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Linfomi

Umberto VitoloHematology

University Hospital Città della Salute e della Scienza

Torino, Italy

Disclosures – Umberto Vitolo

Research Support/P.I. Roche, Celgene, Mundipharma

Employee N/A

Consultant N/A

Major Stockholder N/A

Conferences/Educational Activities

Janssen, Roche, Celgene, Pfizer,

Takeda

Scientific Advisory Board

Janssen, Roche, Celgene

Outline of discussion

• First line treatment in young MCL

• Relapsed MCL

• Rituximab subcute in DLCL

• Relapsed Hodgkin’s lymphoma: standard

agents

• Relapsed Hodgkin’s lymphoma: treatment wih

T-cell check point blockade

• Relapsed DLBCL: inhibitor nuclear export

1st line Induction Treatment

CR/Cru

or PR

ObservationB

LenalidomideA

Consolidation

QuickTime™ and aGIF decompressor

are needed to see this picture.

Arm A: Lenalidomide, once daily on days 1-21, every 28-days

Arm B: Observation with no any active drugs for MCL

R

Randomization within 120 days after the end of consolidation

Advanced MCL

5.

A phase III multicenter, randomized study

with Lenalidomide (Revlimid®) maintenance versus observation

after intensified induction regimen containing rituximab

followed by high dose chemotherapy and Autologous Stem Cell Transplantation as first line

treatment in adult patients with advanced Mantle Cell Lymphoma

Sergio Cortelazzo, MD on behalf of FIL

Unit of Oncology-Hematology, Humanitas

Bergamo, Italy

mailto:[email protected]


Restaging

Restaging

R-HD-Ara-C 2g/m2 q12h x 3

Ritux 375mg/m2 d 4, 10

3. Maintenance:

Phase 3, 1:1 Randomized, comparative, observation-controlled study after completion of intensive immunochemotherapy followed by ASCT

Staging

Restaging

2. Consolidation:

1. Induction:

PR <50%, SD, NROff-study

CR/PR

MRD

MRD

MRD

MRD

MRD

Harvest CD34+

2° Harvest CD34+

R-HD-Ara-C 2g/m2 q12h x 3

Ritux 375mg/m2 d 4, 10

BEAM-PBSCT

R-CHOP-21 x 3

CTX 4g/m2

?DECISION MAKING

RANDOM observation vs. lenalidomide

15 mg (plts >100x109/ L) or 10 mg (plts 60-100x109/L ) once daily on days 1-21 every 28 day cycle) for 24 months.



6.

High-Dose Sequential

Chemotherapy+R (R-HDS)



Response

Final Response (includingIntermediate+Final Response)

R-HDC+ASCT

n = 228

CR/CRu 178(78%)

PR 18 (8%)

SD 3 (1%)

NR/PG 15 (7%)

Deaths during treatment* 7 (3%)

Interruption not due to PD or death

7(3%)

* One not related to treatment: road accident

67%

24%

1%

3%

2%

3%

CR PR SD PD Death Other

Restaging 1 – after Induction+hd-CTX

67%20%

2%

4%

2% 5%


Restaging 2 – after hd-Ara-C

6%

77%

3%

8%

6%

0%


Restaging 3 – afer ASCT

10.





BONE MARROW

0

20

40

60

80

100

R-CHOP LK1 LK2 preASCT postASCT

MRD+

MRD-

43%

73%

27%

56%

44%

78%82%

57%

18%

PERIPHERAL BLOOD

22%

0

20

40

60

80

100

R-CHOP preASCT postASCT

MRD+

MRD-

36%

64%

31%

69%

68%

32%

MRD by ASO RQ-PCR on 100 patients

Patients with molecular marker: 249/283 (88%) IGH + 192/283 (69%) BCL-1 + 101/283 (36%)

1st LK: 152/192 MRD- (79%)

2nd LK: 14/35 MRD- (40%)

MRD assessed by ASO nested-PCR

12.

2-year PFS: 77.7% (95% CI:71.1-83.0)2-year OS: 89.2% (95% CI: 83.7-92.9)

median follow-up 22 months



14.

0.00

0.25

0.50

0.75

1.00

270 226 180 138 106 67 44 26 4 3 0 At risk:

0 6 12 18 24 30 36 42 48 54 60Months from Enrollment

2y PFS 78%

0.00

0.25

0.50

0.75

1.00

270 234 189 150 118 79 49 31 8 4 0 At risk:


2 y OS 89.2%



2-year PFS for MIPI low, intermediate and high

CG Gaisler, Haematologica, 2010

M Magni et al., Bone Marrow Transplant, 2009

15.



0.00

0.25

0.50

0.75

1.00

128 116 99 74 56 38 26 17 2 1 0Low74 61 46 39 29 18 10 6 1 1 0Intermed.52 39 29 20 17 9 6 2 1 1 0High

At risk:


High

Intermed.

