Nuevas Dianas Moleculares en el Tratamiento del Mieloma ... HEMATOLOGIA_Dr_Ocio...flow cytometry, WB...
Transcript of Nuevas Dianas Moleculares en el Tratamiento del Mieloma ... HEMATOLOGIA_Dr_Ocio...flow cytometry, WB...
Centro de Investigación del Cáncer
Centro de Investigación del Cáncer
Servicio de Hematología
Hospital Universitario
Servicio de Hematología
Hospital UniversitarioUniversidad de Salamanca
Nuevas Dianas Moleculares Nuevas Dianas Moleculares en el Tratamiento del en el Tratamiento del
Mieloma MúltipleMieloma MúltipleEnrique M. Ocio
Hospital Universitario y Centro de Investigación del CáncerUniversidad de Salamanca
Novel therapeutic targets
Classic Chemotherapeutics
Plants alkaloidsVinca alkaloidsTopoisomerase II inhibitorsT
Etoposide (VP16) / Teniposide (VM16)•Vincristine / Vimblastine
Taxanes
MethotrexateAntifolate analogs
P i l 6-Mercaptopurine / 6-Tioguanine
Paclitaxel
Antimetabolites
Purine analogs
Pyrimidine analogs
6 Mercaptopurine / 6 TioguanineFludarabine / Cladribine
5-FluoruracilCytosine Arabinoside (Ara-C)
• y g
Ribonucleotide reductase inhibitor
Cytosine Arabinoside (Ara C)Gemcitabine
Hydroxyurea
Alkylating agents•CyclophosphamideChlorambucil (Leukeran)Melphalan / BusulfanCarmustine (BCNU)
Antibiotics•
Carmustine (BCNU)Platinum analogs (Cisplatin)
Anthracyclines (Daunorubicine / Doxorubicine)Bl iAntibiotics
Miscellaneous•Bleomycin
L-AsparaginaseEsteroids San Miguel & Sánchez-Guijo, Cuestiones en Hematología. Harcourt 2008
Novel therapeutic targets
Classic Chemotherapeutics
Plants alkaloids• Interphere with mitotic apparatus (microtubules)
Antimetabolites• Interphere withSynthesis of Nucleotides
or its
incorporation into DNA
Alkylating agents• Interphere withReplication
TranscriptionInterphere with
h i
Antibiotics•
Transcription
Interphere withDNA synthesis
mechanisms of cell division
Antibiotics
Miscellaneous• San Miguel & Sánchez-Guijo, Cuestiones en Hematología. Harcourt 2008
Interphere withDNA repair
Treatment of MMTreatment of MM
1844 1844 1960 1970 1980 1970 1980 1990 2000 2000 2003 2004 2010
Melphalan(1958 Blokhin)(1958 Blokhin)
Mr. McBean1844 Hi h d h(1958, Blokhin)(1958, Blokhin)
Ann NY Acad Sci
MelphalanMelphalan
1844 High-dose chemoStem cell transplantationStem cell transplantation
BisphosphonatesBisphosphonates
Combination chemoCombination chemo
GlucocorticoidsGlucocorticoids(1969)(1969)
Combination chemoCombination chemoVincristine
Doxorubicin DexamethasoneDexamethasone
Treatment of MMTreatment of MM
Despite the benefit observed in the last years,
1971–761977–820 8
1.0
1994–001989–941983–88
viva
l
0.6
0.8
viva
lSu
rv
0.4
Surv
0 0
0.2
TimeTime0 20 40 60 80 100 120 140
0.0
Kumar, Blood 2008
, … other drugs are still needed for relapsed/refractory patients
Treatment of MMTreatment of MM
1844 1844 1960 1970 1980 1970 1980 1990 2000 2000 2003 2004 2010
Melphalan(1958 Blokhin)(1958 Blokhin)
Mr. McBean1844 Hi h d h(1958, Blokhin)(1958, Blokhin)
Ann NY Acad Sci
MelphalanMelphalan
1844 High-dose chemoStem cell transplantationStem cell transplantation
BisphosphonatesBisphosphonates
Combination chemoCombination chemo
GlucocorticoidsGlucocorticoids(1969)(1969)
Bortezomib IMIDsIMIDs
Combination chemoCombination chemoVincristine
Doxorubicin Dexamethasone
Thalidomide
Dexamethasone
Treatment of MMTreatment of MM
Despite the benefit observed with novel agents in the last years,
1971–761977–820 8
1.0
1994–001989–941983–88
viva
l
0.6
0.8
2001 06viva
lSu
rv
0.4
2001–06
Surv
0 0
0.2
TimeTime0 20 40 60 80 100 120 140
0.0
Kumar, Blood 2008
, … other drugs are still needed for relapsed/refractory patients
Treatment of MMTreatment of MM
1844 1844 1960 1970 1980 1970 1980 1990 2000 2000 2003 2004 2010
Melphalan(1958 Blokhin)(1958 Blokhin)
Mr. McBean1844 Hi h d h(1958, Blokhin)(1958, Blokhin)
Ann NY Acad Sci
MelphalanMelphalan
1844 High-dose chemoStem cell transplantationStem cell transplantation
BisphosphonatesBisphosphonates
Combination chemoCombination chemo
GlucocorticoidsGlucocorticoids(1969)(1969)
Bortezomib IMIDsIMIDs
Combination chemoCombination chemoVincristine
Doxorubicin Dexamethasone
Thalidomide
GleevecDexamethasone Gleevec(CML) 2001
Herceptin(Breast) 1998
¿?Rituximab(NHL) 1997
( )
“The Hallmarks of Cancer”Novel therapeutic targets
(-) Tyrosin-K receptors
(+) death receptors (-) proliferative
thpathways(-) antiapopt.
