New Insights into the Biology and Therapy of Waldenström s Macroglobulinemia. Steven P. Treon, MD, MA, MS, PhD Professor of Medicine

Transcription

1 New Insights into the Biology and Therapy of Waldenström s Macroglobulinemia Steven P. Treon, MD, MA, MS, PhD Professor of Medicine

2 Waldenström s Macroglobulinemia first described by Jan Gosta Waldenström in 1944.

3 Manifestations of WM Disease Bone Marrow Hb>>> PLT> WBC Bing Neel Syndrome Hyperviscosity Syndrome: Epistaxis, Headaches Impaired vision >6,000 mg/dl or >4.0 CP 20% at diagnosis; 50-60% at relapse. Hepcidin Fe Anemia Cold Agglutinemia (5%) Cryoglobulinemia (10%) IgM Neuropathy (22%) Amyloidosis (10-15%) Treon S., Hematol Oncol. 2013; 31:76-80.

4 Hyperviscosity Related Retinal Changes in WM Retinal vein dilatation seen IgM >3,000 mg/dl Retrograde flow and hemorrhages >6,000 mg/dl Stone, Clin Lymphoma 2005; Menke et al, Arch Opthal 2006

5 Post-Pheresis Pre-Pheresis Cryoglobulinemia in a patient with Waldenstrom s macroglobulinemia

6 Peripheral Neuropathies in WM 20-25% of WM patients Usually a sensory demyelinating neuropathy related to anti- Myelin Associated Glycoprotein (MAG) IgM antibody. MAG IgM Amyloid neuropathy is rare and associated with axonal degeneration. Treon et al, ASCO 2010; Photomicrograph Courtesy Todd Levine, MD Baldini et al, Am J Hematol 1994; 45(1):25-31; Treon et al, J Clin Oncol 2010; 28:15S (Abstract 8114). Photomicrograph courtesy of Todd Levine, M.D.

7 Waldenstrom s Macroglobulinemia: Genetic Predisposition Strong familial predisposition (20-25%) Ashkenazi Jews (20%) Rare in African Americans (<5%) IgM MGUS 1.8-2% annual progression rate: 40-90% progress to WM. Kyle et al, Blood 2003; 102(10): ; Treon et al, Ann Oncol 2006; 17(3): ; Hanzis et al, Clin Lymph Myeloma 2011; 11(1):88-92.

8 Identifying Genetic Basis for Familial Predisposition WM ONLY WM MM WM CLL WM NHL Sequenced the germline of over 800 patients with sporadic and familial disease. -Targeted sequencing used to identify variants in genes flagged by whole genome sequencing. Results expected Spring 2017.

9 NCCN Guidelines for Initiation of Therapy in WM Hb 10 g/dl on basis of disease PLT <100,000 mm 3 on basis of disease Symptomatic hyperviscosity Moderate/severe peripheral neuropathy Symptomatic cryoglobulins, cold agglutinins, autoimmune-related events, amyloid. Kyle RA, et al. Semin Oncol. 2003;30(2): ; Anderson et al, JNCCN 2012; 10(10):

10 Ixazomib Bortezomib Carfilzomib Benda RAD001 GA101 CAL101 Pom Len WM Treatment Approach

11 Primary Therapy of WM with Rituximab Regimen ORR VGPR/CR TTP (mo) Rituximab x % 0-5% 13 Rituximab x % 5-10% Rituximab/thalidomide 70% 10% 30 Rituximab/cyclophosphamide i.e. CHOP-R, CVP-R, CPR, CDR Rituximab/nucleoside analogues i.e. FR, FCR, CDA-R Rituximab/Proteasome Inhibitor i.e. BDR, VR, CaRD 70-80% 20-25% % 20-30% % 20-40% Rituximab/bendamustine 90% 30-40% 69 Reviewed in Dimopoulos et al, Blood 2014; 124(9): ; Treon et al, Blood 2015; How I Treat WM

