Investigational New Drugs

, Volume 33, Issue 2, pp 371–379 | Cite as

A phase I and pharmacodynamic study of the histone deacetylase inhibitor belinostat plus azacitidine in advanced myeloid neoplasia

  • Olatoyosi OdenikeEmail author
  • Anna Halpern
  • Lucy A. Godley
  • Jozef Madzo
  • Theodore Karrison
  • Margaret Green
  • Noreen Fulton
  • Ryan J. Mattison
  • Karen. W. L. Yee
  • Meghan Bennett
  • Gregory Koval
  • Gregory Malnassy
  • Richard A. Larson
  • Mark J. Ratain
  • Wendy Stock


Background We hypothesized that targeting two mechanisms of epigenetic silencing would be additive or synergistic with regard to expression of specific target genes. The primary objective of the study was to establish the maximum tolerated dose (MTD) of belinostat in combination with a fixed dose of azacitidine (AZA). Methods In Part A of the study, patients received a fixed dose of AZA, with escalating doses of belinostat given on the same days 1–5, in a 28 day cycle. Part B was designed to evaluate the relative contribution of belinostat to the combination based on analysis of pharmacodynamic markers, and incorporated a design in which patients were randomized during cycle 1 to AZA alone, or the combination, at the maximally tolerated dose of belinostat. Results 56 patients with myeloid neoplasia were enrolled. Dose escalation was feasible in part A, up to 1000 mg/m2 dose level of belinostat. In Part B, 18 patients were assessable for quantitative analysis of specific target genes. At day 5 of therapy, MDR1 was significantly up-regulated in the belinostat/AZA arm compared with AZA alone arm (p = 0.0023). There were 18 responses among the 56 patients. Conclusions The combination of belinostat and AZA is feasible and associated with clinical activity. The recommended phase II dose is 1000 mg/m2 of belinostat plus 75 mg/m2 of AZA on days 1–5, every 28 days. Upregulation in MDR1 was observed in the combination arm at day 5 compared with the AZA alone arm, suggesting a relative biologic contribution of belinostat to the combination.


Belinostat Azacitidine Myeloid neoplasm Histone deacetylase inhibitor DNA methyltransferase inhibitor MDR1 DNA hypomethylating agent 



This work was supported by: NCI (grant # U01-CA69852) in collaboration with Spectrum Pharmaceuticals.

Conflict of Interest

Olatoyosi Odenike received research funding from Curagen/Topotarget, and has served on advisory boards convened by Spectrum pharmaceuticals, Suneisis, Sanofi-Aventis, Incyte and Algeta pharmaceuticals.

Lucy A. Godley has received research support from Pharmion/Celgene.

Ryan J Mattison has served on advisory boards convened by Bristol Myers Squibb and Incyte pharmaceuticals.

Karen Yee has served as a consultant for Celgene.

Mark J. Ratain has served as a consultant for Onconova and Cyclacel.


