title: Phase I combination trial of lenalidomide and azacitidine in patients with higher-risk myelodysplastic syndromes.
abstract: OBJECTIVE
  Lenalidomide and azacitidine are active in patients with lower- and higher-risk myelodysplastic syndromes (MDS). These agents may complement each other by targeting both the bone marrow microenvironment and hypomethylating action on the malignant clone.
  
  
  METHODS
  This phase I trial explored the safety of combination therapy in patients with higher-risk MDS. Response and characterization of molecular and methylation status of responders were secondary objectives. Patients were enrolled using a 3 + 3 dose escalation. Cycles lasted 28 days, and patients received a maximum of seven cycles.
  
  
  RESULTS
  Of 18 patients enrolled, median age was 68 years (range, 52 to 78 years), interval from diagnosis was 5 weeks (range, 2 to 106 weeks), and follow-up was 7 months (range, 1 to 26 months). International Prognostic Scoring System categories were intermediate 1 (n = 2), intermediate 2 (n = 10), and high (n = 6). No dose-limiting toxicities occurred, and a maximum-tolerated dose was not reached. Grades 3 to 4 nonhematologic toxicities (> 1) included febrile neutropenia (n = 5), cardiac (n = 2), and CNS hemorrhage (n = 2). Median absolute neutrophil count decrease was 26%, and platelet decrease was 1% (mean, 24%). The overall response rate was 67%: eight patients (44%) had a complete response (CR); three patients (17%) had hematologic improvement; one patient (6%) had marrow CR. Patients achieving CR were more likely to have normal cytogenetics and lower methylation levels.
  
  
  CONCLUSIONS
  The combination of lenalidomide and azacitidine is well tolerated with encouraging clinical activity. The go-forward dose is azacitidine 75 mg/m(2) on days 1 through 5 and lenalidomide 10 mg on days 1 through 21.
authors.affiliation: Myelodsyplastic Syndromes Program, Department of Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, Desk R35, 9500 Euclid Ave, Cleveland, OH 44195, USA. sekerem@ccf.org
authors.forename: Mikkael A
authors.initials: MA
authors.lastname: Sekeres
authors.forename: Alan F
authors.initials: AF
authors.lastname: List
authors.forename: David
authors.initials: D
authors.lastname: Cuthbertson
authors.forename: Ronald
authors.initials: R
authors.lastname: Paquette
authors.forename: Rebecca
authors.initials: R
authors.lastname: Ganetzky
authors.forename: Rebecca
authors.initials: R
authors.lastname: Ganetsky
authors.forename: Deborah
authors.initials: D
authors.lastname: Latham
authors.forename: Katarina
authors.initials: K
authors.lastname: Paulic
authors.forename: Manuel
authors.initials: M
authors.lastname: Afable
authors.forename: Hussain I
authors.initials: HI
authors.lastname: Saba
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Loughran
authors.forename: Jaroslaw P
authors.initials: JP
authors.lastname: Maciejewski
mesh_terms: D000368:Aged; D001374:Azacitidine / Q000008:administration & dosage* / Q000009:adverse effects; D002869:Chromosome Aberrations; D019175:DNA Methylation / Q000187:drug effects*; D015254:DNA Modification Methylases / Q000037:antagonists & inhibitors*; D004252:DNA Mutational Analysis; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D004791:Enzyme Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D005260:Female; D006801:Humans; D007621:Karyotyping; D000077269:Lenalidomide; D008297:Male; D008875:Middle Aged; D009154:Mutation; D009190:Myelodysplastic Syndromes / Q000188:drug therapy* / Q000201:enzymology / Q000235:genetics; D011230:Precancerous Conditions / Q000188:drug therapy* / Q000201:enzymology / Q000235:genetics; D018570:Risk Assessment; D013792:Thalidomide / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
chemical_list: D004791:Enzyme Inhibitors; D013792:Thalidomide; D015254:DNA Modification Methylases; D000077269:Lenalidomide; D001374:Azacitidine