylating agents. Eprenetapopt (APR-246) is a novel, first-in-class, small molecule that restores wild-type p53 functions in <i>TP53</i>-mutant cells. This was a phase Ib/II study to determine the safety, recommended phase II dose, and efficacy of eprenetapopt administered in combination with azacitidine in patients with <i>TP53</i>-mutant MDS or acute myeloid leukemia (AML) with 20%-30% marrow blasts (ClinicalTrials.gov identifier: NCT03072043). Fifty-five patients (40 MDS, 11 AML, and four MDS/myeloproliferative neoplasms) with at least one <i>TP53</i> mutation were treated. The overall response rate was 71% with 44% achieving CR. Of patients with MDS, 73% (n = 29) responded with 50% (n = 20) achieving CR and 58% (23/40) a cytogenetic response. The overall response rate and CR rate for patients with AML was 64% (n = 7) and 36% (n = 4), respectively. Patients with only <i>TP53</i> mutations by next-generation sequencing had higher rates of CR (69% <i>v</i> 25%; <i>P</i> = .006). Responding patients had significant reductions in <i>TP53</i> variant allele frequency and p53 expression by immunohistochemistry, with 21 (38%) achieving complete molecular remission (variant allele frequency < 5%). Median overall survival was 10.8 months with significant improvement in responding versus nonresponding patients by landmark analysis (14.6 <i>v</i> 7.5 months; <i>P</i> = .0005). Overall, 19/55 (35%) patients underwent allogeneic hematopoietic stem-cell transplant, with a median overall survival of 14.7 months. Adverse events were similar to those reported for azacitidine or eprenetapopt monotherapy, with the most common grade ≥ 3 adverse events being febrile neutropenia (33%), leukopenia (29%), and neutropenia (29%). Combination treatment with eprenetapopt and azacitidine is well-tolerated yielding high rates of clinical response and molecular remissions in patients with <i>TP53</i>-mutant MDS and oligoblastic AML.