  1. 1.
    Chen J, Odenike O, Rowley JD (2010) Leukaemogenesis: more than mutant genes. Nat Rev Cancer 10(1):23–36. doi: 10.1038/nrc2765 CrossRefPubMedCentralPubMedGoogle Scholar
  2. 2.
    Jones PL, Veenstra GJ, Wade PA, Vermaak D, Kass SU, Landsberger N, Strouboulis J, Wolffe AP (1998) Methylated DNA and MeCP2 recruit histone deacetylase to repress transcription. Nat Genet 19(2):187–191. doi: 10.1038/561 CrossRefPubMedGoogle Scholar
  3. 3.
    Cameron EE, Bachman KE, Myohanen S, Herman JG, Baylin SB (1999) Synergy of demethylation and histone deacetylase inhibition in the re-expression of genes silenced in cancer. Nat Genet 21(1):103–107. doi: 10.1038/5047 CrossRefPubMedGoogle Scholar
  4. 4.
    Belinsky SA, Grimes MJ, Picchi MA, Mitchell HD, Stidley CA, Tesfaigzi Y, Channell MM, Liu Y, Casero RA Jr, Baylin SB, Reed MD, Tellez CS, March TH (2011) Combination therapy with vidaza and entinostat suppresses tumor growth and reprograms the epigenome in an orthotopic lung cancer model. Cancer Res 71(2):454–462. doi: 10.1158/0008-5472.CAN-10-3184 CrossRefPubMedCentralPubMedGoogle Scholar
  5. 5.
    Steele N, Finn P, Brown R, Plumb JA (2009) Combined inhibition of DNA methylation and histone acetylation enhances gene re-expression and drug sensitivity in vivo. Br J Cancer 100(5):758–763. doi: 10.1038/sj.bjc.6604932 CrossRefPubMedCentralPubMedGoogle Scholar
  6. 6.
    Suzuki H, Gabrielson E, Chen W, Anbazhagan R, van Engeland M, Weijenberg MP, Herman JG, Baylin SB (2002) A genomic screen for genes upregulated by demethylation and histone deacetylase inhibition in human colorectal cancer. Nat Genet 31(2):141–149. doi: 10.1038/ng892 CrossRefPubMedGoogle Scholar
  7. 7.
    Klisovic MI, Maghraby EA, Parthun MR, Guimond M, Sklenar AR, Whitman SP, Chan KK, Murphy T, Anon J, Archer KJ, Rush LJ, Plass C, Grever MR, Byrd JC, Marcucci G (2003) Depsipeptide (FR 901228) promotes histone acetylation, gene transcription, apoptosis and its activity is enhanced by DNA methyltransferase inhibitors in AML1/ETO-positive leukemic cells. Leukemia 17(2):350–358. doi: 10.1038/sj.leu.2402776 CrossRefPubMedGoogle Scholar
  8. 8.
    Kantarjian H, Issa JP, Rosenfeld CS, Bennett JM, Albitar M, DiPersio J, Klimek V, Slack J, de Castro C, Ravandi F, Helmer R 3rd, Shen L, Nimer SD, Leavitt R, Raza A, Saba H (2006) Decitabine improves patient outcomes in myelodysplastic syndromes: results of a phase III randomized study. Cancer 106(8):1794–1803. doi: 10.1002/cncr.21792 CrossRefPubMedGoogle Scholar
  9. 9.
    Silverman LR, Demakos EP, Peterson BL, Kornblith AB, Holland JC, Odchimar-Reissig R, Stone RM, Nelson D, Powell BL, DeCastro CM, Ellerton J, Larson RA, Schiffer CA, Holland JF (2002) Randomized controlled trial of azacitidine in patients with the myelodysplastic syndrome: a study of the cancer and leukemia group B. J Clin Oncol 20(10):2429–2440CrossRefPubMedGoogle Scholar
  10. 10.
    Silverman LR, McKenzie DR, Peterson BL, Holland JF, Backstrom JT, Beach CL, Larson RA (2006) Further analysis of trials with azacitidine in patients with myelodysplastic syndrome: studies 8421, 8921, and 9221 by the Cancer and Leukemia Group B. J Clin Oncol 24(24):3895–3903. doi: 10.1200/JCO.2005.05.4346 CrossRefPubMedGoogle Scholar
  11. 11.
    Byrd JC, Marcucci G, Parthun MR, Xiao JJ, Klisovic RB, Moran M, Lin TS, Liu S, Sklenar AR, Davis ME, Lucas DM, Fischer B, Shank R, Tejaswi SL, Binkley P, Wright J, Chan KK, Grever MR (2005) A phase 1 and pharmacodynamic study of depsipeptide (FK228) in chronic lymphocytic leukemia and acute myeloid leukemia. Blood 105(3):959–967. doi: 10.1182/blood-2004-05-1693 CrossRefPubMedGoogle Scholar
  12. 12.