12 Bendamustine-R vs. CHOP-R: WM Subset Analysis N=41 Rummel et al, Lancet Apr 6;381(9873):

13 Serum IgM (mg/dl) Rituximab induced IgM Flare in WM Patients 14,000 12,000 10, P P P P P P denotes patient-required plasmapheresis for hyperviscosity. P P WM 1 WM 2 WM 3 WM 4 WM 5 WM 6 WM 7 WM 8 WM 9 WM 10 WM Weeks Treon SP, et al. Ann Oncol. 2004;15(10):

14 Clinical Sequelae of Rituximab IgM Flare Symptomatic hyperviscosity possible in patients with high serum IgM (>4,000 mg/dl). IgM Neuropathy, Cryoglobulins, Cold Agglutinins: Rituximab can potentiate symptoms. Consider PP. Patients with IGM> 4,000 mg/dl or Symptomatic HV: Avoid Rituximab until IgM in safe range either by plasmapheresis or chemotherapy without Rituximab. Anderson et al, JNCCN 2012; 10(10):

15 Nucleoside Analogues in WM Risk of Transformation or MDS/AML is 10-15%; Risk of secondary malignant events in 1/3 patients with FCR; Stem cell collection impacted by nucleoside analogues: avoid in ASCT candidates; Consider Impact on future therapy (Bendamustine); Role in CNS Disease (Bing Neel Syndrome) Treon et al, Blood 2008; 113(16):3673-8; Leleu et al, JCO 2009; 27(2): 250-5; Thomas et al, Proc. 5 th International Workshop on WM 2008; Treon et al, Clin Lymphoma 2011; 11(1): Tdeschi et al, ASH 2015; Abstract 3958.; Vos et al, BJH 2015.

16 2X WEEK BORT 1X WEEK BORT Proteasome-Inhibitor Related Peripheral Neuropathy GRADE 1,2 GRADE >3 PI- DISCONTINUED 40-70% 20-30%* 20-30% 20-40% 5-20% 10-20% CaRD 20% 0% 0% Chen et al, JCO 2007; 25(12): ; Treon et al, CCR 2007; 13(11): ; JCO 2009; 27(23): ; Ghobrial, JCO 2010; 28(8):1422-8; AJH 2010; 85(9): 670-4; Agathocleous et al, BJH 2010; 151(4): ; Dimopoulos et al, Blood (19):

17 New directions in WM

18 WHOLE GENOME SEQUENCING IN WM Congratulations it only took you 70 years!! Paired Sequencing from same individuals NORM WM 3,000,000,000 nucleotides

19 MYD88 Mutations in B-cell LPD WM ABC DLBCL 93-95% MYD88 L265P 2% Non-L265P MYD88 29% MYD88 L265P 10% Non-L265P MYD88 Treon et al, NEJM 2012; Treon et al, NEJM 2015; Jiménez et al, 2013; Varettoni et al 2013; Poulain et al, 2013, Xu et al, 2013.

20 MYD88 mutations transactivate NFKB Control MYD88 Inhibitor Ngo et al, Nature 2011 Treon et al, NEJM 2012 BCWM.1 MWCL-1 MYD88 L265P mutated WM cells

21 Signaling Pathways Driven by Mutated MYD88 in Waldenström's Macroglobulinemia TLRs/IL-1R IL-6R IL-6 IL-6 IL-6 Ibrutinib ACP196 CC-292 BGB-3111 MYD88 BTK IRAK4 IRAK1 BTK PIK3R2 PI3K HCK PLCγ gp-130 Ibrutinib TRAF6 TAK1 PKC AKT IKKα NEMO IKKβ ERK1/2 HCK mtor IL-6 Degradation growth survival Yang et al, Blood 2013; Yang et al, Blood 2016

