Leukaemia - New Therapeutic Approaches. Professor Paresh Vyas

Transcription

1 Leukaemia - New Therapeutic Approaches Professor Paresh Vyas Oxford Center for Haematology & MRC Molecular Unit University of Oxford and University of Oxford Hospitals Foundation NHS Trust

2 Outline of Presentation 1. Different types of leukaemia 2. Focus on Acute Myeloid Leukaemia (AML) as an exemplar to illustrate principles of new approaches to therapy 3. Genetic analyses to stratify therapy from diagnosis 4. Genetic approaches to monitor disease response 5. Targeting disease causing mutations 6. Targeting leukemia propagating stem cells

3 Blood cell lineages and clonal blood disorders Red cells Granulocyte/Monocyte Platelet Myeloid (Chronic) Myeloproliferative Myelodysplasia Acute Myeloid Leukaemia B-cells T-cells NK cells APC cells Lymphoid (Chronic) Lymphoproliferative Lymphoma Acute Lymphoid Leukaemia

4 Age, years The AML Paradox - AML incidence increases and survival decreases with age 80% of Acute leukaemia is Acute Myeloid leukaemia. ~ cases/year in the UK Median age at diagnosis is 75 years, and incidence increases with age Incidence per 100, AML 5-year survival rates ( ) < > Age-specific incidence rates for AML,

5 AML Cell Heterogeneity and Relapse Known AML/patient factors predictors of relapse after any therapy Age PS/Comorbidities De novo AML versus secondary AML Cytogenetic profile Mutational profile Response to initial therapy

6 Principles of Therapy Fit patients: Curative therapy 1. Combination chemotherapy to achieve complete remission (marrow blast count 5% with normal blood counts). 2. APL (AML M3): Rx with All Trans Retinoic Acid. Arsenic is also used. 3. Occasionally we give antibodies directed against leukaemic cells (anti-cd33 Mylotarg). 4. In ~40% of patients under the 65 yrs we consider bone marrow transplantation. Several types of transplant -source of do nor stem cells and the type of chemo/radio therapy given. Unfit patients: Increase survival whilst maintaining quality of life 1. Supportive care. Survival is only 2-3 months. 2. Low dose chemotherapy palliative. 3. New agents Epigenetic therapy. Azacitidine specific inhibitors.

7 Genetic Approaches to Stratify Therapy

8 Acute Myeloid Leukaemia, like all cancers, is principally a genetic disease. Genetic changes: Gross chromosomal structural changes - karyotyping Mutations in individual genes sequencing Genetic (and consequent epigenetic) changes drive many of the hallmarks of disease Clonal dominance Differentiation block Genetic changes dictate much of the clinical course and sensitivity to therapy Haematologists are having to understand lab reports of cytogenetic & molecular mutation changes.

9 UK AML Trials: Outcome in 5876 adults <60 yrs Good Intermediate Poor Grimwade et al Blood (2010)

10 Will we ever make sense of it? Cancer Genome Atlas NEJM whole genomes 150 exomes Towards A Complete Understanding of Genetic Heterogeneity in AML (I)

11 Integration of cytogenetic and molecular markers to predict outcome in AML t(15;17) t(8;21) inv(16) NPM mut/ ITD neg CEBPA biallelic Good Other intermediate FLT3-ITD/ NPM wt Other adverse Intermediate Poor Smith ML, Hills RK & Grimwade D. Blood Rev 2011; 25:39-51.

12 Genetic Determinants Of AML Relapse European LeukamiaNet Genetic Risk Groups Genetic Risk Group Genetic Markers Favourable Intermediate-I Intermediate-II Adverse Risk t(8;21)(q22;q22); RUNX1-RUNX1T1 inv(16)(p13.1q22) or t(16;16)(p13.1;q22); CBFB-MYH11 Mutated NPM1 without FLT3-ITD (CN-AML) Bi-allelic mutation of CEBPA (CN-AML) Mutated NPM1 and FLT3-ITD (CN-AML) Wild-type NPM1 and FLT3-ITD (CN-AML) Wild-type NPM1 without FLT3-ITD (CN-AML) t(9;11)(p22;q23); MLLT3-MLL Cytogenetic abnormalities not classified as favorable or adverse inv(3)(q21q26.2) or t(3;3)(q21;q26.2); RPN1-EVI1. t(6;9)(p23;q34); DEK-NUP214. t(v;11)(v;q23); MLL rearranged. -5 or del(5q); -7; abnormal (17p). Complex karyotype* Monosomal karyotype

