Steven P. Treon Dana-Farber Cancer Institute Harvard Medical School

Transcription

1 Steven P. Treon Dana-Farber Cancer Institute Harvard Medical School 1

2 Jan Gosta Waldenstrom Described Macroglobulinemia in 1943

3 2 nd Intl Workshop on Waldenstrom s Macroglobulinemia Athens 2002

4 WM Treatment Approach

5 WM Treatment Approach

6 CHLORAMBUCIL NCCN Options for WM Treatment CYCLOPHOSPHAMIDE NUCLEOSIDE ANALOGUES THALIDOMIDE RITUXIMAB EVEROLIMUS CHOP-R, CVP-R, CPR, CDR BORTEZOMIB (BDR, VR) BENDAMUSTINE (BENDA R)

7 WM centric toxicities with commonly used therapies Agent WM Toxcities Rituximab IgM flare (40-60%)-> Hyperiscosity crisis, Aggravation of IgM related PN, CAGG, Cryos. Hypogammaglobulinemia-> infections, IVIG Intolerance (15%) Nucleoside Analogues Hypogammaglobulinemia-> infections, IVIG Transformation, AML/MDS (15%) IMIDS Peripheral Neuropathy (60% >grade 2 with Thalidomide) Aggravated IgM flare (Revlimid and Pomalidomide) Severe anemia (Revlimid) Bortezomib Grade 2+3 Peripheral neuropathy (60-70%); High discontinuation (20-60%) 7

8 New Directions in WM

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

10 MYD88 L265P Somatic Mutation C to G at position at 3p22.2 in 27/30 WM pts. Acquired UPD at 3p22. Sanger sequencing (91% of WM pts, 10% IGM MGUS Have MYD88 L265P. Treon et al, NEJM 2012

11 MYD88 L265P in WM/IGM MGUS METHOD TISSUE WM IGM MGUS Treon WGS/Sanger BM CD % 10% Xu AS-PCR BM CD % 54% Gachard PCR BM 70% Varettoni AS-PCR BM 100% 47% Landgren Sanger BM 54% Jiminez AS-PCR BM 86% 87% Poulain PCR BM CD % Argentou PCR-RFLP BM 92% 1/1 MGUS Willenbacher Sanger BM 86% Mori AS-PCR/BSiE1 BM 80% Ondrejka AS-PCR BM 100% Ansell WES/AS-PCR BM 97% Patkar AS-PCR BM 85% 11

12 MYD88 L265P by AS-PCR can help distinguish WM from overlapping entities ----MGUS---- HD IGG IGM CLL MM MZL WM WM WM 0% 0% 54% 4% 0% 10% 93% Xu et al, Blood 2013

13 MYD88 Mutation Status in IGM MGUS MYD88 L265P N=36 MYD88 WT N=41 BM (IHC) 9 (43%) 12 (57%) 0.04 IgM 686 ( ) 345 ( ) IgA 141 (26-571) IgG 925 ( ) Progression 6 WM (17%) 1 SMZL (3%) 194 ( ) p= < ( ) WM (3%) 1 SMZL (3%) MYD88 L265P OR 4.7 (95% CI ; p=0.04) NA Varettoni et al, BLOOD

14 Detection of MYD88 L265P using AS-PCR in Peripheral Blood CD19-Selected Cells By Dynabead Magnetic Selection. Sensitivity of 98.2%, specificity of 100%, positive and negative predictive values of 100% and 75%. Xu et al, Leukemia 2014

15 ΔCT of Peripheral Blood MYD88 L265P can help segway IgM MGUS versus WM at time of diagnosis MYD88 L265P ΔCt was <6.5 in 82% of smoldering, and 94% of symptomatic WM patients, whereas all IgM MGUS patients had a ΔCt >6.5 (p<0.0001). Xu et al, Leukemia

16 Copy number losses are common in WM and effect growth and survival regulatory genes. Hunter et al, Blood

17 Generation of MYD88 L265P Conditional Transgenic Mice 3. Blastocyst injection and implantation into pseudopregnant femele 2. ESC electrophoration and selection 1. Vector Preparation 1. Hu-wt-MYD88 2. Hu-mutant-MYD88(L265P) 3. Mo-wt-MYD88 4. Mo-mutantt-MYD88(L26P) MYD88 White coat 4. Generation Chymeric mice Black coat Removal of transcriptional stopper and expression in germinal centre B-cells Black/White coat 5. Checking for germ line transmission AIDCre/+ Conditional MYD88 LSL 6. Generation of MYD88/AIDCre compound mice MYD88 IWMF CANADA Compound MYD88 (L265P) LSL/LSL;AIDCre/+

18 Control MYD88 Inhibitor MYD88 inhibitor blocks p65 NFKB nuclear localization in L265P expressing WM cells. A. B. A. BCWM.1 B. MWCL-1 Treon et al, NEJM 2012