Low

P=0.0076





• Relapsed MCL



agents




Lenalidomide†

25 mg/day PO, days 1-21, q28d (until PD or toxicity)

CT scans every

56 days for

6 months, then

every 90 days

thereafter

Primary endpoint: PFS (per independent central review)Secondary endpoints: ORR, DOR, OS, safety, and QOL

Control: Investigator’s choice

If PD

Crossover tolenalidomide

Chlorambucil or rituximab until PD or toxicityCytarabine, fludarabine, or gemcitabine for ≤6 cycles

NCT00875667; data cut-off March 7, 2014.*≥1 prior combination chemotherapy with an alkylating agent and either an anthracycline and/or cytarabine and/or fludarabine (± rituximab); ≤3 relapses or failure of prior therapy and ineligible for intensified treatment or SCT.†Prophylaxis for all lenalidomide patients included aspirin or low molecular weight heparin, warfarin, or equivalent prophylaxis for thromboembolic events and allopurinol or equivalent with oral hydration during the first 7 days for tumor lysis syndrome.

R/R MCL (N = 254)• Pretreatment*• ECOG PS 0-2• Cyclin D1 or t(11;14)• Measurable disease ≥2

cm

Ran

do

miz

atio

n

Stratification • <3 or ≥3 years from

diagnosis• <6 vs. ≥6 months from

last systemic anti-lymphoma therapy

• Prior SCT

2:1

Impact of Prior Treatment on PFS for R/R MCL Patients Randomized to Lenalidomide vs. Investigator’s Choice: A Subgroup Analysis of the

MCL-002 (SPRINT) Study: Marek Trněný, MD, PhD1

MCL-002: Overall Efficacy (ITT, central review)

Efficacy Lenalidomide (n = 170) IC (n = 84) P value

Median PFS, months (95% CI)*

8.7 (5.5-12.1) 5.2 (3.6-6.9) 0.004

HR = 0.61 (95% CI, 0.44-0.84); P = 0.004

ORR, n (%) 68 (40) 9 (11) <0.001

CR/CRu, n (%) 8 (5) 0 0.043

PR, n (%) 60 (35) 9 (11) —

PD, n (%) 34 (20) 26 (31) —

Median DOR, months (95% CI)

16.0 (9.5-20.0) 10.4 (8.4-18.6) —

Median OS, months (95% CI)

27.8 (20.0-36.9) 21.2 (16.0-28.9) —

• Lenalidomide treatment significantly improved PFS, ORR, and CR/CRu vs. IC

ITT, included all randomized patients irrespective of whether they received study treatment. Data cut-off March 7, 2014.*No response evaluations for several patients in each arm; however, they still contributed to PFS.

13

MCL-002: Progression-Free Survival (Central Review)

• At a median follow-up of 15.9 months, lenalidomide-treated patients

showed a 39% reduction in the risk of progression or death vs. IC,

reflected as an estimated improvement in median PFS of 3.5 months

Lenalidomide

(n = 170)

IC

(n = 84)

Median PFS, mo (95% CI) 8.7 (5.5-12.1) 5.2 (3.6-6.9)

HR (95% CI) 0.61 (0.44-0.84); P = 0.004

Number of patients at risk

Lenalidomide

IC

170

84

86

31

63

15

36

7

27

5

20

4

16

4

12

2

7

0

1 1 0

1.0

0.8

0.6

0.4

0.2

0.0

Su

rviv

al P

rob

ab

ility

Progression-Free Survival, months

0.1

0.3

0.5

0.7

0.9

0 5 10 15 20 25 30 35 40 45 50 55

LenalidomideIC

ITT patients; data cut-off March 7, 2014.

14

MCL-002: Prior Treatment Subgroup Analysis for PFS

Patients, n/N Median PFS, wk

Log-rank P HR (95% CI)Subgroup Len IC Len IC

Time from MCL

diagnosis to

first treatment

<3 years

≥3 years61/91

45/76

30/44

29/39

37.6

39.3

15.1

26.3

0.022

0.052

No. of prior

systemic

therapies

1

2

≥3

30/55

44/70

32/45

20/37

18/23

21/24

52.9

26.6

24.0

40.7

19.4

10.0

0.321

<0.001

0.006

No. of prior

relapses

<2

≥269/112

37/58

28/47

31/37

48.7

24.1

25.9

19.3

0.280

0.003

Time from last

prior therapy

<6 months

≥6 months50/71

56/95

26/36

33/47

25.1

50.6

21.6

24.7

0.061

0.030

Time from last

rituximab to

1st dose

<230 days

≥230 days49/64

50/89

24/33

29/42

26.6

50.6

19.3

24.7

0.223

0.025

Central review of ITT patients; data cut-off March 7, 2014.