proteins
Unfolded prot resp
proteins
(-) angiogenesis
prot. resp.
Cell cycle
Epigenetics
Hanahan & Weinberg, Cell 2000
Cell cycle blockade
ClassificationTreatment of MM
Cell cycle•Cyclin inhibitorsCDK inhibitorsCell cycleAurora Kinases inhibitors
Surface molecules•Activators of Death ReceptorsSurface AntigensTyrosin Kinase inhibitors
Signaling Pathways• PI3K/AKT; MAPK; JAK/STAT; NFKB; WNT
y
“Unfolded protein response”•“Heat Shock Proteins” inhibitorsProteasome inhibitorsUnfolded protein response• Proteasome inhibitorsAgressome formation inhibitors
Epigenetics• Demethylating agentsHistone Deacetilases Inhibitors
ClassificationTreatment of MM
Cell cycle•Cyclin inhibitorsCDK inhibitorsCell cycleAurora Kinases inhibitors
Surface molecules•Activators of Death ReceptorsSurface AntigensTyrosin Kinase inhibitors
Signaling Pathways• PI3K/AKT; MAPK; JAK/STAT; NFKB; WNT
y
“Unfolded protein response”•“Heat Shock Proteins” inhibitorsProteasome inhibitorsUnfolded protein response• Proteasome inhibitorsAgressome formation inhibitors
Epigenetics• Demethylating agentsHistone Deacetilases Inhibitors
Cell Cycle RegulationNovel therapeutic targets
Cyclins & CDKs inhibitorsp16
p15p18
p19p57
p53
Cyclin D Cyclin B
p
p21
p57
p27
G1MCDK 4/6
Cyclin ECDK 1
PP
CDK 2
G1MPPAurora
SG2 E2FRb
Kinases
SG2 E2FCyclin A Cyclin A
CDK 1p27
Schwartz GK. “Targeting the cell cycle: A new approach to cancer therapy”. JCO 2005Schwartz GK. “Targeting the cell cycle: A new approach to cancer therapy”. JCO 2005
CDK 2 CDK 1
p21
p21
Primary IgH translocationsNovel Agents for MM
20%
Cyclin D3Cyclin D3
Cyclin D1Cyclin D115%
p21p21
q13q13FGFR3 /MMSETFGFR3 /MMSET
Oncogenic receptortyrosine kinase
pp
Cyclin D2Cyclin D2Nuclear SET domain
protein
p13p13 p16p16
protein
q32q32B-ZIP transcription
factor
5%CDK
inhibitorsCyclin D1 inhibitors
Aurora K inhibitors
IgHIgH C-MAFC-MAFq23q23P276-00CYC202
PD0332991 VX-680
ClassificationTreatment of MM
Cell cycle•Cyclin inhibitorsCDK inhibitorsCell cycleAurora Kinases inhibitors
Surface molecules•Activators of Death ReceptorsSurface AntigensTyrosin Kinase inhibitors
Signaling Pathways• PI3K/AKT; MAPK; JAK/STAT; NFKB; WNT
y
“Unfolded protein response”•“Heat Shock Proteins” inhibitorsProteasome inhibitorsUnfolded protein response• Proteasome inhibitorsAgressome formation inhibitors
Epigenetics• Demethylating agentsHistone Deacetilases Inhibitors
Host-tumor interactionsNovel Agents for MM
IL-6IL-6
Direct contact & soluble molecules
CD138
IL 6
IGF-1
VEGF
IL 6
IGF-1
VEGFCD44
MM cell
CXCR4CXCR4
ICAM-2TNFTNF
CD44
SDF1
β1-integrinsCXCR4CXCR4
VLA-4LFA-1
BMSC
ECM (Fibronectin, laminin)
ECM (Fibronectin, laminin)
VCAM-1ICAM-1
β1-integrins: VLA-4 (CD49d), VLA-5 (CD49e), VLA-6 (CD49f)β1-integrins: VLA-4 (CD49d), VLA-5 (CD49e), VLA-6 (CD49f)
Cell adhesion induces drug resistance:Cell adhesion induces drug resistance: 1) cell cycle arrest (↑ p27); 2) apoptosis inhibition (↑ FLIP-1 –FAS inhibitor-); 3) protection from drug-induced DNA damagePC adhesion to Fn induces overexpresion of 53 genes ( 11 regulated by NFkB)
San Miguel, Hematol J. 2003
Signaling pathways in MM PCNovel Agents for MM
IGF-1IGF-1IL6IL6
SDF1αSDF1αTNFαTNFα
IL-21IL-21SDF1αSDF1α
VEGFVEGF
JAK/STATRAS
PI3K/AKTRAF/MEK/MAPK
P lif tiProliferation Prevents apoptosis
Surface receptors in MM PCNovel Agents for MM
CD56
CD40 CS1
CD56
VEGFRIL-6R
IGF-1RCD74
FGFR3DR4 5
EGFR
TACI
BCMA
FGFR3DR4-5
Fas
TRAIL
APO010 APRILc-kitc-kit
Surface receptors in MM PCTreatment of MM
CD56
CD40 CS1IMGN901
Dacetuzumab Elotuzumab
CD56
