Systemic mastocytosis

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Section editor
Sanjay mohan.png
 Sanjay R. Mohan, MD, MSCI
Vanderbilt University
Nashville, TN
7 regimens on this page
12 variants on this page


Note: most published trials in this area are for "advanced systemic mastocytosis", which includes more than one WHO category. See individual regimens for details.

Guidelines

NCCN

All lines of therapy

Avapritinib monotherapy

Regimen

FDA-recommended dose
Study Years of enrollment Evidence
DeAngelo et al. 2021 (EXPLORER) 2016-2020 Phase 1 (RT)
Gotlib et al. 2021 (PATHFINDER) 2018-2020 Phase 2 (RT)

Targeted therapy

Avapritinib (Ayvakit) 200 mg PO once per day Continued indefinitely

References

  1. EXPLORER: DeAngelo DJ, Radia DH, George TI, Robinson WA, Quiery AT, Drummond MW, Bose P, Hexner EO, Winton EF, Horny HP, Tugnait M, Schmidt-Kittler O, Evans EK, Lin HM, Mar BG, Verstovsek S, Deininger MW, Gotlib J. Safety and efficacy of avapritinib in advanced systemic mastocytosis: the phase 1 EXPLORER trial. Nat Med. 2021 Dec;27(12):2183-2191. Epub 2021 Dec 6. link to original article link to PMC article contains dosing details in abstract PubMed NCT02561988
  2. PATHFINDER: Gotlib J, Reiter A, Radia DH, Deininger MW, George TI, Panse J, Vannucchi AM, Platzbecker U, Alvarez-Twose I, Mital A, Hermine O, Dybedal I, Hexner EO, Hicks LK, Span L, Mesa R, Bose P, Pettit KM, Heaney ML, Oh ST, Sen J, Lin HM, Mar BG, DeAngelo DJ. Efficacy and safety of avapritinib in advanced systemic mastocytosis: interim analysis of the phase 2 PATHFINDER trial. Nat Med. 2021 Dec;27(12):2192-2199. Epub 2021 Dec 6. link to original article link to PMC article contains dosing details in manuscript PubMed NCT03580655

Cladribine monotherapy

Regimen variant #1, 0.13 mg/kg

Study Evidence
Kluin-Nelemans et al. 2003 Pilot, <20 patients reported

Chemotherapy

Supportive therapy

4- to 6-week cycle for 6 cycles


Regimen variant #2, 0.14 mg/kg

Study Evidence
Barete et al. 2015 Retrospective

Chemotherapy

4- to 12-week cycle for 1 to 6 cycles


Regimen variant #3, 5 mg/m2

Study Evidence
Lim et al. 2009 Retrospective

Note: This is a retrospective series; a range of weight-based dosing was also reported.

Chemotherapy

Median number of treatment cycles was 3 (range 1 to 9)

References

  1. Kluin-Nelemans HC, Oldhoff JM, Van Doormaal JJ, Van 't Wout JW, Verhoef G, Gerrits WB, van Dobbenburgh OA, Pasmans SG, Fijnheer R. Cladribine therapy for systemic mastocytosis. Blood. 2003 Dec 15;102(13):4270-6. Epub 2003 Aug 21. link to original article contains dosing details in manuscript PubMed
  2. Retrospective: Lim KH, Pardanani A, Butterfield JH, Li CY, Tefferi A. Cytoreductive therapy in 108 adults with systemic mastocytosis: Outcome analysis and response prediction during treatment with interferon-alpha, hydroxyurea, imatinib mesylate or 2-chlorodeoxyadenosine. Am J Hematol. 2009 Dec;84(12):790-4. link to original article PubMed
  3. Retrospective: Barete S, Lortholary O, Damaj G, Hirsch I, Chandesris MO, Elie C, Hamidou M, Durieu I, Suarez F, Grosbois B, Limal N, Gyan E, Larroche C, Guillet G, Kahn JE, Casassus P, Amazzough K, Coignard-Biehler H, Georgin-Lavialle S, Lhermitte L, Fraitag S, Canioni D, Dubreuil P, Hermine O. Long-term efficacy and safety of cladribine (2-CdA) in adult patients with mastocytosis. Blood. 2015 Aug 20;126(8):1009-16. Epub 2015 May 22. link to original article PubMed

Dasatinib monotherapy

Regimen

Study Evidence
Verstovsek et al. 2008 Phase 2

Note: Only 9 of 67 patients studied had ASM; 18 has ISM and 6 had SM-AHNMD.