• Significant improvements in PFS favored lenalidomide over IC for <3 years

from MCL diagnosis, ≥2 prior systemic therapies or relapses,

≥6 months from last therapy, and ≥230 days from last rituximab dose

0 1

2

15

MCL-002: Prior Treatment Subgroup Analysis for PFS

cont.

Patients, n/N Median PFS, wk

Log-rank P Subgroup Len IC Len IC HR (95% CI)

Response

status to last

therapy

Refractory

Relapsed45/70

61/100

19/25

40/59

32.7

48.7

7.4

26.3

<0.001

0.143

Prior SCTYes

No17/30

89/140

12/18

47/66

52.9

37.6

19.4

24.7

0.534

0.003

Prior HDT*Yes

No18/31

88/139

12/18

47/66

52.9

37.6

19.4

24.7

0.594

0.002

Type of prior

therapy†

Rituximab

Ara-C

Fludarabine

99/156

39/62

37/53

54/77

24/32

11/16

39.3

22.3

22.3

24.7

19.4

18.6

0.008

0.303

0.075

• Significant improvements in PFS favored lenalidomide over IC for patients with

prior refractory disease, no prior SCT/HDT, and prior rituximab

*HDT includes SCT, hyperCVAD, and R-hyperCVAD. †Most frequent (≥20%) prior therapy in addition to alkylator/anthracycline.

Central review of ITT patients; data cut-off March 7, 2014.

0 1 2



• Relapsed MCL



agents




Stratification by age (<60/≥60 years)

IPI category (low/low-intermediate/high-intermediate/high)

Chemotherapy regimen (CHOP-14/CHOP-21)

*Selected by investigators

**Cheson 1999 criteria

IPI, International Prognostic Index; PD, progressive disease; SD, stable disease

Untreated

CD20+ DLBCL (N=572)

Age 18–80 years

IPI score 1–5 or

IPI 0 with bulky

disease

INTERIM

STAGING

RESPONSE

ASSESSMENT**

SD, PD:

off study

R

A

N

D

O

M

I

S

E

2:1

Rituximab IV

(375 mg/m2)

Rituximab SC

(1400 mg)

n=378

n=194

1 x rituximab IV followed by 7 x rituximab SC

+

6 or 8 CHOP-14 / 6 or 8 CHOP-21*

8 x rituximab IV

+

6 or 8 CHOP-14 / 6 or 8 CHOP-21*

Subcutaneous versus intravenous rituximab in combination with CHOP for previously untreated diffuse large B-cell lymphoma: efficacy and safety results from the phase IIIb MabEase study

At risk

SC, n 342 342 342 322 316 303 264 217 296 183 168 160 135 113 101 88 83 72 44 32 21 11 4 2 1 0

IV, n 177 177 176 169 163 159 141 115 107 97 94 84 72 62 57 48 41 33 20 15 9 6 4 2 0 0

Progression-free survival (ITT)

KM, Kaplan-Meier; NR, not reached; PFS, progression-free survival

PFS was comparable between treatment arms

• The KM PFS curves were almost identical for rituximab SC (1400 mg) and IV (375 mg/m2)

1.0

0.0

Pro

babili

ty o

f P

FS

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Months

Median follow-up: 64 weeks

Censored n Censored Events Median

Rituximab SC 342 288 54 NR

Rituximab IV 177 149 28 NR

Administration time

Administration time was substantially shorter for rituximab SC

R-CHOP administration

at cycle 7Rituximab administration

by cycle

Adverse events grade ≥3 in cycle 2 or later (safety population)

AE of grade ≥3 in cycle 2 or later Rituximab SC Rituximab IV

Total number of patients with ≥1 AE of grade ≥3 195 (52.8%) 93 (49.5%)

Total number of events of grade ≥3 476 229

21,7

12,2

3,5 3,5 3,3

19,7

6,43,7 3,7

1.6

0,0

5,0

10,0

15,0

20,0

25,0

30,0

Neutropenia Febrile neutropenia Anaemia Leukopenia Pneumonia

Pa

tie

nts

(%

)

Rituximab SC (n=369)

Rituximab IV (n=188)

Similar safety profile in both arms, with no unexpected safety signals



• Relapsed MCL



agents




Phase II Study of BEGEV [Bendamustine, Gemcitabine, Vinorelbine] as Induction Regimen Prior to ASCT in R/R HL

R. Mazza, A. Pulsoni, G. Rossi, C. Carlo-Stella, A. Anastasia, M. Bonfichi, C. Rusconi, F. Salvi, S. Luminari, A. Re, M. Gotti, A.M. Liberati, N. Di Renzo, L. Giordano, A. Santoro

on behalf of Fondazione Italiana Linfomi (FIL)