VEGFRIL-6RCNTO-328
IGF-1RCD74Milatuzumab
FGFR3DR4 5
EGFR Cetuximab
TACI
BCMA
FGFR3DR4-5
Fas
TRAIL
APO010 APRILc-kit
Dasatinib Imatinib
c-kit
Surface receptors in MM PCNovel Agents for MM
CD56
CD40 CS1IMGN901
ElotuzumabDacetuzumab
CD56
IL-6RCNTO-328VEGFR
CD74MilatuzumabIGF-1R
FGFR3
EGFR Cetuximab
DR4 5TACI
BCMA
FGFR3
APRILc-kit
DR4-5
Fas
TRAIL
APO010
Dasatinib Imatinib
c-kit
Anti-CS1 in MMTreatment of MM
• Cell surface glycoprotein• Universal gene expression in MM 80
HuLuc63: MoAb that induces ADCCg p
• Confirmed CS1 protein expression by flow cytometry, WB and IHC
c ki
lling
4050607080
• Normal tissue staining shows expression only in tissue PC
% s
peci
fic
10203040
0
0
0.00
01
0.00
1
0.01 0.1 1 10
HuLuc63 μg/ml
PC in normal gut Plasmacytoma MM1RMM1S
U266CD19+B cells
HuLuc63, μg/ml
g y MM1S CD19+B cells
CS1
Tai, Blood 2007. Bensinger ASH 2007. Abstract 1180
Elotuzumab (Anti-CS1 MoAb) in MMTreatment of MM
• Phase I in monotherapy n=23 26% SD Zonder, ASH 2008. Abstract 2773
• Phase I/II Elotuzumab + Len + dex Lonial, ASH 2009. Abstract 432
Elotuzumab days 1, 8, 15 22
Lenal “prepares” PBMCs & then Elotuzumab induces ADCC
n=13 relapsed MM ORR 92% (15% VGPR, 77% PR, 8% SD)
Toxicity: 25% infusion reaction. Haematological.
• Phase I Elotuzumab + Bort Jakubobiak, ASH 2009. Abstract 3876
Elotuzumab days 1, 11
n=16 relapsed MM ORR 44% (6% CR, 19% nCR, 19% PR, 31% MR, 19% SD)
Toxicity: GI, Haematological
Surface receptors in MM PCNovel Agents for MM
CD40 CS1
Elotuzumab
CD56
DaclizumabDacetuzumab
IMGN901
VEGFR
CD56
IL-6RCNTO-328
IGF-1RCD74Milatuzumab
FGFR3
EGFR Cetuximab
DR4 5TACI
BCMA
FGFR3
APRILc-kit
DR4-5
Fas
TRAIL
APO010
Dasatinib Imatinib
c-kit
Drugs targeting TK receptorsNovel Agents for MM
FGFR Kit
MetFLT3
PDGFR
Tie2
FLT3
Zap-70IGF 1R
AblIGF-1R
Jak
Her
SrcEGFR
Primary IgH translocationsNovel Agents for MM
20%
FGFR3 i hibit
PD173074CHIR258
Cyclin D3Cyclin D3
Cyclin D1Cyclin D115%
inhibitors CHIR258AB1010
p21p21
q13q13FGFR3 /MMSETFGFR3 /MMSET
Oncogenic receptortyrosine kinase
pp
Cyclin D2Cyclin D2Nuclear SET domain
protein
p13p13 p16p16
protein
q32q32B-ZIP transcription
factor
5%
IgHIgH C-MAFC-MAFq23q23
ClassificationTreatment of MM
Cell cycle•Cyclin inhibitorsCDK inhibitorsCell cycleAurora Kinases inhibitors
Surface molecules•Activators of Death ReceptorsSurface AntigensTyrosin Kinase inhibitors
Signaling Pathways• PI3K/AKT; MAPK; JAK/STAT; NFKB; WNT
y
“Unfolded protein response”•“Heat Shock Proteins” inhibitorsProteasome inhibitorsUnfolded protein response• Proteasome inhibitorsAgressome formation inhibitors
Epigenetics• Demethylating agentsHistone Deacetilases Inhibitors
Signaling pathways in MM PCNovel Agents for MM
IGF-1IGF-1IL6IL6
SDF1αSDF1αTNFαTNFα
IL-21IL-21SDF1αSDF1α
VEGFVEGF
JAK/STATRAS
PI3K/AKTRAF/MEK/MAPK
P lif tiProliferation Prevents apoptosis
Signaling pathways in MM PCNovel Agents for MM
IGF-1IGF-1IL6IL6
SDF1αSDF1αTNFαTNFαFT inhibition STAT3 inhibition
(Atiprimod)IL-21IL-21
SDF1αSDF1αVEGFVEGF(Tipifarnib) (Atiprimod)
JAK/STATRAS PI3K inhibition (BEZ235)
RAF inhibition (RAF265)
PI3K/AKTRAF/MEK/MAPK
(BEZ235)(RAF265)
AKT inhibition
P lif ti
MEK inhibition (AZD6244)
AKT inhibition (Perifosine)
Proliferation Prevents apoptosis mTOR inhibition (RAD001)(Rapamycin)(CCI 779)
P38/MAPK inhibition (SCIOS 469) (CCI-779)(SCIOS-469)
AKT inhibitorsNovel Agents for MM
PerifosinePerifosinePerifosine
• Phase I/II + Bort ± Dex*
Perifosine
• Phase I/II + Bort ± Dex* *Richardson, IMW 2009. Abstract 349
n=86 all previous Bort.n=86 all previous Bort.