22 Ibrutinib binds to and blocks HCK kinase activity A. Glu 334 Thr 333 A. DMSO A Ibrutinib CC-292 Met Å 3.1Å 3.1Å A Ibrutinib 3.2Å A Ibrutinib Asp 404 BCWM % 25.1% 65.4% 85.4% Asp 348 Ala 390 Asn 391 B. SVB SVB BCWM.1 MWCL-1 TMD-8 Lysates IB-BTN/SVB IB-B TN/SVB CC-BTN/SVB SVB SVB AVL -B TN/SVB IB-BTN/SVB IB-B TN/SVB CC-BTN/SVB AVL -B TN/SVB SVB SVB IB-BTN/SVB IB-B TN/SVB CC-BTN/SVB BCWM.1 AVL -B TN/SVB BCWM. 1 MWCL-1 MW CL-1 TMD-8 TMD -8 MWCL % 35.7% 57.8% 86.9% BTK HCK TMD % 9.63% 67.6% 82.1% C. C. IP: ATP-biotin +Ibrutinib + +CC AVL-292 +A Compounds (µm) ATP-BTN SVB IB: BTK OCI-Ly3 68.8% 4.04% 48.3% 70.5% input IB: HCK input IB: SRC input HBL % 12.2% 48.8% 77.4% IB: LYN Yang et al, BLOOD 2016 input phck

23 HCK gatekeeper mutant (T333M) promotes resistance in MYD88 mutated WM cells treated with Ibrutinib or A Yang et al, BLOOD 2016

24 B WHIM-like CXCR4 C-tail mutations in WM Warts, Hypogammaglobulinemia, Infection, and Myelokathexis 30-40% of WM patients >30 Nonsense, Frameshift Mutations Segue with MYD88 L265P Transcriptional silencing of TLR pathway regulators Promote SDF-1 hyperactivation, WM cell growth and ibrutinib resistance through enhanced AKT/ERK signaling. Hunter et al, Blood 2013: 122:4254; Rocarro et al, Blood 2014: 123 (26): ; Poulain et al, Blood 2014: 124:1627 Cao et al, Leukemia 2014; Cao et al, BJH 2015; Hunter et al, ASH 2015.

25 CXCR4 Signaling in WM Patients with WHIM mutations CXCL12 Ulucuplomab CXCR4 PHASE II STUDY OF ULOCUPLOMAB AND IBRUTINIB IN WALDENSTROM S Cao et al, Leukemia 2014 Rocarro et al, Blood 2014 Cao et al, BJH 2015 Ser 346/7 Β-arrestins WM CELL ERK AKT SURVIVAL DRUG RESISTANCE

26 Multicenter study of Ibrutinib in Relapsed/Refractory WM (>1 prior therapy) Study O Opened May 2012 Progressive Disease (PD) or Unacceptable Toxicity Screening Registration 420 mg po qd Ibrutinib R R. Advani L. Palomba Stable Disease or Response Continue R. Advani L. Palomba Stop Ibrutinib Event Monitoring Event Monitoring MYD88, CXCR4 NCT Mutation Status

27 Baseline Characteristics for Study Participants (n=63) Median Range Age (yrs) Prior therapies Hemoglobin (mg/dl) Serum IgM (mg/dl) 3, ,390 B 2 M (mg/dl) BM Involvement (%) Adenopathy >1.5 cm 37 (59%) N/A Splenomegaly >15 cm 7 (11%) N/A Treon et al, NEJM 2015; 372:1430

28 Serum IgM and Hb Levels Following Ibrutinib Serum IgM (mg/dl) Baseline Cycle 2 Cycle 3 Serum IgM Best IgM Response: 3,520 to 880 mg/dl; p<0.001 Cycle 6 Cycle 9 Cycle 12 Cycle 15 N=63 Cycle 18 Cycle 21 Best IgM Response: 3,520 to 880 mg/dl; p<0.001 Hemoglobin (g/dl) Best Hemoglobin Response: 10.5 to 13.8; p< Baseline Cycle 2 Cycle 3 Cycle 6 Hb Cycle 9 Cycle 12 Cycle 15 N=63 Cycle 18 Cycle 21 Best Hemoglobin Response: 10.5 to 13.8; p<0.001 Treon et al, N Engl J Med. 2015; 372(15):

29 Best Clinical Responses to Ibrutinib Median duration of treatment: 19.1 (range ) months ORR: 91% Major RR (> PR): 73% (N=) (%) VGPR PR MR Median time to > MR: 4 weeks Median time to > PR or better: 8 weeks Treon et al, N Engl J Med. 2015; 372(15):