ClinicalTrials.gov Identifier: NCT01884441

Day Medication Dose Route

1 Gemcitabine 800 mg/sqm IV

Vinorelbine 20 mg/sqm IV

2 Bendamustine 90 mg/sqm IV

3 Bendamustine 90 mg/sqm IV

4 Gemcitabine 800 mg/sqm IV

Four cycles every 21 days

Treatment Plan

Cycle 1 Cycle 2 Cycle 4Cycle 3

BEGEV BEGEV BEGEV BEGEV

PET/C

T

PET/C

T ASCT

PDOff Tx

CR, PR, SD

On Therapy

2-yr P

ET/CT

SC Mobilization/Harvesting

CR, PR

Patient Characteristics Prior to BEGEV

Characteristics # %

Patients 59 100

M/F 31/28 52/48

Age, median (range) 33 (18 - 68) -

Response to primary therapyPrimary refractoryRelapsed disease

2732

4654

B symptomsYesNo

2732

46 54

Extranodal sites of diseaseYesNo

2435

4159

Relapsed diseaseCR < 1 yrCR > 1 yr

2210

6931

Overall Response and by Disease Status

Disease Status at

Study Entry CR + PR SD PD P

Relapse30

(94%)1

(3%)1

(3%)0.033*

Refractory19

(70%)- 8

(30%)

* CR-PR vs SD-PD

n %

Patients 59 100

CR 43 73

PR 6 10

SD 1 2

PD 8 13

Drop out 1 2

OS and PFS

0 10 20 30 40

0

20

40

60

80

100

Months

Overa

ll S

urv

ival (%

)

n = 59, 48 censoredMedian OS: not reached

0 10 20 30 40

0

20

40

60

80

100

Months

Overa

ll S

urv

ival (%

)n = 59, 38 censoredMedian PFS: 26 mos

G1 G2 G3 G4 TotalN % N % N %

Asthenia 5 8.5 0 0.0 5 8.5Skin 6 10.2 0 0.0 6 10.2

Hepatic 7 11.9 2 3.4 9 15.3Fever 5 8.5 7 11.9 12 20.3

Gastrointestinal 10 16.9 4 6.8 14 23.7Infection 9 15.3 4 6.8 13 22.0

G1 G2 G3 G4 totalN % N % N %

Anemia 3 5.1 2 3.4 5 8.5

Neutropenia 1 1.7 8 13.6 9 15.3

Thrombocytopenia 0 0.0 4 6.8 4 6.8

Piastinopenia 0 0.0 4 6.8 4 6.8

Adverse Events by Patients



• Relapsed MCL



agents




• PD-1 is expressed on the surface of activated T cells

• Its ligands, PD-L1 and PD-L2, are overexpressed in certain tumor cells

• Binding of PD-1 to its ligands inhibits T-cell activation, allowing tumors to evade the immune response

PD-1 Pathway and Immune Surveillance

Nivolumab

Philippe Armand1, John Timmerman2, Alexander M. Lesokhin3, Ahmad Halwani4, Michael M. Millenson5, Stephen J. Schuster6, Martin Gutierrez7, Emma C. Scott8,

Deepika Cattry3, Gordon J. Freeman1, Bjoern Chapuy1, Azra H. Ligon9, Scott J. Rodig9, Lili Zhu10, Joseph F. Grosso10, Jason Simon10, Margaret A. Shipp1,

Adam D. Cohen6, Daniel Lebovic11, Madhav Dhodapkar12, David Avigan13, Stephen M. Ansell14, Ivan Borrello15

Nivolumab in Relapsed or Refractory Lymphoid Malignancies and

Classical Hodgkin Lymphoma: Updated Results of a Phase 1 Study

1Dana-Farber Cancer Institute, Boston, MA; 2Jonsson Comprehensive Cancer Center, University of California, Los Angeles, CA; 3Memorial Sloan Kettering Cancer Center, New York, NY; 4University of Utah Huntsman Cancer Institute, Salt Lake City, UT; 5Fox Chase Cancer

Center, Philadelphia, PA; 6Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; 7John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ; 8Oregon Health and Science University, Portland, Oregon; 9Brigham and

Women’s Hospital, Boston, MA; 10Bristol-Myers Squibb, Princeton, NJ; 11University of Michigan Hematology, Ann Arbor, MI; 12Yale Cancer Center, New Haven, CT; 13Beth Israel Deaconess Medical Center, Boston, MA; 14Mayo Clinic, Rochester, MN; 15Johns Hopkins University

School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD

E H A 2 0 T H C O N G R E S S

J U N E 2 0 1 5

V I E N N A , A U S T R I A

Relapsed or Refractory Lymphoid Malignancies

(n=105)