≥MR 38% (3% CR, 19% PR, 16% MR)
In 45 Bort refrac. ≥MR 33%
≥MR 38% (3% CR, 19% PR, 16% MR)
In 45 Bort refrac. ≥MR 33%In 45 Bort refrac. ≥MR 33%In 45 Bort refrac. ≥MR 33%
• Phase I + Len + Dex**
30 l/ f ≥MR 70% (7% CR 10% VGPR 33% PR 20% MR)
• Phase I + Len + Dex**
30 l/ f ≥MR 70% (7% CR 10% VGPR 33% PR 20% MR)
**Jakubowiak, IMW 2009. Abstract 347
n=30 rel/ref ≥MR 70% (7% nCR, 10% VGPR, 33% PR, 20% MR)n=30 rel/ref ≥MR 70% (7% nCR, 10% VGPR, 33% PR, 20% MR)
mTOR inhibitors in MMNovel Agents for MM
Temsirolimus - (CCI-779)
• Phase II + Bortezomib
Temsirolimus - (CCI-779)
• Phase II + Bortezomib Ghobrial, ASH 2009. Abstract 748
n=19 rel/refr. MM ≥MR 73% (5% CR, 16% VGPR, 26% PR, 26% MR, 10% SD)n=19 rel/refr. MM ≥MR 73% (5% CR, 16% VGPR, 26% PR, 26% MR, 10% SD)
• Phase I + Lenalidomide
n= 21 1 CR, 1 PR, 3 MR
• Phase I + Lenalidomide
n= 21 1 CR, 1 PR, 3 MR
Hofmeister, ASH 2009. Abstract 2884
Everolimus - (RAD001)Everolimus - (RAD001)
Guenther, ASH 2009. Abstract 3850• Phase I/II Monotherapy
n=7 14% PR, 57% SD
• Phase I/II Monotherapy
n=7 14% PR, 57% SD
Raje, ASH 2009. Abstract 3856• Phase I + Lenalidomide• Phase I + Lenalidomide
MTD: Len 15 mg & Ever. 5 mg x21 days of 28 days cycle (Hemat. Tox.)
n=15 ≥MR 46% (13% PR, 33% MR, 7% SD)
MTD: Len 15 mg & Ever. 5 mg x21 days of 28 days cycle (Hemat. Tox.)
n=15 ≥MR 46% (13% PR, 33% MR, 7% SD)
Ig production and DNA regulation in MM PCNovel Agents for MM
Inhibitors of
Agents acting on
epigenetics
–AcAc–
Inhibitors of the unfolded
protein responseAc
–AcAc
p
Ac–
ClassificationTreatment of MM
Cell cycle•Cyclin inhibitorsCDK inhibitorsCell cycleAurora Kinases inhibitors
Surface molecules•Activators of Death ReceptorsSurface AntigensTyrosin Kinase inhibitors
Signaling Pathways• PI3K/AKT; MAPK; JAK/STAT; NFKB; WNT
y
“Unfolded protein response”•“Heat Shock Proteins” inhibitorsProteasome inhibitorsUnfolded protein response• Proteasome inhibitorsAgressome formation inhibitors
Epigenetics• Demethylating agentsHistone Deacetilases Inhibitors
Unfolded Protein ResponseTreatment of MM
TanespimycinAl i i
Ub
Hsp90
Alvespimycin
inhibitors Novel proteasome
inhibitors
Hsp-90Chaperone
NPI-0052Carfilzomib
AB1010
HDAC6HDAC6 inhibitors
Kindly provided by Dr. James Bradner and adapted
TubacinVorinostat
Panobinostat
Effects of Proteasome Inhibition in MMTreatment of MM
↓ Adhesion ↓ Cytokines ↓ Angiogenesis
MM cells TNFa↓↓ Extracellular level
BMSCBMSC VEGF
IGF-I
IL-6 BM Vessels
X↓↓
↓
26S P
NFkBNFkB
Intracellular levelIL-6, VEGF
Block activationBlock activation
26S Proteasome
X NFkBNFkB
↓ Apoptosis Inhibitors↓ Apoptosis Inhibitors
Block activation NFkB
Block activation NFkB ↑ pIkB↑ pIkBX
(IAP, FLICE)(IAP, FLICE)
Caspases 8,3Caspases 8,3
↑ FAS
MAPKMAPKPI3KPI3K
InhibitionDNA-repair effectors
InhibitionDNA-repair effectors
Decreased P lif tiDecreased
P lif tiIncreased A t iIncreased A t i
Disruption of Disruption of Disruption of Disruption of ProliferationProliferationApoptosisApoptosis unfolded protein unfolded protein
responseresponseunfolded protein unfolded protein
responseresponseSan Miguel J. Hematol J. 2003;4(suppl 3):201-207.
