FDA Approves Copanlisib for Follicular Lymphoma

The FDA has granted an accelerated approval to copanlisib (Aliqopa) as a treatment for patients with relapsed follicular lymphoma who have received at least 2 least prior systemic therapies.

The approval of copanlisib is based primarily on findings from the phase II CHRONOS-1 trial, which included patients with multiple types of lymphoma. In the study, 59% of patients achieved objective responses to the intravenous inhibitor of PI3K-alpha and delta. Responses were durable, and the median progression-free survival (PFS) approached 1 year.

“For patients with relapsed follicular lymphoma, the cancer often comes back even after multiple treatments,” Richard Pazdur, MD, director of the FDA’s Oncology Center of Excellence and acting director of the Office of Hematology and Oncology Products in the FDA’s Center for Drug Evaluation and Research, said in a statement. “Options are limited for these patients and today’s approval provides an additional choice for treatment, filling an unmet need for them.”

Copanlisib is an intravenous pan-class I PI3K inhibitor that has predominant activity against the PI3K-alpha and delta isoforms. The alpha isoform is broadly expressed and involved in insulin signaling and angiogenesis, as well as resistance mechanisms to lymphoma. The delta isoform is expressed by leukocytes and is involved in B-cell signaling, development, and survival.

Lymphoma subtypes included in the CHRONOS-1 study were follicular lymphoma (grades 1-3a), marginal zone lymphoma, small lymphocytic lymphoma, and lymphoplasmacytic lymphoma (LHL)/Waldenstrom macroglobulinemia (WM). Eligible patients had relapsed or refractory disease and failure of at least 2 prior lines of therapy.

Patients received copanlisib at 60 mg on days 1, 8, and 15, repeated every 28 days until disease progression or development of unacceptable toxicity. The primary endpoint was objective response by central review after a minimum of 16 weeks of treatment. Secondary endpoints included PFS, duration of response, overall survival, safety, and quality of life.

Data analysis included 142 patients who had a median age of 63. The median time since the most recent disease progression was 8.3 months, and the study population had received a median of 3 prior regimens. All of the patients had prior exposure to rituximab (Rituxan) and 1 or more alkylating agents, and 60.6% had disease that was refractory to the last regimen received.

Across the lymphoma subgroups, 80.3% of the patients had advanced disease (stage III or IV) at enrollment. Follicular lymphoma was the dominant lymphoma subtype, accounting for 73.2% of the study population.

Patients remained on treatment for a median duration of 22 weeks, during which time they received a median of 5.5 cycles of therapy and 96% of planned copanlisib doses.

All but a few patients had some degree of target lesion shrinkage in response to treatment with copanlisib. Patients with all lymphoma subtypes had lesion shrinkage.

The 59.2% overall response rate included complete responses in 12.0% of patients and partial responses in 47.2% of patients. An additional 29.6% of patients had stable disease, resulting in a disease control rate of 85.9%. Objective response rates were 59% or higher across all lymphoma subtypes except LHL/WM, wherein 1 of 6 patients with the subtype achieved an objective response with copanlisib.

The study population had a median PFS of 11.2 months (95% CI, 8.1-24.2). In the follicular lymphoma subgroup, the median PFS was also 11.2 months.

The most common adverse events (all grades) were hyperglycemia (48.6%), hypertension (28.9%), and decreased neutrophil count (24.6%). Grade 3 hyperglycemia occurred in 33.1% of patients and grade 4 in 7.0%. Grade 3 hypertension occurred in 22.5%. Grade 3 decreased neutrophil count occurred in 6.3% and grade 4 in 12.7% of the patients. The most common laboratory abnormalities were elevated liver enzymes, which was grade 1/2 in all but a few cases.

The accelerated approval of copanlisib is contingent upon the results of a confirmatory trial.

Dreyling M, Santoro A, Mollica L, et al. Copanlisib in patients with relapsed or refractory indolent B-cell lymphoma: primary results of the pivotal CHRONOS-1 study. Presented at: 2017 AACR Annual Meeting; April 1-5, 2017; San Washington, DC. Abstract CT149.