•No autoimmune disease•No organ/stem cell allograft•No prior checkpoint blockade

Endpoints

Primary•Safety and Tolerability

Secondary•Best Overall Response•Objective Response•Duration of Response•Progression-free survival•Biomarker studies

Study Design

August 2012Start

June 2014(ASH 2014)

April 2015(EHA 2015)

Dose Escalation(n=13)

1 mg/kg 3 mg/kg

Dose Expansion(n=92)

3 mg/kg

Wk 1,4 then q2wk until PD, toxicity, CR or 2y

Classical Hodgkin (n=23)B-cell NHL (n=31)T-cell NHL (n=23)Myeloma (n=27)

CML (n=1)

• CA 209-039: Phase 1 study of nivolumab in lymphoid malignancies

Baseline Characteristics

CharacteristicMultipleMyeloma

(n=27)

B-cell NHL

(n=31)

T-cellNHL

(n=23)

HodgkinLymphoma

(n=23)

Histology, n

Follicular: 11DLBCL: 10PMBL: 2 Other: 8

CTCL/MF:13PTCL: 5Other: 5

NS HL: 22MC HL: 1

Age, median (range)63

(32–81)65

(23–74)61

(29–81)35

(20–54)

Prior auto transplant, n (%)Prior brentuximab vedotin, n (%)

15 (56)0 (0)

4 (14)3 (10)

2 (9)6 (26)

18 (78)18 (78)

Prior therapies, median (range) 4 (1–12) 3 (1–16) 4 (1–9) 5 (2–15)

0

5

10

15

20

25

30

35

Nu

mb

er

of

Pa

tie

nts

Grade 1Grade 2Grade 3Grade 4Grade 5

Drug-Related AEs

General Blood Skin GI Pulmonary Lab Infections Eye

Tumor Type # pts ORR CR PR SD

Multiple Myeloma 27 1 (4) 1 (4) 0 17 (63)

B-Cell Non-Hodgkin Lymphoma 31 8 (26) 3 (10) 5 (16) 16 (52)

Diffuse Large B-Cell 11 4 (36) 2 (18) 2 (18) 3 (27)

Follicular NHL 10 4 (40) 1 (10) 3 (30) 6 (60)

Mantle Cell Lymphoma 4 0 0 0 3 (75)

Primary Mediastinal B-Cell 2 0 0 0 2 (100)

Other B-NHL 4 0 0 0 2 (50)

T-Cell Non-Hodgkin Lymphoma 23 4 (17) 0 4 (17) 10 (43)

CTCL/MF 13 2 (15) 0 2 (15) 9 (69)

Peripheral T-Cell 5 2 (40) 0 2 (40) 0

Other T-NHL 5 0 0 0 1 (20)

Hodgkin Lymphoma 23 20 (87) 6 (26) 14 (61) 3 (13)

Best Response

Tumor type n ORR Median

Follow-upin weeks

Median Response Durationin weeks

OngoingResponses

Multiple Myeloma 27 1 (4%) 46 12+ 1 (100%)

DLBCL 11 4 (36%) 23 22 (6 , 77+) 1 (25%)

Follicular NHL 10 4 (40%) 91 NR (27+ , 82+) 3 (75%)

CTCL/MF 13 2 (15%) 43 NR (24+ , 50+) 2 (100%)

PTCL 5 2 (40%) 31 NR (11 , 79+) 1 (50%)

Hodgkin Lymphoma 23 20 (87%) 86 NR (2 , 91+) 10 (50%)

Durability of Response

74 weeks median follow-up

DLBCL and Follicular NHL

First response X First occurrence of new lesion

8 16 24 32 40 48 56 64 72 80 88 96

-100

-50

0

50

100200

400

600

X

X

X

X

X

Pe

rce

nt

Ch

an

ge

Fro

m B

ase

lin

e

Time Since First Dose, Weeks0

X

Pe

rce

nt

Ch

an

ge

Fro

m B

ase

lin

e

8 16 24 32 40 48 56 64 72 80 88 96

-100

-50

0

50

100200

400

600

Time Since First Dose, Weeks

0

DLBCL Follicular NHL

Hodgkin Lymphoma Durability of Response



• Relapsed MCL



agents




Presented at the 20th Congress of the European Hematology Association, Vienna, Austria 201539

Patients with Heavily Pretreated Diffuse Large B-Cell Lymphoma (DLBCL) Who Respond

to Oral Selinexor Therapy Show Prolonged Survival: Updated Phase I Results

J. Kuruvilla1, M. Mau-Sorensen2, R. Stone3, N. Wagner-Johnston4, R. Garzon5, L. Savoie6, I. Flinn7, R. Baz8, M. Wang9, P. Martin10, N. Gabrial11, P. Brown2, A. Goy13, T. Rashal12, R. Carlson12, Y. Landesman12, JR. Saint-Martin12, T. Marshal12, M. Savona15, S. Norori14, S. Shacham12, Michael Kauffman12 and M. Guttierez13