19 TLR4 IL1R MYD88 L265P Signal Pathway BTK TIRAP MYD88 MYD88 TAK1 TRAF6 NEMO IKKα IKKβ Nuclear Translocation and Signaling IκBα p50 p65 NFKB Yang et al, Blood 2013

20 MYD88 binds to Bruton s Tyrosine Kinase (BTK) in L265P expressing WM cells A. BCWM.1 MWCL-1 OCI-Ly19 Ramos B. IP: IB: MYD Ratio: MYD88 / BTK (%) IB: BTK IP: IB: BTK IB: MYD88 IgG - heavy chain IgG - heavy chain C. BCWM.1 MWCL-1 OCI-Ly3 OCI-Ly19 Ramos RPMI-8226 IP: IgG MYD88 IB: BTK IB: MYD88 Yang et al, Blood

21 MYD88 L265P induces BTK in WM cells BCWM.1 MWCL-1 BCWM.1 MWCL-1 MYD88 p-btk relative density of phos-/total BTK (%) BTK p-btk BTK GAPDH GAPDH BCWM.1 MWCL p-btk relative density of phos- / total BTK (%) BTK GAPDH Flag-MYD88 endogenous-myd88 Yang et al, Blood

22 IBRUTINIB: Small Molecule Inhibitor of BTK Binds to and inactivates BTK O Orally drug taken daily resulting in 24-hr BTK inhibition. Watch for drug interactions N N H 2 N N N No coumadin Well tolerated. Side effects also depend on prior therapies. N O Blocks signaling that allows lymphoma cells to grow and survive. IBRUTINIB Honigberg LA et al: Proc Natl Acad Sci U S A.107:13075, 2010 Herman SEM et al: : Blood Mar 21. [Epub] Ponader, et al., Proc ASH, 2010; Yang et al. Proc. ASH 2012.

23 Phase II Study of Ibrutinib in Relapsed/Refractory WM Screening Informed Consent and Registration Ibrutinib 420 mg po daily Progressive Disease or Unacceptable Toxicity SD or Response Continue x 26 cycles Stop Ibrutinib Event Monitoring Event Monitoring Opened May 2012 DFCI, MSKCC, STANFORD N=35; expanded to 63

24 Baseline Characteristics for Study Participants (n=63) Median Range Age (yrs) Male/Female 48/15 N/A Prior therapies Hemoglobin (mg/dl) Platelet (k/ul) Serum IgM (mg/dl) 3, ,390 B 2 M (mg/dl) BM Involvement (%) Adenopathy >1.5 cm 38 (60.3%) N/A Splenomegaly >15 cm 7 (11.1%) Data Lock: November 8,

25 Reasons for Treatment Initiation Anemia 55 (87.3%) Adenopathy and/or Splenomegaly 16 (25.3%) Neuropathy 10 (15.9%) Hyperviscosity 6 (9.5%) Thrombocytopenia 5 (7.9%) Malignant Pleural Effusions 3 (4.7%) Amyloidosis 2 (3.1%) Acquired VWF deficiency 2 (3.1%) Fatigue 2 (3.1%) Nephropathy 1 (1.6%) Data Lock November 8, 2013 (Multiple reasons can apply for a patient) 25

26 Serum IgM (mg/dl) Serial Serum IgM Levels Following Ibrutinib Best IgM Response: 3,610 to 1,260 mg/dl; p= Median of 9 (range 1-18) Cycles N= Baseline Cycle 2 Cycle 3 Cycle 6 Cycle 9 Cycle 12 Cycle 15 Data Lock November 8,

27 Hemoglobin (g/dl) 16 Serial Hemoglobin Levels Following Ibrutinib Best Hemoglobin Response: 10.5 to 13.4; p = N=63 Median of 9 (range 1-18) Cycles 8 Baseline Cycle 2 Cycle 3 Cycle 6 Cycle 9 Cycle 12 Cycle 15 Cycle 18 Data Lock November 8,

28 BM Involvement (%) Bone Marrow Disease Burden following Ibrutinib At Cycle 6: 62.5% to 36.75%; p = Data Lock November 8, 2013 N= 61 (with baseline and cycle 6 BM Biopsy) 28

29 Best Clinical Responses to Ibrutinib Median of 9 (range 1-18) Cycles (N=) (%) VGPR PR MR ORR: 83% Major RR (> PR): 64% 87% on therapy at 9 months Data Lock November 8, 2013 Response criteria adapted from 3 rd International Workshop on WM (Treon et al, BJH 2011) 29

30 ORR 85.7% Major (PR or better) 66.7% Response by relapse or refractory status Relapse ORR 84% Major 63% Refractory ORR 88% Major 72% p=0.73 and 0.58 for ORR and Major RR Response by previous lines of treatment 1 ORR 82% Major 59% 2-4 ORR 86% Major 66% >4 ORR 92% Major 83% p=0.81 and 0.37 for ORR and Major RR Updated investigator response assessments (May 2014)

