ENGINE: a Phase III randomized placebo controlled study of enzastaurin/R-CHOP as frontline therapy in high-risk diffuse large B-cell lymphoma patients with the genomic biomarker DGM1.

While combination of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) cures most patients with diffuse large B-cell lymphoma (DLBCL), those with high-risk international prognostic index disease have inferior survival. Enzastaurin as a potent inhibitor of PKC-ß and PI3K/AKT pathway suppressor has been tested in many clinical trials including two key studies in DLBCL: Phase III maintenance study (Preventing Relapse in Lymphoma Using Daily Enzastaurin [PRELUDE]) and a first-line Phase II study (S028). DNA extracted from PRELUDE patients' blood samples was retrospectively genotyped identifying a novel genetic biomarker, DGM1 that showed high correlation with response to enzastaurin. A similar finding observed in the S028 study suggested that addition of enzastaurin to R-CHOP may significantly improve outcomes as frontline therapy for high-risk DGM1 positive DLBCL patients. ENGINE is a global, multicenter, placebo-controlled and randomized study to compare the effect of R-CHOP/enzastaurin as frontline treatment in high-risk DLBCL patients. The primary end point for this study is overall survival in patients who are DGM1 positive. Clinical Trial Registration Identifier: NCT03263026.

Population doubling: a simple and more accurate estimation of cell growth suppression in the in vitro assay for chromosomal aberrations that reduces irrelevant positive results.

International guidelines for cytotoxicity limits for the in vitro chromosomal aberration assay require reductions in cell growth of greater than 50%. This sets no upper limit on toxicity and there is concern about the number of false or irrelevant results obtained in the aberration assay, i.e., positive results at toxic dose levels only, with no evidence for primary DNA damaging ability and with negative results in the other genotoxicity tests. We have previously proposed that no truly genotoxic compound would be missed if the toxicity of the highest dose did not exceed 50%. Cell growth measured by cell counts as a percentage of controls can underestimate toxicity. For example, if we seed half a million cells per culture, and the controls double to 1 million during the experiment, a culture that truly has no growth will still have a cell count 50% of the control. Measurement of population doublings (PDs) more accurately assesses cell growth. To assess the use of PD in dose selection, we examined previous data from this lab and data from new experiments with "true," primary DNA damaging clastogens, and with clastogens, including drugs, thought to act indirectly, through cytotoxicity-associated mechanisms. We compared aberration results where the highest doses scored were based on 50% reductions in final cell counts with results obtained when the highest doses were based on PD. The PD method allows detection of true clastogens, including those that are active in a range with some toxicity, and reduces the number of toxicity-related "false"-positive results.