(1) Princess Margaret Cancer Center, Toronto, Canada; (2) Dept. of Oncology, Rigshospitalet, Copenhagen, Denmark; (3) Dana-Farber Cancer Institute, Boston, MA, USA; (4) Washington University St. Louis, MO, USA; (5) The Ohio State University, OH, USA; (6) University of Calgary Calgary, Canada; (7) Sarah Cannon Research Institute, Tennessee Oncology, Nashville, TN, USA; (8) H. Lee Moffitt Cancer Center & Research Institute Inc., Tampa, FL, USA; (9) MD Anderson Cancer Center, Houston, TX USA; (10) Weil Cornell Medical College, New York, NY, USA; (11) GabrailCancer Center, Canton, OH; (12) Karyopharm Therapeutics Inc, Newton, MA, USA; (13) Hackensack University Medical Center, Hackensack, NJ, USA; (14) Ozmosis Research Inc, Toronto, ON, Canada; (15) Vanderbilt University School of Medicine, Nashville, TN, USA

Presented at the 20th Congress of the European Hematology Association, Vienna, Austria 2015 40

• The nuclear export protein Exportin 1 (XPO1) is overexpressed in all types of malignant lymphoma, including DLBCL

• Selinexor is a Selective Inhibitor of Nuclear Export (SINE) compound that inhibits XPO1 to force nuclear retention of tumor suppressors and other proteins integral to tumorigenesis

• Selinexor interferes with proteins known to play critical roles in DLBCL

– Reduces Myc, Bcl2 and Bcl6 protein through forced nuclear retention of eIF4E

• Overexpression and translocations of Myc, Bcl2 and Bcl6 lead to more aggressive DLBCL

– Blocks NF- B activation through nuclear retention of IkB

• NF- B activation is important for DLBCL ABC subtype survival

Selinexor – Mechanism of Action


Exportin 1 (XPO1) Expression in DLBCL

XPO1 Expression in DLBCL Tissues (by IHC)

XPO1 Expression in Chemo-sensitive and Chemo-refractory DLBCL Patient Cells

• XPO1 is highly expressed in DLBCL, specially in chemo relapsed/refractory cases with 60% of patients having >70% XPO1 positive cells

Marullo et al AACR 2015

!!

Background

Materials and Methods

Results

Conclusions

XPO1 is highly expressed in DLBCL preferentially

in chemorefractory cases

Inhibition of XPO1 by KPT-330 impairs proliferation and survival in double/triple

hit DLBCLs

Inhibition of XPO1 by KPT-330 reduces the expression of multiple oncogenic

proteins by affecting the nuclear export of their mRNA

XPO1 inhibition impairs DNA damage response and repair in DLBCL

KPT-330 is active as single agent and improves the response to CHOP in a

patient-derived xenograft model of triple-hit DLBCL

46.5%

41.3%

12.3%

>5% <30% >5% <30%

XPO1 expression in DLBCL tissues by IHC

% of XPO1-positive cells

XPO1 expression in chemosensitive and chemorefractory DLBCL patients

60%

40%

18.1%

45.4%

36.3

>5% <30%

>30% <70%

>70%

Sustained Response Relapsed/refractory

n=23 n=20 n=58

Double/triple hit cell lines in our study

KPT-330 induces cell cycle arrest in Toledo cells

Ly1

KPT-330 IC50

- + - + - + - + DoHH2 K422 Toledo

p53

β-actin

KPT-330-induced cell cycle arrest is independent of p53

Cell$line Myc$ BCL2$ BCL6$

Toledo Dup/t3,8 Rea Del/t3,8

DoHH2 Rea Amp Amp

LY1 Amp/Del t14,8 3q27

SUDHL6 Amp T14,18 WT

XPO1

MYC

BCL2

BCL6

RAD51

CHEK1

KPT330

(0.5 µM)

KPT V

eh KPT

CHOP

KPT+

CHOP

0

10000

20000

30000

p<0.0001

p<0.0001

p=0.0355

p=0.0015

p<0.0001

Treatment

AU

C

CTRL KPT330 CHOP CHOP + KPT330

p=0.0355

p<0.0001

p=0.0015

Cells were exposed to a dose range of KPT330 for 48h

and viability measured by Cell Titer Blue

Double-Triple hit cells were identified by performing

FISH analysis for MYC, BCL6 and BCL2 genes

Cells were exposed to KPT330 at IC50 dose (0.2 µM) and cell

cycle profile was determined at 24h and 48h by Propidium Iodide

staining and subsequent flow cytometry analysis

KPT-330 is active at nanomolar dose in

DLBCL cell lines

48h 24h

Cells were exposed to KPT330 at IC50 dose

and p53 accumulation was evaluated at 24h

by Western Blot

Exposure to KPT-330 for 24h reduces the expression of multiple proteins in DLBCL cell lines

