Blood Adv in press

Targeted therapy with nanatinostat and valganciclovir in recurrent
Epstein-Barr virus-positive lymphoid malignancies: a Phase 1b/2 study.

Haverkos BM, Alpdogan O, Baiocchi RA, Brammer JE, Feldman T, Capra M, Brem EA, Nair S, Scheinberg P, Pereira J, Shune L, Joffe E, Young P, Spruill SE, Katkov A, McRae R, Royston I, Faller DV, Rojkjaer L, Porcu P

Lymphomas are not infrequently associated with Epstein-Barr virus, with EBV-positivity linked to worse outcomes in several subtypes. Nanatinostat is a Class-I selective oral histone deacetylase inhibitor (HDACi) that induces expression of lytic EBV BGLF4 protein kinase in EBV+ tumor cells, activating ganciclovir via phosphorylation, resulting in tumor cell apoptosis. This Phase 1b/2 study (NCT03397706) investigated the combination of nanatinostat with valganciclovir in patients aged >=18 with EBV+ lymphomas relapsed/refractory to >=1 prior systemic therapies with no viable curative treatment options. In the Phase 1b part, 25 patients were enrolled into 5 dose escalation cohorts to determine the recommended Phase 2 dose (RP2D) for Phase 2 expansion. Phase 2 patients (n=30) received the RP2D (nanatinostat 20 mg daily, 4 days per week with valganciclovir 900 mg orally daily) in 28-day cycles. Primary endpoints were safety and RP2D determination (Phase 1b) and overall response rate (ORR; Phase 2). Overall, 55 patients were enrolled (B-NHLs [n=10], T/NK-NHLs [n=21], classical Hodgkin lymphoma [n=11], and immunodeficiency-associated lymphoproliferative disorders (IA-LPD) [n=13]). The ORR was 40% in 43 evaluable patients (complete response rate [CRR] 19% [n=8]) with a median duration of response of 10.4 months. For T/NK-NHLs (n=15; all refractory to last prior therapy), the ORR/CRR was 60%/27%. The most common adverse events (AEs) were nausea (38% any grade) and cytopenias (Grade 3/4 neutropenia [29%], thrombocytopenia [20%], and anemia [20%]). This novel oral regimen provided encouraging efficacy across several EBV+ lymphoma subtypes and warrants further evaluation; a confirmatory Phase 2 study (NCT05011058) is underway.