31 Ibrutinib Related Adverse Events Adverse event # Grade 2 Events # Grade 3 Events # Grade 4 Events Total # of Events Neutropenia Thrombocytopenia Bleeding Pneumonic Infection Anemia Tachyarrhythmia Syncope/Pre-syncope Herpes Zoster Endocarditis infective 1 1 Fever 1 1 Hypertension 1 1 Pruritus 1 1 Mucositis 1 1 Oral Pain 1 1 Diarrhea 1 1 Arthralgia 1 1 Data Lock November 8,

32 At a median of 9 (range 1-18) cycles of ibrutinib: 55 (87.3%) participants continue on treatment. 8 participants discontinued protocol therapy: 1 Non-responder (MYD88 WT); 3 Progressive Disease; 1 MDS/RAEB (Heavily pretreated; Pre-existing 5 q- in 10% metaphases; PR, progressed off treatment); 1 Recurring thrombocytopenia (aggravated by hyper-splenism, resolved after splenectomy; SD on follow-up); 1 Hematoma (post-procedure); 1 Participant Decision (continues on follow-up); Data Lock November 8,

33 WHIM-like CXCR4 C-tail mutations in WM Warts, Hypogammaglobulinemia, Infection, and Myelokathexis. B Most common: CXCR4 C1013G (S338X ) Somatic WHIM-CXCR4 Mutations are present in WM patients: 8/30 (27%) by WGS ; 47/152 (31%) by Sanger Sequencing. Hunter et al, ASH 2012; Blood

34 Over 30 types of CXCR4 C-terminal somatic mutations in WM Treon et al, Blood

35 MYD88 and CXCR4 Mutation Status Impacts Clinical Presentation of WM Patients MYD88 WT L265P L265P L265P CXCR4 MYD88WT WT FS NS MYD88 WT L265P L265P L265P CXCR4 WT WT FS NS Treon et al, Blood

36 S338X somatic mutation impairs CXCR4 receptor Internalization following SDF1a in transfected WM cells Cao et al, ASH 2012,

37 CXCR4 WHIM Mutations lead to enhanced perk and pakt activity in response to SDF1a. Vector Wild type Mut S338X perk44/42 pakt(s473) pbtk(y223) GAPDH SDF1a AMD3100 PCI Cao et al, ASH 2012; 2013

38 SDF-1a CXCR4 WM CELL 38

39 SDF1a protects CXCR4 S338X WM cells from ibrutinib triggered apoptosis Cao et al, ASH

40 Fold Change Relative to Baseline Serial changes in serum IgM levels following Ibrutinib Stratified by CXCR4 status CXCR4 WHIM-Like CXCR4 Wild Type Baseline Cycle 2 Cycle 3 Cycle 6 Cycle 9 Cycle 12 Cycle 15 Cycle 18 Serum IgM Mean Fold Change and Standard Error of the Mean by Cycle ANOVA p-values: Mutation Status = 1.88e-10 Therapy Cycle = 2.63e-36 Interaction effect = 8.93e-02

41 Fold Change Relative to Baseline Serial Hemoglobin levels following Ibrutinib Stratified by CXCR4 status CXCR4 WHIM-Like CXCR4 Wild Type Baseline Cycle 2 Cycle 3 Cycle 6 Cycle 9 Cycle 12 Cycle 15 Cycle 18 Hb Mean Fold Change and Standard Error of the Mean by Cycle ANOVA p-values: Mutation Status = 9.75e-07 Therapy Cycle = 8.13e-16 Interaction effect = 8.64e-02

42 MYD88 /CXCR4 status and Ibrutinib Major Responses MYD88 N= VGPR/PR MR/SD/NR L265P (65%) 17 (35%) Wild Type 5 2 (40%) 3 (60%) p = Odds ratio = % CI CXCR4 N= VGPR/PR MR/SD/NR WHIM 10 3 (30%) 7 (70%) Wild Type (80%) 6 (20%) p = Odds ratio = % CI Data Lock November 8,

43 SDF1a protects CXCR4 S338X WM cells from chemotherapy triggered apoptosis - - AMD SDF1α Cleaved PARP Cleaved Caspase3 GAPDH Cao et al, ASH 2013

44 Phase II Study of Ibrutinib plus Plerixafor in Relapsed/Refractory CXCR4 WHIM WM Patients Screening Informed Consent and Registration Progressive Disease or Unacceptable Toxicity Stop Ibrutinib/Pleixafor Event Monitoring Ibrutinib 420 mg po daily + Plerixafor sq qd SD or Response Continue x 26 cycles Event Monitoring