Exposure to KPT330 results in nuclear entrapment of mRNA encoding key oncogenic proteins in DLBCLs

Cells were exposed to KPT330 (0.5 µM) for 24 h and subsequent cellular fractionation was performed by differential

centrifugation. mRNA transcript for each gene were determined by RT-qPCR. Nuclear/Cytoplasm mRNA ratio in treated

vs. untreated cells was computed by using total cellular RNA for each condition as calibrator

LY1

- + - + - +

Toledo DoHH2

Experiment plan:

- 5 NSG mice engrafted in both flanks per group

- Treatment started at tumor size of 50-70 mm3

- Mice received 5 somministrations of KPT330 and one

somministration of CHOP

- Tumor volume and weight were evaluated every two

days

XPO1 inhibition by KPT330 impairs the repair of doxorubicin-induced DNA damage in Toledo cells

Doxorubicin 4 hours Doxorubicin 4 followed by 4h recovery

XPO1 inhibition by KPT-330 impairs doxorubicin-induced cell cycle arrest in Toledo cells

Cells were pretreated with KPT330 (IC50, 0.2 uM) for 24h and then exposed to Doxorubicin (IC50, 1.2 uM) for 4h.

DNA damage was assessed by alkaline comet assay at the end of the 4h Doxorubicin treatment or after allowing cells

to recover for additional 4 hours.

Ctrl KPT330 Doxorubicin Doxorubicin + KPT330

Cells were treated with KPT330 (IC50, 0.2 µM) and Doxorubicin (IC50, 1.2 µM) alone or in combination for 24h. After treatment

cell cycle profile was determined by Propidium Iodide staining and subsequent flow cytometry analysis

p<0.0001

30000

20000

10000

0

Mon$ Wed$ Fri$

Group A vehicle vehicle vehicle

Group B KPT330 7.5 mg/Kg KPT330 7.5 mg/Kg vehicle

Group C vehicle vehicle CHOP

Group D KPT330 7.5 mg/Kg KPT330 7.5 mg/Kg CHOP

AU

C

β-ACTIN

β-ACTIN

β-ACTIN

KPT330

(0.5 µM)

LY1

- + - + - +

Toledo DoHH2 • XPO1 is required for proliferation and survival of double/triple hit lymphomas

• XPO1 regulates the nuclear export of transcripts encoding key lymphomagenesis drivers, such as

MYC and BCL6; thus, exposure to KPT330 results in nuclear entrapment of MYC and BCL6

transcripts and subsequent reduction in protein expression

• XPO1 regulates the nuclear export of transcripts encoding members of DNA damage response

and repair pathways, such as CHEK1 and RAD51; thus, exposure to KPT330 results in nuclear

entrapment of CHEK1 and RAD51 transcripts and subsequent reduction in protein expression

• KPT-330 pretreatment increases the effectiveness of first line chemotherapy (CHOP) in vivo in a

triple-hit patient-derived xenograft model

Mutation and constitutive expression of MYC, BCL2 and/or BCL6 (double and triple-hit

lymphomas) defines a subsets of diffuse large B-cell lymphoma (DLBCL) patients with particularly

poor outcome due to chemo-refractory disease, a prognosis that cannot be overcome with

intense chemotherapy.

Exportin 1 (XPO1/CRM1) is a well characterized mammalian export protein that facilitates the

transport of large macromolecules including RNAs and proteins across the nuclear membrane to

the cytoplasm.

XPO1 binds to a diverse array of protein cargos through their canonical leucine-rich nuclear export

signals (NES) domain. XPO1 exports many tumor-suppressor proteins and thus acts as a proto-

oncogene by removing oncosuppressor protein from the nucleus, where they are active, to the

cytoplasm.

XPO1 overexpression is common in solid tumors and hematologic malignancies and

correlates with poor prognosis and resistance to therapy.