13 Genetic AML subtypes in Patients <60 yrs of age RUNX1 ~40% MLL-PTD ~30% ASXL1 ~30% SRSF2 ~20% U2AF1 ~15% STAG2 ~15% BCOR ~10% SF3B1 ~10% EZH2 ~5% ZRSR2 ~5% Complex and Monosomal Karyotype ~90% TP53 mutant/loss 8% Secondary Type 13% Other 10% t(15;17)(q22;q21)/pml-rara 13% FLT3-ITD ~35% FLT3-TKD ~20% WT1 ~10% t(8;21)(q22;q22)/runx1-runx1t1 7% inv(16)(p13q22)/cbfb-myh11 5% 11q23/MLL-X 4% KIT ~25% ASXL2 ~20% ASXL1 ~10% KRAS ~20% NRAS ~20% NRAS ~40% KIT ~35% FLT3-TKD ~20% KRAS ~10% GATA2 ~30% bicebpa mutant 4% t(9;22)(q34;q11)/bcr-abl 1% t(6;9)(p23;q34)/dek-nup214 1% t(5;11)(q35;p15.5)/nup98-nsd1 1% FLT3-ITD ~70% FLT3-ITD ~85% NPM1 mutant 33% DNMT3A ~50% FLT3-ITD ~40% Cohesin ~20% IDH1 ~15% IDH2-R140 ~15% PTPN11 ~15% inv(3)(q21q26)/gata2-evi1 1% Other rare fusions 1% t(3;5)(q21~25;q31-35)/npm1-mlf1 t(8;16)(p11;p13)/myst3-crebbp t(16;21)(p11;q22)/fus-erg t(10;11)(p13;q21)/picalm-mllt10 t(7;11)(p15;p15)/nup98-hoxa9 t(3;21)(q26;q22)/runx1-mecom NRAS ~40% SF3B1 ~20% ASXL1 ~15% BCOR ~15% GATA2 ~15% RUNX1 ~15% Heterogeneity? Clinical Impact therapies given and outcome Grimwade D, Ivey A, Huntly BJP. Blood 2015

14 Genetic Approaches to Monitor Therapy

15 Assessment of kinetics of disease response to inform risk-stratification Leukaemic cell burden >10 12 Relapse Residual disease detectable by genetic tests Rapid responders Slow responders e.g. RT-PCR 10 6 MRD undetectable range

16 Molecular pathogenesis of AML in younger adults RUNX1 ~40% MLL-PTD ~30% ASXL1 ~30% SRSF2 ~20% U2AF1 ~15% STAG2 ~15% BCOR ~10% SF3B1 ~10% EZH2 ~5% ZRSR2 ~5% Complex and Monosomal Karyotype ~90% TP53 mutant/loss 8% Secondary Type 13% Other 10% t(15;17)(q22;q21)/pml-rara 13% FLT3-ITD ~35% FLT3-TKD ~20% WT1 ~10% t(8;21)(q22;q22)/runx1-runx1t1 7% inv(16)(p13q22)/cbfb-myh11 5% 11q23/MLL-X 4% KIT ~25% ASXL2 ~20% ASXL1 ~10% KRAS ~20% NRAS ~20% NRAS ~40% KIT ~35% FLT3-TKD ~20% KRAS ~10% GATA2 ~30% bicebpa mutant 4% t(9;22)(q34;q11)/bcr-abl 1% t(6;9)(p23;q34)/dek-nup214 1% t(5;11)(q35;p15.5)/nup98-nsd1 1% FLT3-ITD ~70% FLT3-ITD ~85% NPM1 mutant 33% DNMT3A ~50% FLT3-ITD ~40% Cohesin ~20% IDH1 ~15% IDH2-R140 ~15% PTPN11 ~15% inv(3)(q21q26)/gata2-evi1 1% Other rare fusions 1% t(3;5)(q21~25;q31-35)/npm1-mlf1 t(8;16)(p11;p13)/myst3-crebbp t(16;21)(p11;q22)/fus-erg t(10;11)(p13;q21)/picalm-mllt10 t(7;11)(p15;p15)/nup98-hoxa9 t(3;21)(q26;q22)/runx1-mecom NRAS ~40% SF3B1 ~20% ASXL1 ~15% BCOR ~15% GATA2 ~15% RUNX1 ~15% Grimwade D, Ivey A, Huntly BJP. Blood 2015