30 Progression-free and overall survival for 63 previously WM patients treated with ibrutinib. PFS OS 2 yrs (69%) 2 yrs (95%) Median follow-up of 37 months, no change in PFS Palomba et al, IWWM9, 2016 Treon et al, N Engl J Med. 2015; 372(15):1430-4

31 Ibrutinib Related Adverse Events in previously treated WM patients Toxicities >1 patient; N=63 Neutropenia Anemia Thrombocytopenia Arrythmia Lung Infection Skin Infection Diarrhea Post-procedure bleed Epistaxis Dehydration Pre/Syncope Hypertension Mucositis Number of Subjects with Toxicity # of patients with toxicity Grade 2 Grade 3 Grade 4 No impact on IGA and IGG immunoglobulins 10% incidence with larger WM Experience; earlier presentation for those patients with prior Afib history. Treon et al, 2015; Gustine et al, 2016

32 FDA News Release FDA expands approved use of Imbruvica for rare form of non-hodgkin lymphoma First drug approved to treat Waldenstrom s January 29, 2015 EMA Approval for symptomatic previously treated and chemoimmunotherapy unsuitable frontline WM First ever for Waldenstrom s May 22, 2015 July 8, 2015 April 5, 2016 September, 2015

33 Responses to ibrutinib are impacted by MYD88 (L265P and non-l265p) and CXCR4 mutations. MYD88 MUT CXCR4 WT MYD88 MUT CXCR4 WHIM MYD88 WT CXCR4 WT p-value N= Overall RR Major RR 100% 85.7% 60% < % 61.9% 0% < patients subsequently found to have other MYD88 mutations not picked up by AS-PCR Treon et al, N Engl J Med. 2015; 372(15): ; NEJM 2015; Letter, August 6, 2015.

34 Major Responses (%) Kinetics of major responses following ibrutinib therapy in genotyped WM patients. MYD88 L265P CXCR4 WT MYD88 L265P CXCR4 WHIM MYD88 WT CXCR4 WT Cycle Treon et al, NEJM 372: 1430, 2015

35 Ibrutinib in Rituximab-Refractory WM Patients: Multicenter, Open-Label Phase 3 Substudy (innovate ) Median Prior Therapies: 4 (range 1-7) Median follow-up: 18.1 (range months) ORR: 90% Major RR (> PR): 71% (N=) (%) VGPR 4 13 PR MR 6 19 Median time to > MR: 4 weeks Median time to best response: 8 weeks 18 mo PFS: 86% 18 mo OS: 97% Dimopoulos et al, IWWM

36 Impact of CXCR4 Mutation Status on IgM and HgB Response Dimopoulos et al, IWWM9; Lancet Oncology, 2016 (Accepted)

37 Phase II Study of Ibrutinib plus Ulucuplomab in Relapsed/Refractory CXCR4 WHIM WM Patients Screening Informed Consent and Registration Progressive Disease or Unacceptable Toxicity Stop Ibrutinib/Ulucuplomab Event Monitoring Ibrutinib 420 mg po daily + Ulucuplomab SD or Response Continue Event Monitoring

38 Primary Therapy of WM with Ibrutiinib N= mg a day x 4 years All patients are undergoing whole genome sequencing at 6, 12, 24, 36, 48 months Clonal sequencing to determne how individual cells respond to ibrutinib. Study fully enrolled

39 Signaling Pathways Driven by Mutated MYD88 in Waldenström's Macroglobulinemia Ibrutinib ACP196 CC-292 BGB-3111 MYD88 BTK IRAK4 IRAK1 TRAF6 BTK TLRs/IL-1R MYD88 BTK IRAK4 BTK IL-6R HCK PIK3R2 PLCγ gp-130 Ibrutinib IL-6 IL-6 IL-6 Microenvironment TAB1 TAK1 TAB2 TAB1 IRAK1 TRAF6 TAK1 TAB2 PI3K PKC AKT IKKα NEMO IKKβ ERK1/2 HCK IkBα p50 p65 mtor IL-6 Degradation growth survival p50 p65