Carfilzomib (PR-171) monotherapyTreatment of MM
Irreversible & specific inh. of the chymotrypsin-like activity of the proteasomeDosing schedule: 20 mg/m2 iv d 1-2, 8-9, 15-16 of 28 days cycles (up to 12 cycles)
• 2 Phase I trials ≥ MR 38% - 51% Orlowsky, ASH 2007. Abstract 409 Alsina, ASH 2007. Abstract 411
Dosing schedule: 20 mg/m iv d 1 2, 8 9, 15 16 of 28 days cycles (up to 12 cycles)
• 2 Phase II trials in monotherapy
PX-171-004
PX-171-003 Brtz naive (54 ev) ORR 46%
In pts prev. Btz & IMID pts (n=39)
2% CR, 44 % PR, 15% MR & 22% SD TTP 7.6 m
Brtz treated (33 ev) ORR 18%13% PR, 13% MR & 41% SD
Bz refr (n=26) 4% PR, 15% MR
Brtz treated (33 ev) ORR 18%
3% CR, 15% PR, 12% MR & 39% SD TTP 5.3 m
Brtz refr/intol (15) 6% PR 6% MR 53% SDJagannath, IMW 2009. Abstract 377
Wang, ASH 2009. Abstract 302
Brtz refr/intol (15) 6% PR, 6% MR, 53% SD
Siegel, ASH 2009. Abstract 303
ClassificationTreatment of MM
Cell cycle•Cyclin inhibitorsCDK inhibitorsCell cycleAurora Kinases inhibitors
Surface molecules•Activators of Death ReceptorsSurface AntigensTyrosin Kinase inhibitors
Signaling Pathways• PI3K/AKT; MAPK; JAK/STAT; NFKB; WNT
y
“Unfolded protein response”•“Heat Shock Proteins” inhibitorsProteasome inhibitorsUnfolded protein response• Proteasome inhibitorsAgressome formation inhibitors
Epigenetics• Demethylating agentsHistone Deacetilases Inhibitors
Agents acting on EpigeneticsNovel Agents for MM
Hypomethylating agents (5-Azacytidine)Hypomethylating agents (5-Azacytidine) Kiziltepe, Mol Cancer Ther 2007
• DNA methyltransferase inhibitors
• Anti-MM effect through induction of DSBs
• DNA methyltransferase inhibitors
• Anti-MM effect through induction of DSBsg
• Synergy with Doxorubicine and Bortezomib
• Clinical trial ongoing
g
• Synergy with Doxorubicine and Bortezomib
• Clinical trial ongoing• Clinical trial ongoing
Histone deacetylase inhibitors
• Clinical trial ongoing
Histone deacetylase inhibitorsHistone deacetylase inhibitors• Panobinostat (LBH589)
• V i t t (SAHA)
Histone deacetylase inhibitors• Panobinostat (LBH589)
• V i t t (SAHA)• Vorinostat (SAHA)
• ITF-2357
• Vorinostat (SAHA)
• ITF-2357
• Depsipeptide• Depsipeptide
Effect of HDAC on transcriptionTreatment of MM
Balanced HAT and HDAC Activity Results in Regulated Gene Expression
Hi t t l ti llHistone deacetylation prevents gene expression
Histone acetylation allows gene expression HAT
TFAc Ac
HDAC
Ac Ac Ac
Deacetylation Acetylation
Normal Cell
• DNA is packaged by wrapping around histone octamers
Effect of HDAC on transcriptionTreatment of MM
In tumor cells unbalance: deacetilation and inhibition of transcription
IncreasedIncreasedHDAC ActivityHDAC Activity
Decreased Decreased HAT ActivityHAT Activity
TFAc
HDAC
HAT
Ac
Ac Ac
Ac
AcHDAC
HDAC
Uncontrolled CellUncontrolled CellGrowth and SurvivalGrowth and Survival
DACInhibitor
Decreased TumorDecreased Tumor
TumorCell
Decreased Tumor Decreased Tumor Suppressor Gene Suppressor Gene Activity (p21, p27)Activity (p21, p27)
Effect of DAC on Non Histone proteinsTreatment of MM
DACInhibitor
DACDAC DAC DAC
DAC
Proteins modulatedby DACs
Histone p53 α-tubulin HSP90HIF-1α
Loss of tumor Microtubule depolymerization VEGF OncoproteinsDownstream
Tumorsuppressor
functiondepolymerization aggresome form.