    Odenike OM, Alkan S, Sher D, Godwin JE, Huo D, Brandt SJ, Green M, Xie J, Zhang Y, Vesole DH, Stiff P, Wright J, Larson RA, Stock W (2008) Histone deacetylase inhibitor romidepsin has differential activity in core binding factor acute myeloid leukemia. Clin Cancer Res 14(21):7095–7101. doi: 10.1158/1078-0432.CCR-08-1007 CrossRefPubMedGoogle Scholar
  13. 13.
    Cashen A, Juckett M, Jumonville A, Litzow M, Flynn PJ, Eckardt J, LaPlant B, Laumann K, Erlichman C, DiPersio J (2012) Phase II study of the histone deacetylase inhibitor belinostat (PXD101) for the treatment of myelodysplastic syndrome (MDS). Ann Hematol 91(1):33–38. doi: 10.1007/s00277-011-1240-1 CrossRefPubMedCentralPubMedGoogle Scholar
  14. 14.
    Kirschbaum MH, Foon KA, Frankel P, Ruel C, Pulone B, Tuscano JM, Newman EM (2014) A phase 2 study of belinostat (PXD101) in patients with relapsed or refractory acute myeloid leukemia or patients over the age of 60 with newly diagnosed acute myeloid leukemia: a California Cancer Consortium Study. Leuk Lymphoma. doi: 10.3109/10428194.2013.877134 PubMedGoogle Scholar
  15. 15.
    Blum W, Klisovic RB, Hackanson B, Liu Z, Liu S, Devine H, Vukosavljevic T, Huynh L, Lozanski G, Kefauver C, Plass C, Devine SM, Heerema NA, Murgo A, Chan KK, Grever MR, Byrd JC, Marcucci G (2007) Phase I study of decitabine alone or in combination with valproic acid in acute myeloid leukemia. J Clin Oncol 25(25):3884–3891. doi: 10.1200/JCO.2006.09.4169 CrossRefPubMedGoogle Scholar
  16. 16.
    Garcia-Manero G, Kantarjian HM, Sanchez-Gonzalez B, Yang H, Rosner G, Verstovsek S, Rytting M, Wierda WG, Ravandi F, Koller C, Xiao L, Faderl S, Estrov Z, Cortes J, O’Brien S, Estey E, Bueso-Ramos C, Fiorentino J, Jabbour E, Issa JP (2006) Phase 1/2 study of the combination of 5-aza-2′-deoxycytidine with valproic acid in patients with leukemia. Blood 108(10):3271–3279. doi: 10.1182/blood-2006-03-009142 CrossRefPubMedCentralPubMedGoogle Scholar
  17. 17.
    Gore SD, Baylin S, Sugar E, Carraway H, Miller CB, Carducci M, Grever M, Galm O, Dauses T, Karp JE, Rudek MA, Zhao M, Smith BD, Manning J, Jiemjit A, Dover G, Mays A, Zwiebel J, Murgo A, Weng LJ, Herman JG (2006) Combined DNA methyltransferase and histone deacetylase inhibition in the treatment of myeloid neoplasms. Cancer Res 66(12):6361–6369. doi: 10.1158/0008-5472.CAN-06-0080 CrossRefPubMedGoogle Scholar
  18. 18.
    Steele NL, Plumb JA, Vidal L, Tjornelund J, Knoblauch P, Rasmussen A, Ooi CE, Buhl-Jensen P, Brown R, Evans TR, DeBono JS (2008) A phase 1 pharmacokinetic and pharmacodynamic study of the histone deacetylase inhibitor belinostat in patients with advanced solid tumors. Clin Cancer Res 14(3):804–810. doi: 10.1158/1078-0432.CCR-07-1786 CrossRefPubMedGoogle Scholar
  19. 19.
    Cheson BD, Bennett JM, Kopecky KJ, Buchner T, Willman CL, Estey EH, Schiffer CA, Doehner H, Tallman MS, Lister TA, Lo-Coco F, Willemze R, Biondi A, Hiddemann W, Larson RA, Lowenberg B, Sanz MA, Head DR, Ohno R, Bloomfield CD (2003) Revised recommendations of the international working group for diagnosis, standardization of response criteria, treatment outcomes, and reporting standards for therapeutic trials in acute myeloid leukemia. J Clin Oncol 21(24):4642–4649. doi: 10.1200/JCO.2003.04.036 CrossRefPubMedGoogle Scholar
  20. 20.
    Cheson BD, Greenberg PL, Bennett JM, Lowenberg B, Wijermans PW, Nimer SD, Pinto A, Beran M, de Witte TM, Stone RM, Mittelman M, Sanz GF, Gore SD, Schiffer CA, Kantarjian H (2006) Clinical application and proposal for modification of the International Working Group (IWG) response criteria in myelodysplasia. Blood 108(2):419–425. doi: 10.1182/blood-2005-10-4149 CrossRefPubMedGoogle Scholar