17 Molecular MRD status provides powerful prognostic information in NPM1 mutant AML Results from the UK NCRI Phase III Trial AML17 PCR status in peripheral blood post-chemotherapy course 2 Cumulative Incidence of Relapse Overall Survival MRD +ve 83% MRD neg 77% 2P< MRD neg 28% 2P< MRD +ve 25% In multivariate analysis MRD status was only significant independent prognostic factor, considering: Age WBC Mutational profile (51 gene panel including FLT3-ITD, DNMT3A, WT1) Ivey A, NEJM 2016

18 Monitor vs No Monitor : Impact of MRD monitoring on survival, cost-effectiveness & quality of life NCRI AML17 trial NPM1 mutation (19 assays) 65% Other 2% BCR-ABL(2) NUP98-HOXA9 MOZ-CBP CALM-AF10 RUNX1-CBFA2T3 PRMD1-RUNX1 t(6;9)/dek-can 2% 438 patients randomised Covered by 40 RT-qPCR assays t(11q23)/mll fusions (9 assays) 9% >3000 samples analysed t(8;21)/aml1-eto 11% Inv(16)/CBFB-MYH11 (3 assays) 11%

19 Targeted Therapy dependent of Genetic Changes

20 First description of Acute Promyelocytic Leukaemia (APL AML M3)

21 Development of All Trans-Retinoic Acid to treat APL ATRA found to differentiate 1 APL cells (Breitman 1981) Demonstration of benefit of addition of ATRA to chemo in RCTs (Fenaux 1993; Tallman 1997) Cloning of the t(15;17) (Borrow; de Thé 1990) ATRA reported to induce remission in APL patients (Huang 1988) t(15;17) identified (Rowley 1977) ATRA as standard of care in UK First description of APL (Hillestad 1957)

22 Arsenic: Evolution from poison to targeted therapy Millais, Ophelia (1851) Elizabeth Siddal Fowler s Solution (1786) 1% Potassium arsenite First used to treat leukaemia in 1845 Harbin, 1970 s 1% As 2 O 3 Traces HgCl 2 32 APL pts treated 65% CR See Degos L. Br J Haem 2003

23 Impact of molecularly-targeted therapy: Progress in treatment of APL in UK over last 25 years: Testing Arsenic + ATRA as frontline therapy Testing deintensified therapy with MRD monitoring + Arsenic for relapse Improved ATRA dosing ATRA therapy first tested Chemotherapy only Courtesy Robert Hills.

24 Isocitrate Dehydrogenase (IDH) Mutations Represent Important Cancer Metabolism Targets IDHwt: catalyzes oxidative decarboxylation of isocitrate to produce CO 2 and α-kg 3 isoforms exist: IDH1, IDH2, IDH3 - IDH1: cytoplasm - IDH2: mitochondria IDH mutations have neomorphic activity: - Produce high levels of oncometabolite 2-HG (gain of function) - 2HG leads to differentiation block via epigenetic alterations

25 IDH1m and IDH2m: Distinct Genetically Defined Populations IDH Mutations Seen in Multiple Cancer Types Target Indication IDHm (%) AML 15% MDS/MPN 5% IDH2m Angio-immunoblastic NHL 25% Others (melanoma, glioma, chondrosarcoma) 2 3-5% Type II D-2HG Aciduria (inborn error of metabolism) 100% Low-grade glioma & 2 ary GBM 1 70% Chondrosarcoma >50% IDH1m AML 8% MDS/MPN 5% Intrahepatic cholangiocarcinoma 20% Others (colon, melanoma, lung) 2 1-2% 1 Includes 8.5% of Primary GBM 2 Includes basket of emerging unconfirmed indications

26 Effects of IDH1/2 mutations Gain of function = neomorphic activity = reduction of αkg to D-2HG = Production in vast excess (X10 to 100) of D-2HG (intracellular & serum) Inhibit αkg dependent dioxygenases including DNA & histones demethylases JHDM & TET2 Histone/DNA hypermethylation with block of differentiation C. LU & C. Thomson 3 july 2012