40 IRAK1/4 kinase survival signaling remains intact in WM cells from ibrutinib treated patients. On ibrutinib > 6 cycles Yang et al, ASH 2015

41 Combination Index JH-X Combination Index JH-X Combining of Novel IRAK1 inhibitor JH-X-119 with Ibrutinb A scaffold Shows selective Synergism for IRAK1 in MYD88 over IRAK4 Mutated Cells Sara Buhrlage Nathanael Gray BCWM.1 THZ2-118 Ibrutinib IRAK1 IC 50 = 14.2 nm μm IRAK4 IC 50 > 10,000 nm TMD-8 Ibrutinib μm THZ2-118 docked to an 2.000IRAK homology model LC-MS/MS analysis confirmed THZ2-118 covalently labels C302 or IRAK THZ2-118 does not inhibit signaling of IRAK1C302L

42 Acquired Resistance in WM Patients on Ibrutinib. Patient* L265P positive cells with BTK C481R T>C L265P positive cells with BTK C481S T>A L265P positive cells with BTK C481S G>C L265P positive cells with BTK C481Y G>A L265P positive cells with PLCG2 Y495H T>C L265P positive cells with CARD11 L878F C>T P1 None None None None None None P2 32.4% 6.6% 5.8% 1.0% None None P3 0.3% 34.4% 6.5% 0.3% None 0.2% P4 None None None None None None P5 None None None None None None P6 None None 10.3% None 11.9% None Targeted next-generation sequencing for MYD88, CXCR4, BTK, PLCG2, CARD11, LYN. All patients are MYD88 Mutated. P2, P3, P6 are CXCR4 WHIM Mutated. Xu et al, IWWM9, Plenary Abstract 001

43 % Serial samples from WM Patient P3 with multiple BTK Cys 481 mutations Patient P3: Fraction of MYD88-L265P positive cells with BTK Cys481 mutations Cys481ArgT>C Cys481SerT>A Cys481SerG>C Ibrutinib treatment Sampling date Cys481ArgT>C Cys481SerT>A Cys481SerG>C Baseline Month Month % 0.19% Month % 26.08% 3.62% Xu et al, IWWM9, Plenary Abstract 001

44 BTK C481S expressing cells displayed persistent activation of BTK and ERK1/2 following Ibrutinib treatment. ASH 2016

45 HCK Inhibitors Overcome BTK-C481S mutation caused Ibrutinib Resistance in WM and ABC-DLBCL cell lines A scaffold selective for IRAK1 over IRAK4 THZ2-118 IRAK1 IC 50 = 14.2 nm IRAK4 IC 50 > 10,000 nm THZ2-118 docked to an IRAK1 homology model LC-MS/MS analysis confirmed THZ2-118 covalently labels C302 or IRAK1 THZ2-118 does not inhibit signaling of IRAK1C302L Yang et al, IWWM9 2016

46 Ibrutinib (560 mg/day) induced response in a WM patient with Bing Neel Syndrome Mason et al, BJH 2016

47 BCL-2 is overexpressed in primary WM patient cells by next generation sequencing (RNAseq) in MYD88 and CXCR4 mutated and unmutated patients. onor B-Cells, WM Cell Lines, and Primary Patient Samples 1 PB B-Cell Memory B-Cell WM L265P+ WM L265P+WHIM+ WM WT Healthy Donor CD19 + CD27 - Healthy Donor CD19 + CD27 + WM CD19 + MYD88 L265P CXCR4 WT WM CD19 + MYD88 L265P CXCR4 WHIM WM CD19 + MYD88 WT CXCR4 WT p<0.001 for healthy donor samples versus any MYD88 L265P CXCR4WT or WHIM Castillo et al, ICML 2015; Hunter et al, Manuscript in progress.

