MS-275 and GM-CSF in Treating Patients With Myelodysplastic Syndrome and/or Relapsed or Refractory Acute Myeloid Leukemia or Acute Lymphocytic Leukemia

PRIMARY OBJECTIVE:

I. Determine clinical response in patients with myelodysplastic syndromes and/or relapsed or refractory acute myeloid leukemia or acute lymphocytic leukemia treated with MS-275 in combination with sargramostim (GM-CSF).

SECONDARY OBJECTIVES:

I. Determine the clinical activity of this regimen, in terms of changes in peripheral blood counts and changes in individual patient transfusion requirements, in these patients.

II. Determine the biologic activity of this regimen, in terms of changes in the peripheral blood and bone marrow phenotype (i.e., induction of markers of myeloid differentiation or lymphoid differentiation) and changes in detectable cytogenetic abnormalities in the blood and marrow compartments, in these patients.

III. Determine the toxicity profile of this regimen in these patients.

OUTLINE:

Patients receive oral MS-275 on days 1, 8, 15, and 22. Patients also receive sargramostim (GM-CSF) subcutaneously once daily on days 1-42 in courses 3 and 5 and on days 1-35 in courses 1, 2, 4, and 6. Treatment repeats every 6 weeks for 2-6 courses in the absence of disease progression or unacceptable toxicity.

After completion of 2 courses of study therapy, patients who achieve a complete or partial response may receive an additional 4 courses. Patients who maintain stable disease for more than 2 months after completion of 6 courses of study therapy may receive an additional 6 courses at the time of disease progression, provided they meet original eligibility criteria.

Patients undergo blood and bone marrow (BM) collection at baseline and periodically during study for biologic correlative studies. Peripheral blood and bone marrow samples are assessed for changes in progenitor phenotype and clonogenic growth by flow cytometry and for changes in cytogenetics (i.e., malignant:nonmalignant cell ratio in BM CD34-positive cells, peripheral blood monocytes, peripheral blood neutrophils, and bone marrow and peripheral blood lymphoblasts) by FISH. Terminal differentiation of CD34-positive progenitor cells is studied in vitro in long-term cultures.

After completion of study therapy, patients are followed periodically for up to 2 years.

Inclusion criteria

• Diagnosis of 1 of the following diseases by bone marrow aspiration and/or biopsy:

• Myelodysplastic syndromes (MDS) meeting the following criteria:
• Must have 1 of the following subtypes:
• Refractory anemia (RA) (no RA with 5q-syndrome),
• RA with ringed sideroblasts or
• Refractory cytopenia with multilineage dysplasia
• Myelodysplastic syndromes (MDS) meeting the following criteria:

Must have 1 of the following subtypes:

• Refractory cytopenia with multilineage dysplasia and ringed sideroblasts,
• RA with excess blasts (RAEB)-1, RAEB-2,
• Myelodysplastic syndromes, unclassified or
• Chronic myelomonocytic leukemia

• International Prognostic Scoring System score of intermediate-2 or high-risk
• Acute myeloid leukemia (AML) meeting 1 of the following criteria:
• Relapsed or refractory AML, including any of the following subtypes:
• * AML with recurrent cytogenetic abnormalities (i.e., AML with 11q23 [MLL] abnormalities)
• AML with multilineage dysplasia
• AML that is therapy-related
• AML, not otherwise categorized (M0 [minimally differentiated], M1 [without maturation], M2 [with maturation], M4 [myelomonocytic leukemia], M5 [monoblastic/monocytic leukemia], M6 [erythroid leukemia], and M7 [megakaryoblastic leukemia])

• Untreated AML
• Newly diagnosed patients are eligible provided they do not qualify for potentially curative intensive chemotherapeutic regimens

• Acute lymphocytic leukemia (ALL) meeting 1 of the following criteria:
• Relapsed or refractory ALL
• Patients with any measurable residual disease are eligible, including cytogenetic abnormalities

• Untreated ALL
• Newly diagnosed patients are eligible provided they do not qualify for potentially curative intensive chemotherapeutic regimens, including any of the following:
• Patients who have refused chemotherapy for untreated ALL
• Patients who are deemed to be poor candidates medically for ALL induction chemotherapy

• Relatively stable bone marrow function for > 7 days prior to study entry
• WBC count that has not doubled within the past 7 days
• WBC =<10,000/mm³

• No uncontrolled peripheral leukemia (i.e., blast count > 30,000/mm³)
• No active CNS disease
• Lumbar puncture with negative cytology required for patients with clinical symptoms of active CNS disease

• Not a candidate for a potentially curative allogeneic stem cell transplantation OR considered a poor candidate for such a procedure due to age, medical comorbidities, or lack of a suitable donor
• Hemoglobin >= 8 g/dL (transfusions allowed)
• Creatinine =< 2.0 mg/dL
• Bilirubin =< 1.6 mg/dL (unless secondary to hemolysis)
• AST or ALT =< 3 times upper limit of normal (unless disease-related)
• Not pregnant or nursing
• Negative pregnancy test
• Fertile patients must use effective contraception
• No untreated or progressive infections
• No history of intolerance to sargramostim (GM-CSF)
• Recovered from all treatment-related toxicities
• More than 2 weeks since prior therapy for AML, ALL, or MDS, including chemotherapy, hematopoietic growth factors, or biologic therapy such as monoclonal antibodies
• Concurrent hydroxyurea allowed during course 1 for control of leukocytosis if WBC > 30,000/mm³
• ECOG performance status 0-2