VEGF Oncoproteins Downstream effects
suppressorgene activity
Tumor ff t
Cell proliferation
Cell motility and Invasion
Cell proliferation and survivaleffects proliferation
Apoptosis Angiogenesis
Activity of HDACi in monotherapy in MMHDACi in MM
ORR Rn ORR Responses
Vorinostat 10 10% 1 PR 9 SDVorinostat 10 10% 1 PR, 9 SD
Panobinostat 38 3% 1PR 1 MR 1 SDPanobinostat 38 3% 1PR, 1 MR, 1 SD
ITF2357 15 7% 1 PR 1 SDITF2357 15 7% 1 PR, 1 SD
Romidepsin 12 0% 11 SDRomidepsin 12 0% 11 SD
Richardson PG, Leuk Lymphoma 2008
Wolf, ASH 2008. Abstract 2774
Galli, ASH 2007. Abstract 1175
Niesvizky, ASH 2005. Abstract 2574
Triple combinations of Panobinostat in MMPanobinostat in MM
Panobinostat + Bortezomib + Dexamethasone
trol
)
100
120
1.0
upta
ke (%
con
t
40
60
80
0.20.40.60.8
Effe
ct
0 0.2 0.4 0.6 0.8 1.00
0.20.40.6
mb.
inde
x.
Panobinostat
MTT
u
0
20
40
- + - + - +- +
0 1 2 3 40
DosePanob+BortPanob + Dex
Bort + DexPanob + Bort + Dex
0 0.2 0.4 0.6 0.8 1.0
-0.6-0.4-0.2
Fractional Effect
Com
)
120
Dex Bort+DexBort
Panobinostat + Lenalidomide + Dexamethasone
ake
(% c
ontr
ol)
60
80
100
0 40.60.81.0
ffect
0.20.40.6
ndex
MTT
upt
a
0
20
40
0 200 400 600 800 1.0000
0.20.4
Dose
Ef
0 0.2 0.4 0.6 0.8 1.0
-0.6-0.4-0.20
0.2
F ti l Eff t
Com
b. in
Ocio EM, Haematologica in press
Panobinostat
Len Dex Len+Dex
- + - + - +- + Panob + Lenal
Panob + DexLenal + DexPanob + Len + Dex
Fractional Effect
Panobinostat in MM
In vivo combinations of PanobinostatEfficacy in a xenograft of human sc plasmocytoma in mice
120 CB17-SCID mice were sc injected with 3x106 MM1S cells
When tumors became palpable randomization to:p p
• Vehicle
P bi t t 10 /K 21 d d 5 /K ft d• Panobinostat 10 mg/Kg x 21 days and 5 mg/Kg afterwards
• Dexamethasone 1 mg/Kg
• Bortezomib 0 1 mg/Kg• Bortezomib 0.1 mg/Kg
• Lenalidomide 15 mg/Kg
• Doubles: PD PB PL BD LD• Doubles: PD, PB, PL, BD, LD
• Triples: PBD, PLD
M it i ti f t l & t i it i 3 ti / kMonitorization of tumor volume & toxicity signs: 3 times / week
Mice were sacrificed when the tumor diameter > 2 cm
Triple combinations of Panobinostat in MMPanobinostat in MM
* p<0.05 related to singles
In vivo anti-MM activity of Panobinostat + Dex + either Len or Bort
Panobinostat + Bort + Dex ** p<0.05 related to doublesPanobinostat + Bort + Dex
Panobinostat + Lenal + DexPanobinostat Lenal Dex
Ocio EM, Haematologica in press
Unique genes deregulated by triple comb.Panobinostat in MM
GEP of MM1S cells treated with single agents and the triple combinationsApoptosis 15 25%Apoptosis 15-25%
895 genes exclusive of PBD
Panobinostat + Bort + Dex
gApoptosis
APAF1 3.01
C 1 3 54
Cell Cycle regulation
CDK 4 -2.95
C li E1 2 58Casp-1 3.54
Casp-4 4.76
TP53 -2.87
Cyclin E1 -2.58
Cyclin D2 -4.29
E2F2 -4.49
1323 genes exclusive of PLDApoptosis Cell Cycle regulation
Panobinostat + Lenal + Dex
APAF1 3.16GADD45 7.88Casp-8 2.73
Cyclin E1 -2.34
Cyclin A2 -2.76
Cyclin D2 -2.63
Ocio EM, Haematologica in press
Casp-10 2.62 E2F2 -3.03
Deacetylase inhibitors in MMTreatment of MM
Panobinostat (LBH589)
• Single agent (n=38 prev Bort & IMIDs) ORR 6%
Panobinostat (LBH589)
• Single agent (n=38 prev Bort & IMIDs) ORR 6% Wolf, ASH 2008. Abstract 2774Single agent (n 38 prev Bort & IMIDs) ORR 6%
• Bort ± Dex (n=29) ORR 64% (4 CR IF-)
In 10 pts prev ref to Bz 6 responses (4 PR 2 MR)
Single agent (n 38 prev Bort & IMIDs) ORR 6%
• Bort ± Dex (n=29) ORR 64% (4 CR IF-)
In 10 pts prev ref to Bz 6 responses (4 PR 2 MR)
San Miguel JF. ASH 2009 Abstract 3852