48 48

49 Venetoclax (ABT-199) enhances Ibrutinib killing in CXCR4 WT and CXCR4 WHIM expressing WM Cells. Untreated *CXCR WHIM d. DMSO Ibrutinib ABT IB/ABT BCWM.1 CXCR4 WT CXCR4 S338X 6.1% 6.10% 16.7% 16.70% 24.9% 24.90% 50.4% 50.41% 5.8% 5.76% 19.6% 19.60% 26.2% 26.20% 50.9% 50.90% * * WM1 WM2 WM3 WM4 DMSO IB ABT ABT+IB MWCL-1 CXCR4 WT CXCR4 S338X 13.4% 13.40% 16.6% 16.60% 20.5% 20.50% 44.5% 44.50% 10.8% 10.80% 12.6% 12.60% 19.6% 19.60% 54.5% 54.50% Cao et al, BJH 2015 (Epub ahead of print) Ibrutinib >6 mo. * * WM5 WM6 WM7 DMSO IB ABT ABT+IB

50 Responses to the anti-bcl2 agent Venetoclax (ABT- 199) in previously treated NHL Patients Histology Overall Response (CR + PR) Complete Response n (%) Partial Response n (%) Total (n=33) 53% 3/36 (8) 16/36 (44) MCL (n=11)* 82% 1/11 (9) 8/11 (73) FL (n=11) 27% - 3/11 (27) DLBCL (n=8) 38% 1/8 (13) 2/8 (25) WM (n=3) 100% 1/3 (33) 2/3 (67) MZL (n=2) 50% - 1/2 (50) MM (n=1) Davids et al, ASH 2013

51 Phase I/II Study of ABT-199 in Previously Treated WM Screening Informed Consent and Registration Progressive Disease or Unacceptable Toxicity Stop ABT-199 Event Monitoring ABT mg a Day SD or Response Continue Event Monitoring

52 Approach to Frontline Therapy of Symptomatic WM Hyperviscosity, Severe Cryos, CAGG, PN Plasmapheresis MYD88 Mutated/No CXCR4 mutation No bulky disease, no contraindications Ibrutinib (if available) Bulky disease Benda-R Amyloidosis Bortezomib/Dex/Rituximab (BDR) IgM Peripheral Neuropathy Rituximab + Alkylator MYD88 Mutated/CXCR4 mutation Same caveats as above If immediate response needed, either BDR or Benda-R MYD88 Wild-Type non-l265p MYD88 mutations BDR or Benda-R Hold Rituximab until IgM <4000 mg/dl or empiric pheresis is performed. Consider Maintenance Rituximab Consider Ofatumumab if R intolerant.

53 Salvage Therapy of Symptomatic WM Consider repeat primary therapy if response >2 years MYD88 Mutated/No CXCR4 mutation Same caveats as primary therapy MYD88 Mutated/CXCR4 mutation Same caveats as primary therapy If immediate response needed, either BDR or Benda-R MYD88 Wild-Type Same caveats as primary therapy non-l265p MYD88 mutations Everolimus >2 prior therapies Nucleoside analogues (non-asct candidates) ASCT in multiple relapses, chemosensitive disease Consider Maintenance Rituximab Consider Ofatumumab if R intolerant.

54 Can the epigenome give us the next giant leap forward for WM?

55 Summary WM can present with broad symptomatology. Asymptomatic patients should be observed. Treatment options include rituximab alone and in combination. Objectives as well risks of therapy should be considered when making treatment choices. MYD88 and CXCR4 mutations are common in WM. MYD88 activates BTK and HCK in WM cells. Ibrutinib represents a novel treatment option for WM. MYD88 and CXCR4 mutation status impacts ibrutinib responses. Multiple mutations common with acquired ibrutinib resistance.

56 Acknowledgements Ranjana Advani, MD BING LAB Zachary Hunter, PhD Guang Yang PHD Jorge Castillo, MD Kirsten Meid MPH Joshua Gustine MPH Lian Xu, MS Xia Liu MD George Chen Nicholas Tsakmaklis Maria Demos Amanda Kofides M. Lia Palomba, MD Peter S. Bing, M.D. Bauman Family Fund for WM Bailey Family Fund for WM Edward and Linda Nelson Tannehauser Family Fund Kerry Robertson Fund NIH Spore Funding