Hypothesis

DLBCL cell lines

Toledo

DoHH2

SUDHL-4

OCI-Ly1

OCI-Ly10

SUDHL-6

HBL-1

SC-1

K422

In vitro: In vivo:

Patient-Derived

Xenograft

Double hit DLBCL

XPO1 amplification

Stage IVb

IPI:4

Chemo-refractory

(relapse within 3

months)

In vitro experiments:

Viability: fluorescent assay based on the reduction of

resazurin into resorufin (Cell Titer Blue)

Cell Cycle Profile: Propidium Iodide Staining and

subsequent Flow Cytometry analysis

Protein expression: SDS-PAGE and Western Blot Analysis

mRNA expression in nuclear vs. cytoplasm: cellular

fractionation by differential centrifugation followed by RNA

isolation and RT-qPCR

DNA damage repair kinetic: Alkaline Comet Assay

XPO1 inhibitor: KPT-330 (a.k.a. Selinexor, Karyopharm) –

Selective Inhibitor or Nuclear Export (SINE)

Since double-triple hit lymphomas are characterized by the concomitant deregulation of multiple

oncogenic pathways, we hypothesize that XPO1 may be an effective target for these tumors as

it simultaneously impacts multiple oncogenic mechanisms

We also hypothesize that inhibition of XPO1 by the selective small molecule KPT-330 may also

revert the chemo-refractory status of aggressive lymphomas.

Sustained Response (CR 2 years) Relapsed/Refractory


• 31% ORR and 51% DCR for all evaluable DLBCL patients

• 43% ORR and 71% DCR for evaluable DLBCL patients on study ≥ 1 month

• ORR and DCR are equivalent across DLBCL origin or subtype

• Duration of response was >9 months

• Responses were also observed in “double-hit” DLBCL

Best Responses in DLBCL patients

CategoryTotal

EvaluableORR CR PR SD PD DCR

All Patients 39* 31% 4 (10%) 8 (21%) 8 (21%) 19 (49%) 51%

Patients on study ≥ 1 Month 28 43% 4 (14%) 8 (29%) 8 (29%) 8 (29%) 71%

OriginDe novo 28 25% 3 (11%) 4 (14%) 6 (21%) 15 (54%) 46%

Transformed 11 45% 1 (9%) 4 (36%) 2 (18%) 4 (36%) 64%

SubtypeGCB 14 43% 3 (21%) 3 (21%) 5 (36%) 3 (21%) 79%

non-GCB 4 25% 1 (25%) -- 3 (75%) -- 100%

*Three patients were non-evaluable for response due to consent withdrawal with lack of disease assessment prior to one cycle on study.

Responses (as of 1-June-2015) were adjudicated according to the International Working Group Response Criteria for Non-Hodgkin’s

Lymphoma (NHL) 2007 based on interim unaudited data. ORR=Objective Response Rate (CR+PR), CR=Complete Response, PR=Partial

Response, SD=Stable Disease, PD=Progressive Disease, DCR=Disease Control Rate (CR+PR+SD) GCB=Germinal Center B Cell.

GCB/non-GCB subtypes were not defined for all patients.

Allpatients


• OS and PFS for all DLBCL pts was 4.6 and 1.7 months, respectively

• Patients with objective responses had greatly increased OS and PFS

Overall and Progression Free Survival in DLBCL

0 3 6 9 12 15 18 21 24 27 30 330

20

40

60

80

100

Time (months)

Ov

era

ll o

r P

rog

res

sio

n F

ree

Su

rviv

al (%

)

All DLBCL patients

OS (4.6 mo)

OS 42

PFS 42

25

12

13

8

10

6

7

5

1

1

6

5

3

2

2

1

PFS (1.7 mo)

0 3 6 9 12 15 18 21 24 27 30 330

20

40

60

80

100

Time (months)

Ov

era

ll S

urv

iva

l (%

)

OS (CR/PR vs SD/PD)

SD/PD (3.5 mo)

CR/PR (>10 mo)

p < 0.0001HR=0.12

CR/PR 12

SD/PD 27

12

13

10

4

8

3

6

2

5

1

3

1

1

1

6

1

2

1

0 3 6 9 12 15 18 21 24 270

20

40

60

80

100

Time (months)

Pro

gre

ss

ion

Fre

e S

urv

iva

l (%

)

CR/PR vs SD/PD

SD/PD (1.2 mo)

CR/PR (24 mo)

p < 0.0001HR=0.06

CR/PR 12

SD/PD 27

10

3

8

1

5

1

4

1

3

1

1

1

2

1

Patientsat risk

Presented at the 20th Congress of the European Hematology Association, Vienna, Austria 2015

Domande al gruppo di lavoro

• Terapia di mantenimento nel Linfoma Mantellare

del giovane post ASCT?

• Terapia di salvataggio nel Linfoma di Hodgkin:

ruolo dei farmaci non chemioterapici e ruolo

Bendamustina?

• Come migliorare il salvataggio dei DLBCL?

Acknowledgments

G. Benevolo

C. Boccomini

B. Botto

A. Castellino

C. Ciochetto

A. Chiappella

M. Nicolosi

L. Orsucci

P. Pregno

P. Riccomagno

Lymphoma Team

Hematology Torino

FIL Secretary Alessandria

All FIL Centers

Biostatistics Torino

Trial Office Modena

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