In 10 pts prev ref to Bz 6 responses (4 PR, 2 MR)
• Len + Dex (n=13. No prev Len) ≥MR 69% (2CR, 4 VGPR, 2 PR, 1MR)
In 10 pts prev ref to Bz 6 responses (4 PR, 2 MR)
• Len + Dex (n=13. No prev Len) ≥MR 69% (2CR, 4 VGPR, 2 PR, 1MR) Spencer, IMW 2009. Abstract 329
Vorinostat (SAHA)
• Single agent (n=10) 10% MR
Vorinostat (SAHA)
• Single agent (n=10) 10% MR Richardson, ASH 2007. Abstract 1179 Badros, Clin Cancer Res 2009
• Bort ± Dex (n=23, 34 & 21) ≥MR 42%, 47% & 42%
Prev Btz: n=22 ≥MR 41% (36% PR, 5% MR) + 50% SD
• Bort ± Dex (n=23, 34 & 21) ≥MR 42%, 47% & 42%
Prev Btz: n=22 ≥MR 41% (36% PR, 5% MR) + 50% SD
Marunder, IMW 2009. Abstract 306Weber, IMW 2009. Abstract 242 & 248
• Len + Dex (n=28) ≥MR 64% (2 CR, 11 PR, 5 MR, 6 SD)
Romidepsin (D i tid )
• Len + Dex (n=28) ≥MR 64% (2 CR, 11 PR, 5 MR, 6 SD)
Romidepsin (D i tid )
Siegel D. ASH 2009 Abstract 305
Romidepsin (Depsipeptide)• Bort + Dex (n=25) ORR 67% (22% CR, 22% VGPR, 22% PR)
Romidepsin (Depsipeptide)• Bort + Dex (n=25) ORR 67% (22% CR, 22% VGPR, 22% PR)
Harrison, ASH 2008. Abstract 3698
Immunomodulatory DrugsTreatment of MM
antiproliferativeMM Plasma Cells
IL-6
Bone Marrow
TNF-αIL-1βAdhesion
Molecules Lenalidomide Lenalidomide
Stromal cells
Lenalidomide
IL-2
interferon-γ
Bone Marrow vessels
VEGF (FGFb) Lymphocytes
γ
T ll CD8
(FGFb)
Lenalidomide
immunomodulatoryLenalidomide
ti i i T cells CD8NK cells
immunomodulatoryantiangiogenic
Immunomodulatory Drugs - LenalidomideNovel Agents for MM
O
NHO
NH
O O
N O
O
N O
O
ThalidomideNH2
Lenalidomide
• More “potent” immunomodulator • Different side-effect profile
– more potent inhibitor of TNF-α– increased stimulation of T-cell proliferation– augmented production of IL-2 and IFN-γ
– no significant constipation, neuropathy, or sedation
– greater myelosuppression augmented production of IL 2 and IFN γ– Augmented NK-cell activity • Not teratogenic in animal models
(including New Zealand white rabbit)
– embryotoxic at 100 × human dose
Bartlett JB, et al. Nat Rev Cancer. 2004;4:314-22. Marriott JB, et al. Curr Drug Targets Immune Endocr Metabol Disord. 2003;3: 181-6. Rajkumar S, Kumar SV. Eur J Cancer. 2006;42:1612-22. Richardson P, Anderson K. J Clin Oncol. 2004;22:3212-4.
– embryotoxic at 100 × human dose
Immunomodulatory DrugsTreatment of MM
NHO O
HO ON
NO
NNH
OO
Thalidomide
O O
ONH2
Thalidomide
Actimid™ (pomalidomide) (CC-4047)
NNHO O
O
NH2
Revlimid ™ (lenalidomide)(CC-5013)
Pomalidomide (CC-4047) monotherapy Treatment of MM
• Phase I/II Richardson, ASH 2009. Abstract 301
Pomalidomide escal. (2, 3, 4, 5 mg) days 1-21 (28 days) + Dex (40 mg /wk) if PD
n=21 relapsed/refr. patients
15% ORR (5% CR, 10% PR + 24% MR + 43% SD) TTP 8.3 weeks
Dex added in 13 pts 38% ORR (15% CR, 23% PR + 46% SD) TTP 20 weeks
• Phase I
Pomalidomide every day or alternate days (+ Dex added if no response)
Streetly, ASH 2009. Abstract 3878
Pomalidomide every day or alternate days (+ Dex added if no response)
n=44 rel/ref pts
52% ORR (14% CR 39% PR 9% MR 30% SD)52% ORR (14% CR, 39% PR, 9% MR, 30% SD) PFS 13.7 m
Dex added in 10 pts 50 % ≥MR
Pomalidomide (CC-4047) + Dex Treatment of MM
• Phase II Pomalidomide + Dex Lacy, JCO 2009 Lacy, ASH 2009. Abstract 429
n=60 relapsed MM pts to 1-3 previous lines (62% previous IMID)
2 mg/24h vo continuous + Dex 40 mg vo days 1, 8, 15, 22
63% ORR (5% CR, 28% VGPR, 30% PR + 25% SD)
34 Len refr. Pts 32% ORR (3% VGPR, 29% PR, 18% MR, 32% SD)
Toxicity: Myelosupression (Neutropenia).