27 Baseline characteristics of pivotal first-in-class first-in-man Phase I trial of oral AG-221 (IDH2 inhibitor) monotherapy in AML/MDS Data cut-off: 1 Sept 2015 All (N = 209) RR-AML (n=159) Age (years), median (range) 69 (19 100) 68 (19 100) Gender, % M/F 56/44 50/50 IDH2 mutation, n (%) R (70) 109 (69) R (24) 41 (26) ECOG PS, n (%) (77) 120 (76) 2 41 (20) 34 (21) Diagnosis, n (%) RR-AML 159 (76) 159 (100) Untreated AML 24 (11) - MDS 14 (7) - Other 12 (6) - Number of prior Tx, median (range) - 2 (1 6) Hematology, median (range) ANC (10 9 /L) 0.4 (0 38) 0.3 (0 38) WBC (10 9 /L) 2.5 ( ) 2.7 ( ) Hgb (g/dl) 5.7 ( ) 5.7 ( ) Platelets (10 9 /L) 44 (1 644) 39 (1 507) Efficacy-evaluable population Large High risk patients Heavily pretreated ECOG PS, Eastern Cooperative Oncology Group performance status; Tx, treatment; Hgb, hemoglobin; WBC, white blood cells

28 Induction of Differentiation with IDH inhibitor AG -221 AGI 22 C1D1 BM C1D1 90% Blasts BM C1D14 Monocytic differentiation Blood C1D15 BM C1D28 Granulocytic differentiation Blood C2D2

29 Response Overall Response (CR, CRp, CRi, mcr, PR) CR RR-AML (n = 159) 59 (37%) [95%CI: 30%, 45%] 29 (18%) [95%CI: 13%, 25%] Untreated AML (n = 24) 10 (42%) [22%, 63%] 4 (17%) [5%, 37%] MDS (n = 14) 7 (50%) [23%, 77%] 3 (21%) [5%, 51%] All (N = 209) 79 (38%) [31%, 45%] 37 (18%) [13%, 24%] CRp 1 (1%) 1 (4%) 1 (7%) 3 (1%) CRi 3 (2%) (1%) mcr 9 (6%) 1 (4%) 3 (21%) 14 (7%) PR 17 (11%) 4 (17%) 0 22 (11%) SD 72 (45%) 9 (38%) 6 (43%) 96 (46%) PD 10 (6%) 1 (4%) 0 11 (5%) Not evaluable 18 (11%) 4 (17%) 1 (7%) 23 (11%) CR, complete response; CRp, CR with incomplete platelet recovery; CRi, CR with incomplete hematologic recovery; mcr, marrow CR; PR, partial response; SD, stable disease; PD, progressive disease

30 Targeting Leukaemic Stem Cells

31 Advances in Leukaemia Stem Cell Biology Cell of origin in myeloid malignancies Preleukaemic phase Identification of leukemic stem cell populations Leukaemic phase Normal stem cell initiating cell population Clonal evolution Acquisition of genetic or epigenetic mutations Tehranchi et al NEJM 2010 Jan et al Sci Translational Medicine 2012 Roy et al PNAS 2012 Roberts et al Blood 2013 Woll et al Cancer Cell 2014 Stem/progenitor populations Hong et al Science 2008 Anderson et al Nature 2011 Goardon et al Cancer Cell 2011 Blasts Bulk leukaemia

32 Tracking LSC pre and post therapy Relapse Limit of detection Blocks of Therapy Cure time leukaemic cell normal cell Do LSC disappear in patients who are eventually cured and persist in those that relapse? Oxford MHU UK AML Trial Group MRC Disease Team Award

33 Therapeutic Anti-CD47 Antibody Oxford Stanford Collaboration Phagocytic cells remove ( eat ) unwanted cells. Cancer cells express pro-phagocytic (eat me) signals AML stem cells avoid phagocytosis by expressing CD47 a don t-eat me signal. Anti-CD47 Ab blocks the don t eat me signal allowing cancer cell phagocytosis. eat me Phagocyte phagocytosis cancer cell CD47 don t eat me X No phagocytosis eat me phagocytosis Anti-CD47 antibodies Majeti Cell 2009; Jaiswal Cell 2009; Chao Cell 2010; Goardon Cancer Cell 2011; Edris PNAS 2012; Kim Leukaemia 2012; Willingham PNAS 2012; Pang PNAS 2013; Weiskopf Science 2013

34 Examples of Pre-clinical Efficacy Data Inject Leukemia Cells IV Bone Marrow Engraftment Assessment, Then Initiate Treatment 6 Weeks 2 Weeks Evaluate Bone Marrow Engraftment Control Hu5F9-G4

35 Challenges And Opportunities Going Forward Genetic Revolution Risk stratification more precise but there may be too many risk groups More genetic information WGS clarity about clinically relevant genetic changes Allows for measurement of residual disease need a clinical intervention that deals with residual disease. Clonal structures and the single cell revolution designing rational therapy combinations Leukaemic Stem Cells Definition of Leukaemic Stem Cells Understand how to target with antibodies or through an allo-immune response or engineered T-cells Understand how to make them differentiate