Targeted therapy

Supportive therapy

28-day cycles

References

  1. Verstovsek S, Tefferi A, Cortes J, O'Brien S, Garcia-Manero G, Pardanani A, Akin C, Faderl S, Manshouri T, Thomas D, Kantarjian H. Phase II study of dasatinib in Philadelphia chromosome-negative acute and chronic myeloid diseases, including systemic mastocytosis. Clin Cancer Res. 2008 Jun 15;14(12):3906-15. link to original article contains dosing details in manuscript link to PMC article PubMed

Imatinib monotherapy

Regimen variant #1, 100 mg/day

Study Evidence
Pardanani et al. 2003 Phase 2, <20 pts reported

Targeted therapy

Continued indefinitely


Regimen variant #2, 400 mg/day x 6 mo

Study Evidence
Droogendijk et al. 2006 Phase 2, <20 pts reported

Targeted therapy

Supportive therapy

6-month course


Regimen variant #3, 400 mg/day indefinitely

Study Evidence
Pardanani et al. 2003 Phase 2, <20 pts reported

Targeted therapy

Continued indefinitely


Regimen variant #4, 400 mg/day with dose escalation

Study Evidence
Vega-Ruiz et al. 2009 Phase 2

Targeted therapy

  • Imatinib (Gleevec) as follows:
    • Cycle 1: 400 mg PO once per day
    • Cycle 2: 600 mg PO once per day
    • Cycle 3 onwards: 800 mg PO once per day

Supportive therapy

Monthly cycles

References

  1. Pardanani A, Elliott M, Reeder T, Li CY, Baxter EJ, Cross NC, Tefferi A. Imatinib for systemic mast-cell disease. Lancet. 2003 Aug 16;362(9383):535-6. link to original article contains dosing details in abstract PubMed
  2. Droogendijk HJ, Kluin-Nelemans HJ, van Doormaal JJ, Oranje AP, van de Loosdrecht AA, van Daele PL. Imatinib mesylate in the treatment of systemic mastocytosis: a phase II trial. Cancer. 2006 Jul 15;107(2):345-51. link to original article contains dosing details in manuscript PubMed
  3. Retrospective: Pagano L, Valentini CG, Caira M, Rondoni M, Van Lint MT, Candoni A, Allione B, Cattaneo C, Marbello L, Caramatti C, Pogliani EM, Iannitto E, Giona F, Ferrara F, Invernizzi R, Fanci R, Lunghi M, Fianchi L, Sanpaolo G, Stefani PM, Pulsoni A, Martinelli G, Leone G, Musto P. Advanced mast cell disease: an Italian Hematological Multicenter experience. Int J Hematol. 2008 Dec;88(5):483-8. Epub 2008 Nov 26. link to original article PubMed
  4. Vega-Ruiz A, Cortes JE, Sever M, Manshouri T, Quintás-Cardama A, Luthra R, Kantarjian HM, Verstovsek S. Phase II study of imatinib mesylate as therapy for patients with systemic mastocytosis. Leuk Res. 2009 Nov;33(11):1481-4. Epub 2009 Feb 3. link to original article contains dosing details in manuscript link to PMC article PubMed
  5. Retrospective: Lim KH, Pardanani A, Butterfield JH, Li CY, Tefferi A. Cytoreductive therapy in 108 adults with systemic mastocytosis: Outcome analysis and response prediction during treatment with interferon-alpha, hydroxyurea, imatinib mesylate or 2-chlorodeoxyadenosine. Am J Hematol. 2009 Dec;84(12):790-4. link to original article PubMed

Interferon alfa-2b monotherapy

Regimen

Study Evidence
Casassus et al. 2002 Phase 2

Note: Doses were escalated based on tolerance.

Immunotherapy

  • Interferon alfa-2b (Intron-A) as follows:
    • Week 1: 1,000,000 units SC once per day
    • Week 2: 3,000,000 units SC once per day
    • Weeks 3 & 4: 3,000,000 units/m2 SC once per day
    • Week 5 onwards: 5,000,000 units/m2 SC once per day

6-month course, continued at physician's and patient's discretion

References

  1. Casassus P, Caillat-Vigneron N, Martin A, Simon J, Gallais V, Beaudry P, Eclache V, Laroche L, Lortholary P, Raphaël M, Guillevin L, Lortholary O. Treatment of adult systemic mastocytosis with interferon-alpha: results of a multicentre phase II trial on 20 patients. Br J Haematol. 2002 Dec;119(4):1090-7. link to original article contains dosing details in manuscript PubMed
  2. Retrospective: Lim KH, Pardanani A, Butterfield JH, Li CY, Tefferi A. Cytoreductive therapy in 108 adults with systemic mastocytosis: Outcome analysis and response prediction during treatment with interferon-alpha, hydroxyurea, imatinib mesylate or 2-chlorodeoxyadenosine. Am J Hematol. 2009 Dec;84(12):790-4. link to original article PubMed

Midostaurin monotherapy

Regimen

FDA-recommended dose
Study Years of enrollment Evidence Efficacy
Gotlib et al. 2016 (CPKC412D2201) 2009-2012 Phase 2 (RT) ORR: 60% (95% CI 49 to 70)
Chandesris et al. 2016 (CEREMAST) 2012-2015 Phase 2 (RT)

Note: CPKC412D2201 included untreated and previously untreated patients.