  21. 21.
    Jiemjit A, Fandy TE, Carraway H, Bailey KA, Baylin S, Herman JG, Gore SD (2008) p21(WAF1/CIP1) induction by 5-azacytosine nucleosides requires DNA damage. Oncogene 27(25):3615–3623. doi: 10.1038/sj.onc.1211018 CrossRefPubMedCentralPubMedGoogle Scholar
  22. 22.
    Robey RW, Zhan Z, Piekarz RL, Kayastha GL, Fojo T, Bates SE (2006) Increased MDR1 expression in normal and malignant peripheral blood mononuclear cells obtained from patients receiving depsipeptide (FR901228, FK228, NSC630176). Clin Cancer Res 12(5):1547–1555. doi: 10.1158/1078-0432.CCR-05-1423 CrossRefPubMedGoogle Scholar
  23. 23.
    Prebet T, Sun Z, Figueroa ME, Ketterling R, Melnick A, Greenberg PL, Herman J, Juckett M, Smith MR, Malick L, Paietta E, Czader M, Litzow M, Gabrilove J, Erba HP, Gore SD, Tallman MS (2014) Prolonged administration of azacitidine with or without entinostat for myelodysplastic syndrome and acute myeloid leukemia with myelodysplasia-related changes: results of the US Leukemia Intergroup trial E1905. J Clin Oncol 32(12):1242–1248. doi: 10.1200/JCO.2013.50.3102 CrossRefPubMedGoogle Scholar
  24. 24.
    Henrique R, Oliveira AI, Costa VL, Baptista T, Martins AT, Morais A, Oliveira J, Jeronimo C (2013) Epigenetic regulation of MDR1 gene through post-translational histone modifications in prostate cancer. BMC Genomics 14:898. doi: 10.1186/1471-2164-14-898 CrossRefPubMedCentralPubMedGoogle Scholar
  25. 25.
    Kantharidis P, El-Osta A, deSilva M, Wall DM, Hu XF, Slater A, Nadalin G, Parkin JD, Zalcberg JR (1997) Altered methylation of the human MDR1 promoter is associated with acquired multidrug resistance. Clin Cancer Res 3(11):2025–2032PubMedGoogle Scholar
  26. 26.
    Lee TB, Park JH, Min YD, Kim KJ, Choi CH (2008) Epigenetic mechanisms involved in differential MDR1 mRNA expression between gastric and colon cancer cell lines and rationales for clinical chemotherapy. BMC Gastroenterol 8:33. doi: 10.1186/1471-230X-8-33 CrossRefPubMedCentralPubMedGoogle Scholar
  27. 27.
    Efferth T, Futscher BW, Osieka R (2001) 5-Azacytidine modulates the response of sensitive and multidrug-resistant K562 leukemic cells to cytostatic drugs. Blood Cells Mol Dis 27(3):637–648. doi: 10.1006/bcmd.2001.0427 CrossRefPubMedGoogle Scholar
  28. 28.
    Hauswald S, Duque-Afonso J, Wagner MM, Schertl FM, Lubbert M, Peschel C, Keller U, Licht T (2009) Histone deacetylase inhibitors induce a very broad, pleiotropic anticancer drug resistance phenotype in acute myeloid leukemia cells by modulation of multiple ABC transporter genes. Clin Cancer Res 15(11):3705–3715. doi: 10.1158/1078-0432.CCR-08-2048 CrossRefPubMedGoogle Scholar
  29. 29.
    David GL, Yegnasubramanian S, Kumar A, Marchi VL, De Marzo AM, Lin X, Nelson WG (2004) MDR1 promoter hypermethylation in MCF-7 human breast cancer cells: changes in chromatin structure induced by treatment with 5-Aza-cytidine. Cancer Biol Ther 3(6):540–548CrossRefPubMedGoogle Scholar
  30. 30.
    Garcia-Manero G, Tambaro FP, Bekele NB, Yang H, Ravandi F, Jabbour E, Borthakur G, Kadia TM, Konopleva MY, Faderl S, Cortes JE, Brandt M, Hu Y, McCue D, Newsome WM, Pierce SR, de Lima M, Kantarjian HM (2012) Phase II trial of vorinostat with idarubicin and cytarabine for patients with newly diagnosed acute myelogenous leukemia or myelodysplastic syndrome. J Clin Oncol 30(18):2204–2210. doi: 10.1200/JCO.2011.38.3265 CrossRefPubMedGoogle Scholar
  31. 31.