36 Acknowledgements UK NCRN AML Working Party (UK AML Clinical Trial Group) Professor Nigel Russell Professor Charles Craddock Dr Mike Dennis Professor David Grimwade Dr Steven Knapper Stanford University Dr I Weissman Dr R Majeti Institut Gustave Roussy Dr S De Botton

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38 FLT3: ITDs and TKD mutations WT in absence ITD TKD of ligand (26%) (10%) Extracellular domain ATP binding pocket Juxtamembrane domain Activation loop Kinase domain ATP binding pocket exposed Rosemary Gale, UCL

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40 Relapse Is Main Cause For Therapy Failure After Allogeneic SCT for AML AML is the most common indication for allogeneic SCT Relapse is most common reason for Rx failure Russell et al Leukaemia 2013

41 Gemtuzumab Ozogamicin (Mylotarg) CD33 Antigen present on >90% AML blast cells Humanized anti-cd33 antibody Highly specific Minimally immunogenic Murine humanized monoclonal Ac IgG4 kappa (hp67.6) Calicheamicine γ1i : base bicyclotridécadiynene + chain tétrasaccharidique and thiobenzoate Pont N-acétyl gamma Ac But linker Stable in circulation Hydrolyzed in AML cells Calicheamicin Highly-potent cytotoxic agent Non immunogenic

42 Patient and trial details Trial GO schedule Induction Chemo No. of patients in MA ALFA mg/m 2 d1,4,7 DA (3+7) GOELAMS AML2006IR 6mg/m 2 DA (3+7) MRC AML15 3mg/m 2 d1 ADE,DA,FLAG- Ida NCRI AML16 3mg/m 2 d1 DA, DClo SWOG mg/m 2 d4 DA (3+7) Median age

43 GO Meta Analysis: Relapse

44 Overall Survival: Favourable, Intermediate Cytogenetics

45 Induction of Differentiation: Patient who achieved a CRi AGI 22 C1D1 BM C1D1 90% Blasts BM C1D14 Monocytic differentiation Blood C1D15 BM C1D28 Granulocytic differentiation Blood C2D2

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49 Clones Are The Unit Of Selection With Therapy A, B, C, D = mutations Genetic/Clonal heterogeneity AD AB ABC A ABC AB AB A ABC A ABC AB AB AD ABC AB AD AD AD A ABC ABC ABC ABC ABC ABC ABC ABC ABC AB AB AB AB AB AB 1-5 clones per patient Cancer Genome Atlas NEJM 2013 AD AB ABC A ABC AB AB A ABC A ABC AB AB AD ABC AB Therapy AD AD AD Clone selection relapse AD AD AD AD AD AD AD AD AD AD AD AD We have to establish clonal structure which mutations are within the same cell. Bioinformatically Single cell genotyping

50 Integration of cytogenetic and molecular markers to predict outcome in AML t(15;17) t(8;21) NPM mut/ ITD neg inv(16) CEBPA biallelic Other intermediate FLT3-ITD/ NPM wt Other adverse Smith ML, Hills RK & Grimwade D. Blood Rev 2011; 25:39-51.

51 IDH1m and IDH2m: Distinct Genetically Defined Populations IDH Mutations Seen in Multiple Cancer Types Target Indication IDHm (%) AML 15% MDS/MPN 5% IDH2m Angio-immunoblastic NHL 25% Others (melanoma, glioma, chondrosarcoma) 2 3-5% Type II D-2HG Aciduria (inborn error of metabolism) 100% Low-grade glioma & 2 ary GBM 1 70% Chondrosarcoma >50% IDH1m AML 8% MDS/MPN 5% Intrahepatic cholangiocarcinoma 20% Others (colon, melanoma, lung) 2 1-2% 1 Includes 8.5% of Primary GBM 2 Includes basket of emerging unconfirmed indications

52 Towards A Complete Understanding of Genetic Heterogeneity in AML (II) Fewer frequently mutated genes 23 genes mutated at a higher prevalence than expected. Cancer Genome Atlas NEJM 2013

53 Gene mutations Are Co-selected - And This Is Clinically Meaningful. Favourable Risk AML - CBF AML Relapse risk modulated by c-kit mutation. Paschka et al JCO 2006; Freeman et al Leuakemia 2013 Patel et al NEJM 2012 Intermediate Risk AML NPM mutant AML Relapse risk modulated by FLT3-ITD.