Targeted therapy

28-day cycles

References

  1. CPKC412D2201: Gotlib J, Kluin-Nelemans HC, George TI, Akin C, Sotlar K, Hermine O, Awan FT, Hexner E, Mauro MJ, Sternberg DW, Villeneuve M, Huntsman Labed A, Stanek EJ, Hartmann K, Horny HP, Valent P, Reiter A. Efficacy and safety of midostaurin in advanced systemic mastocytosis. N Engl J Med. 2016 Jun 30;374(26):2530-41. link to original article contains dosing details in manuscript link to supplementary appendix PubMed NCT00233454
  2. CEREMAST: Chandesris MO, Damaj G, Canioni D, Brouzes C, Lhermitte L, Hanssens K, Frenzel L, Cherquaoui Z, Durieu I, Durupt S, Gyan E, Beyne-Rauzy O, Launay D, Faure C, Hamidou M, Besnard S, Diouf M, Schiffmann A, Niault M, Jeandel PY, Ranta D, Gressin R, Chantepie S, Barete S, Dubreuil P, Bourget P, Lortholary O, Hermine O; CEREMAST Study Group. Midostaurin in advanced systemic mastocytosis. N Engl J Med. 2016 Jun 30;374(26):2605-7. link to original article PubMed

Nilotinib monotherapy

Regimen

Study Years of enrollment Evidence
Kantarjian et al. 2006 (A2101) 2004-2005 Phase 1/2

Targeted therapy

28-day cycles

References

  1. A2101: Kantarjian H, Giles F, Wunderle L, Bhalla K, O'Brien S, Wassmann B, Tanaka C, Manley P, Rae P, Mietlowski W, Bochinski K, Hochhaus A, Griffin JD, Hoelzer D, Albitar M, Dugan M, Cortes J, Alland L, Ottmann OG. Nilotinib in imatinib-resistant CML and Philadelphia chromosome-positive ALL. N Engl J Med. 2006 Jun 15;354(24):2542-51. link to original article PubMed NCT00109707
    1. Subgroup analysis: Hochhaus A, Baccarani M, Giles FJ, le Coutre PD, Müller MC, Reiter A, Santanastasio H, Leung M, Novick S, Kantarjian HM. Nilotinib in patients with systemic mastocytosis: analysis of the phase 2, open-label, single-arm nilotinib registration study. J Cancer Res Clin Oncol. 2015 Nov;141(11):2047-60. Epub 2015 May 23. link to original article contains dosing details in manuscript link to PMC article PubMed

Placebo

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Lortholary et al. 2017 (AB06006) 2009-2015 Phase 3 (C) Masitinib Inferior cumulative response

No active antineoplastic treatment.

References

  1. AB06006: Lortholary O, Chandesris MO, Bulai Livideanu C, Paul C, Guillet G, Jassem E, Niedoszytko M, Barete S, Verstovsek S, Grattan C, Damaj G, Canioni D, Fraitag S, Lhermitte L, Georgin Lavialle S, Frenzel L, Afrin LB, Hanssens K, Agopian J, Gaillard R, Kinet JP, Auclair C, Mansfield C, Moussy A, Dubreuil P, Hermine O. Masitinib for treatment of severely symptomatic indolent systemic mastocytosis: a randomised, placebo-controlled, phase 3 study. Lancet. 2017 Feb 11;389(10069):612-620. Epub 2017 Jan 6. link to original article link to PMC article PubMed NCT00814073

Response criteria

IWG-MRT & ECNM consensus response criteria (2013)

  1. Gotlib J, Pardanani A, Akin C, Reiter A, George T, Hermine O, Kluin-Nelemans H, Hartmann K, Sperr WR, Brockow K, Schwartz LB, Orfao A, Deangelo DJ, Arock M, Sotlar K, Horny HP, Metcalfe DD, Escribano L, Verstovsek S, Tefferi A, Valent P. International Working Group-Myeloproliferative Neoplasms Research and Treatment (IWG-MRT) & European Competence Network on Mastocytosis (ECNM) consensus response criteria in advanced systemic mastocytosis. Blood. 2013 Mar 28;121(13):2393-401. Epub 2013 Jan 16. link to original article link to PMC article PubMed
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