    Gojo I, Tan M, Fang HB, Sadowska M, Lapidus R, Baer MR, Carrier F, Beumer JH, Anyang BN, Srivastava RK, Espinoza-Delgado I, Ross DD (2013) Translational phase I trial of vorinostat (suberoylanilide hydroxamic acid) combined with cytarabine and etoposide in patients with relapsed, refractory, or high-risk acute myeloid leukemia. Clin Cancer Res 19(7):1838–1851. doi: 10.1158/1078-0432.CCR-12-3165 CrossRefPubMedCentralPubMedGoogle Scholar
  32. 32.
    Piekarz RL, Frye R, Turner M, Wright JJ, Allen SL, Kirschbaum MH, Zain J, Prince HM, Leonard JP, Geskin LJ, Reeder C, Joske D, Figg WD, Gardner ER, Steinberg SM, Jaffe ES, Stetler-Stevenson M, Lade S, Fojo AT, Bates SE (2009) Phase II multi-institutional trial of the histone deacetylase inhibitor romidepsin as monotherapy for patients with cutaneous T-cell lymphoma. J Clin Oncol 27(32):5410–5417. doi: 10.1200/JCO.2008.21.6150 CrossRefPubMedCentralPubMedGoogle Scholar
  33. 33.
    Klco JM, Spencer DH, Lamprecht TL, Sarkaria SM, Wylie T, Magrini V, Hundal J, Walker J, Varghese N, Erdmann-Gilmore P, Lichti CF, Meyer MR, Townsend RR, Wilson RK, Mardis ER, Ley TJ (2013) Genomic impact of transient low-dose decitabine treatment on primary AML cells. Blood 121(9):1633–1643. doi: 10.1182/blood-2012-09-459313 CrossRefPubMedCentralPubMedGoogle Scholar
  34. 34.
    Fenaux P, Mufti GJ, Hellstrom-Lindberg E, Santini V, Gattermann N, Germing U, Sanz G, List AF, Gore S, Seymour JF, Dombret H, Backstrom J, Zimmerman L, McKenzie D, Beach CL, Silverman LR (2010) Azacitidine prolongs overall survival compared with conventional care regimens in elderly patients with low bone marrow blast count acute myeloid leukemia. J Clin Oncol 28(4):562–569. doi: 10.1200/JCO.2009.23.8329 CrossRefPubMedGoogle Scholar
  35. 35.
    Pleyer L, Burgstaller S, Girschikofsky M, Linkesch W, Stauder R, Pfeilstocker M, Schreder M, Tinchon C, Sliwa T, Lang A, Sperr WR, Krippl P, Geissler D, Voskova D, Schlick K, Thaler J, Machherndl-Spandl S, Theiler G, Eckmullner O, Greil R (2014) Azacitidine in 302 patients with WHO-defined acute myeloid leukemia: results from the Austrian Azacitidine Registry of the AGMT-Study Group. Ann Hematol 93(11):1825–1838. doi: 10.1007/s00277-014-2126-9 CrossRefPubMedCentralPubMedGoogle Scholar
  36. 36.
    Al-Ali HK, Jaekel N, Junghanss C, Maschmeyer G, Krahl R, Cross M, Hoppe G, Niederwieser D (2012) Azacitidine in patients with acute myeloid leukemia medically unfit for or resistant to chemotherapy: a multicenter phase I/II study. Leuk Lymphoma 53(1):110–117. doi: 10.3109/10428194.2011.606382 CrossRefPubMedGoogle Scholar
  37. 37.
    Tawfik B, Sliesoraitis S, Lyerly S, Klepin HD, Lawrence J, Isom S, Ellis LR, Manuel M, Dralle S, Berenzon D, Powell BL, Pardee T (2014) Efficacy of the hypomethylating agents as frontline, salvage, or consolidation therapy in adults with acute myeloid leukemia (AML). Ann Hematol 93(1):47–55. doi: 10.1007/s00277-013-1940-9 CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Olatoyosi Odenike
    • 1
    • 2
    • 5
    Email author
  • Anna Halpern
    • 1
  • Lucy A. Godley
    • 1
    • 2
  • Jozef Madzo
    • 1
  • Theodore Karrison
    • 2
  • Margaret Green
    • 1
  • Noreen Fulton
    • 1
  • Ryan J. Mattison
    • 3
  • Karen. W. L. Yee
    • 4
  • Meghan Bennett
    • 1
  • Gregory Koval
    • 1
  • Gregory Malnassy
    • 1
  • Richard A. Larson
    • 1
    • 2
  • Mark J. Ratain
    • 1
    • 2
  • Wendy Stock
    • 1
    • 2
  1. 1.Department of MedicineThe University of ChicagoChicagoUSA
  2. 2.The University of Chicago Comprehensive Cancer CenterChicagoUSA
  3. 3.The University of Wisconsin and the Carbone Comprehensive Cancer CenterMadisonUSA
  4. 4.Princess Margaret HospitalTorontoUSA
  5. 5.Section of Hematology/OncologyThe University of ChicagoChicagoUSA

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