45 TLR4 IL1R MYD88 L265P Signal Pathway BTK TIRAP MYD88 MYD88 IBRUTINIB TAK1 TRAF6 NEMO IKKα IKKβ IκBα Nuclear Translocation and Signaling p50 p65 Yang et al, Blood 2013

46 IRAK1 remains active in WM patients on ibrutinib and supports survival of 46

47 Combination of Ibrutinib and IRAK inhibitors show synergistic NFkB inhibition and WM cell killing (Yang et al, Blood 2013). Inhibition of NFkB Normalized Isobologram Combination Index Fraction Affected 100.0% 80.0% 60.0% 40.0% a b c d e f g h i j k l a + g b + h c + i d + j e + k f + l IKBα-pS % IKBα 0.0% Ibrutinib IRAK1/4-In Ibrutinib + IRAK1/4-In GAPDH

48 TLR4 IL1R Targeting MYD88 L265P Signal Pathway BTK TIRAP MYD88 MYD88 MYD88 ASO and Homodimer Inhibitors TAK 1 1 TRAF6 NEMO IKKα IKKβ PI3Kδ IκBα Nuclear Translocation and Signaling p50 p65

49 Idelalisib Selective, oral inhibitor of PI3K-delta Inhibits proliferation and induces apoptosis in many B-cell malignancies Inhibits homing and retention of malignant B-cells in lymphoid tissues reducing B-cell survival Class I PI3K Isoform a b g d Expression Ubiquitous Ubiquitous Leukocytes Leukocytes EC 50 (nm) >10, *Benson D et al. ASCO 2013, abstr 8526

50 Responses in relapsed/refractory indolent NHL patients to idelalisib. Gopal et al, NEJM 2014

51 Phase II Study of Idelalisib in Relapsed/Refractory WM Patients Screening Informed Consent and Registration Progressive Disease or Unacceptable Toxicity Stop Ibrutinib/Pleixafor Event Monitoring Idelalisib 150 mg Twice a Day SD or Response Continue x 26 cycles Event Monitoring

52 Effect Ibrutinib Shows Synergistic WM Cell Killing with the PI3K-delta Inhibitor Idelalisib (CAL 101) A B 0.8 CAL101_0uM D CAL101_0.02uM CAL101_0.06uM CAL101_0.20uM CAL101_0.63uM CAL101_2.00uM 0.1 Combination Index (CI) < 1 : Synergism 0 BCWM.1 Cells Yang et al, ASH 2013

53 What about MYD88 WT WM Patients? High levels of circulating B-cells. CD27+ disease more common (75-90%) Decreased IGHV3 23 rearrangements and somatic hypermutation. Express mutations in the MLL2 gene. MLL2 encodes for the histone modifying enzyme histone-lysine N-methyltransferase. MLL2 frequently mutated in follicular (89%) and DLBCL lymphomas (32%). Treon et al, NEJM 2012; Gachard et al, Leukemia 2013; Jiminez et al, Leukemia 2013.

54 Overall Survival in WM is Inferior with MYD88 Wild-Type Genotype Adjusted risk of death with MYD88 WT HR (95% CI ; p=0.002). Treon et al, Blood

55 Summary MYD88 L265P is present >90% of WM patients and triggers activation of Bruton s Tyrosine Kinase (BTK) in WM cells. The BTK inhibitor ibrutinib is associated with rapid reduction of serum IgM and improved HCT with an ORR of 83%, major RR of 65% in relapsed/refractory patients. CXCR4 status impacts serum IgM and hemoglobin levels, and major response attainment. Inhibitors to MYD88 and CXCR4 pathways represent novel approaches to the treatment of WM, alone and in combination. 55

56 Acknowledgements Zach Hunter PhD Ranjana Advani, MD M. Lia Palomba, MD IWMF Irene Ghobrial, MD Jacob Laubach, MD Sandra Kanan, NP Jorge Castillo, MD Gaurav Varma, MPH Diane Warren Sarah Daadi Rebecca Green Leslie Cheteyan Stephen Cropper Guang Yang, PhD Lian Xu, MA Yang Cao, MD Peter S. Bing, M.D. IWMF Coyote Fund for WM Waldenstrom s Cancer Fund NIH Spore Funding Bailey Family Fund for WM D Amato Fund for Genomic Discovery Edward and Linda Nelson Fund for WM Bauman Family Trust Tannenhauser Family Foundation 56

57 Bing Center for Waldenstrom s Macroglobulinemia Chris Patterson (617)

58 IWWM-8 London, UK Aug ,

59 IN GRATITUDE TO THE IWMF FOR THEIR TIRELESS EFFORTS ON BEHALF OF WM PATIENTS. We shall defend our island, whatever the cost may be, we shall fight on the beaches, we shall fight on the landing grounds, we shall fight in the fields and in the streets, we shall fight in the hills; WE SHALL NEVER SURRENDER. 59