Therapeutic and Prognostic Role of Epigenetic Abnormalities in MDS. Stephen D. Nimer, MD Sylvester Comprehensive Cancer Center December 5, 2014
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1 Therapeutic and Prognostic Role of Epigenetic Abnormalities in MDS Stephen D. Nimer, MD Sylvester Comprehensive Cancer Center December 5, 2014
2 DISCLOSURE I have no relevant financial relationships to disclose.
3 Outline Epigenetics: study of heritable traits independent of underlying DNA sequence; maintenance of cell identity, cellular response to the environment Epigenetic abnormalities in MDS: what is their role in disease initiation? Phenotype? Disease evolution? Response to therapy? Epigenetic therapies: What epigenetic-based therapies exist? Do they work? How do they work? Why do they stop working? Can they be rationally combined (and with what)? What is on the horizon? How will we make progress (mouse models, biomarkers, randomized clinical trials)?
4
5 EPIGENETICS Taken from Resverlogix Corp.website
6 PATHOPHYSIOLOGY H-C Tsai and S. Baylin; Cell Res 2011
7 CELLULAR IDENTITY H-C Tsai and S. Baylin; Cell Res 2011
8 Epigenetic abnormalities in MDS Aberrant DNA methylation, DNA hydroxymethylation, histone modifications (gene promoters, enhancers, super-enhancers, gene bodies, intergenic regions) Are they distinct from other cancers? Distinct from AML? Mutations in epigenetic modifiers (e.g. DNMT3A, IDH1/2, TET2, ASXL1, EZH2, )
9 Epigenetic abnormalities in MDS Graubert & Walter, ASH Ed. Program, 2011
10 Acquisition of mutations in epigenetic regulators with age M. Xie et al Nature Medicine 2014
11 Acquisition of mutations in epigenetic regulators with age M. Xie et al Nature Medicine 2014
12 Age-related mutations associated with clonal hematopoietic expansion and malignanices M. Xie et al Nature Medicine 2014
13 Impact of mutations on prognosis: independent of clinical variables? response to therapies? Epigenetic mutations Patterns of epigenetic modifications (aren t they linked?)
14 Clinical Effect of Point Mutations in Myelodysplastic Syndromes Rafael Bejar, M.D., Ph.D., Kristen Stevenson, M.S., Omar Abdel-Wahab, M.D., Naomi Galili, Ph.D., Björn Nilsson, M.D., Ph.D., Guillermo Garcia-Manero, M.D., Hagop Kantarjian, M.D., Azra Raza, M.D., Ross L. Levine, M.D., Donna Neuberg, Sc.D., and Benjamin L. Ebert, M.D., Ph.D. Bejar R et al. N Engl J Med 2011;364:
15 Hazard Ratios for Death in a Multivariable Model Bejar R et al. N Engl J Med 2011;364:
16 EZH2, TP53, RUNX1, ASXL1 EZH2: POOR PROGNOSIS IN LR-PSS MDS PATIENTS
17 Effect of EZH2 mutations on survival in MDS
18 ASXL1 PROGNOSTIC IMPORTANCE
19 Effect of DNMT3A mutations on outcome in MDS (N=150 patients) M. Walter et al Leukemia 25: 1153; 2011
20
21 Variant allele frequencies help order the sequence of mutations Bejar R et al. Blood 2014;124:
22 Overall survival data (146/213 patients) Bejar R et al. Blood 2014;124:
23 TET2 PROGNOSTIC IMPORTANCE IN HIGH RISK MDS T-L. Lin et al Haematologica 2013
24 THERAPEUTICS S. Greenblatt and S. Nimer Leukemia 2014
25 IDH MUTATIONS LEAD TO CELL DIFFERENTIATION BLOCK IDH Mutation IDH Mutation: Inhibition: Differentiation Restored Blocked Inhibitor IDH Isocitrate midh IDH akg 2HG Me Me Me Epigenetic Re-Wiring Appropriate Differentiation of Cells Unchecked Cell Proliferation Normal Cell Death / CANCER HOMEOSTASIS HSC Progenitor Mature Cell Dang L et al. Nature. 2009;462(7274): Figueroa ME et al. Cancer Cell. 2010; 18: Yen KE, Schenkein DP. The Oncologist. 2012;17:5-8.
26 HISTONE METHYLTRANSFERASE INHIBITORS EPZ-5676 A highly potent and selective inhibitor of DOT1L in clinical development. EPZ-6438 A potent and selective small molecule inhibitor of EZH2 in clinical development. GSK126, GSK343 Small molecule inhibitors of EZH2. PFI-2 A potent and selective SETD7 inhibitor. SGC0946 A potent and selective inhibitor of DOT1L. UNC0638, UNC0642, UNC0646 Selective and cell permeable inhibitors of G9a and GLP HISTONE DEMETHYLASE INHIBITORS Daminozide A small molecule inhibitor of the KDM2/7 family of JmjC demethylases. GSK-J1 / GSK-J4 Selective inhibitors of the UTX and JMJD3 H3K27 demethylases GSK-LSD1 A specific and irreversible inhibitor of LSD1. LSD1-C12, LSD1-C76 Specific, and reversible LSD1 inhibitors, with in vivo efficacy JIB-04 (NSC693627) A cell permeable Jumonji demethylase inhibitor, ML324 A potent and cell permeable inhibitor of the JMJD2 histone demethylase. PBIT A reversible and cell-permeable inhibitor of JARID1 histone demethylases.
27 COMBINATION THERAPY
28 CONCLUSIONS Epigenetic abnormalities can predict prognosis in untreated and treated MDS pts (DNMT3A bad, EZH2 bad, ASXL1 bad, TET2 neutral) Certain abnormalities may predict for a response to specific therapies (e.g. TET2) HDACi plus HMAs not a home run. New epigenetic focused therapies are in the pipeline
29 JANET ROWLEY
30 Sylvester Comprehensive Cancer Center U. Michigan Maria Figueroa Weill Cornell MC Ari Melnick Monica Guzman Ronan Swords Justin Watts Joseph Rosenblatt JC Ramos Julio Barredo Arthur Zelent Lan Wang Feng-Chun Yang Krishna Komanduri MSKCC Virginia Klimek Ross Levine Steven Chung
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