1 (2%) tromboembolic events (AAS 325 mg/24h)
PN gr. 1/2 in 37%
F ti 1/2 i 57% d 3 i 1Fatigue gr 1/2 in 57%; grade 3 in 1
Zalypsis (PM00104) in MMNovel Agents for MM
• Zalypsis (PM00104) is a new synthetic alkaloid related to Me
Me
Me
OMe
OAc
N
HO
H
Jorumycin, Renieramycins, Safracins and Saframycins.Me
CF3
N
N
OH
O
O
NH
O
• Jorumycin was originally isolated fromJo u yc as o g a y so ated oJorunna funebris, a marine mollusk gastropod.
• Zalypsis has shown preclinical activity in bladder, gastric, breast, pancreatic and liver cancerpancreatic and liver cancer.
• Phase I clinical trial ongoing withpreliminary evidence of activity
• Phase I clinical trial ongoing with favorable safety profile
Potent anti-MM activity of ZalypsisDevelopment of novel drugs
48 hours)
MM cell lines
)
2400 Control Zalypsis 1 /K
Model of subcutaneous plasmacytoma
48 hours120
80
100
ion
(% c
ontr
ol)
1200
1600
2000
olum
e (m
m3 )
Zalypsis 0.8 mg/Kg
1 mg/Kg
Tumor volume
20
40
60
TT m
etab
oliz
at
0 0
400
800
Tum
or v
o
*
*
volume
5 100 0.1 0.5 1 500.2 2 20[Zalypsis], nM (Log)
MT 0
Pl ll
00 10 20 30 40
Days of treatment50
80
100
inin
g (%
)
Plasma cells
ndpo
int
1.0
0.8
0.6Zalypsis 1 mg/Kg
p<0.001*
Survival
0
20
40
60
Ann
exin
V s
tai
Tim
e to
en
0.4
0.2Control Zalypsis
0.8 mg/Kg
g g
* *
Survival
Ocio et al, Blood 2009
01 2 3 4 5 6
Patients 00.0
Days of treatment80604020 100
p53 dependent DNA Damage ResponseDevelopment of novel drugs
48 hours120100
% c
ontr
ol)DNA Damage Response genes deregulated
C &
20
40
60
80
tabo
lizat
ion
(%• ATM repair pathway TLK2, ATR, CHEK2, RAD5 & BRIP1
• DNA repair genes RAD23B, XPC, XRCC1, XRCC5 & GADD45A
5 100 0.1 0.5 1 500.2 2 20[Zalypsis], nM (Log)
20
MTT
me
0
p53 upregulationDSB induction
0 3 6 12
Time with Zalypsis, hours
p53 upregulation
Time with Zalypsis, hours
DSB induction
53
MM1S
MM1R
0 3 6 12
p53
MM1S
0 3 6 12
pH2AX
pCHK2p53
GAPDHMM144
p
GAPDH
The anti-MM activity of Zalypsis is, dependent of p53
WT p53 mutant p53
Ocio et al, Blood 2009
ConclusionsTreatment of MM
• Treatment of MM has improved over the years with several milestones:
Melphalan Polichem. ASCT Novel drugs (Thal / Btz / Len)
• Novel proteasome inhibitors (Carfilzomib) and IMIDs (Pomalidomide)display similar efficacy as their precedent drugs and seem to overcome theresistance to these compounds.
• Other promising drugs (in combination with Btz or Len/Dex) are HDAC(Panobinostat or Vorinostat), AKT pathway inhibitors (Perifosine & mTORinhibitors), Anti-CS1 MoAb and other MoAbs.inhibitors), Anti CS1 MoAb and other MoAbs.
• Urgent need for novel combinations based on preclinical studies and, overall, on good clinical trials. INCLUDE PATIENTS IN CLINICAL TRIALS.
Centro de Investigación del Cáncer
Centro de Investigación del Cáncer
Servicio de Hematología
Hospital Universitario
Servicio de Hematología
Hospital UniversitarioUniversidad de Salamanca
Nuevas Dianas Moleculares Nuevas Dianas Moleculares en el Tratamiento del en el Tratamiento del
Mieloma MúltipleMieloma MúltipleEnrique M. Ocio
Hospital Universitario y Centro de Investigación del CáncerUniversidad de Salamanca