Emoglobinuria Parossistica Notturna: principi di terapia e ruolo della rete

regionale

LANZA FRANCESCO

UOC EMATOLOGIA Lab. Specialistico

di Citometria e Cellule Staminali

Az Ospedaliera CREMONA

EPN

Malattia clonale di natura acquisita delle cellule staminali emopoietiche che

provoca:

1.   Anemia dovuta ad emolisi intravascolare cronica e acuta;

2.   Diatesi tromboembolica; 3.   Leuco-piastrinopenia 4.   Distonia della muscolatura liscia

Glicosil-Fosfatidil-Inositolo (GPI)

il glicosil-fosfatidil-inositolo (GPI) svolge un ruolo importante nell’ancoraggio di proteine che non possono entrare nella membrana lipidica per la mancanza di un segmento idrofobo sufficientemente esteso.

EPN

4

In PNH, GPI-Deficient Cells Are Positively Selected in Pathologic Bone Marrow

Inoue N et al. Int J Hematol. 2003;77:107:107-112.

RBCs  

Monocytes  

Platelets  

Granulocytes  

Lymphocytes  

Step 1 Step 2

Hematopoie9c  Stem  Cells  

RBCs = red blood cells

GPI-­‐Deficient  Cell  

Selected Cells*

GPI = glycerophosphatidylinositol.

Somatic Mutation in PIG-A

Immunologic Attack

Clonal Expansion by

Immuno-selection

Benign Tumor-Like Expansion

*Clones presumed to have a conferred growth advantage, in addition to the PIG-A mutation, resulting in GPI deficiency.

CLASSIFICATION OF HAEMOLYTIC ANAEMIAS

•  Malaria •  Auto-immune •  Drug-induced •  Micro-angiopathic •  Other

Paroxysmal Nocturnal

Haemoglobinuria (PNH)

Acquired

Familial HUS (due to defective

C regulatory protein)

•  emoglobinopathies •  Enzimopathies •  Membranopathies •  Other

Hereditary

Extracorpuscolar causes

Intracorpuscolar causes

EPN: rilievi laboratoristici

•  Anemia, reticolocitosi, <aptoglobina •  Aumento del valore serico LDH (800-3000) •  Citopenia: neutropenia, trombocitopenia •  Emoglobinuria a poussee •  “Perpetual Hemosiderinuria” •  Segni di trombosi (dimero D) >40% pts •  Aumento parametri di flogosi (infezioni) •  Ipertensione polmonare •  Insufficenza renale

EPN: Emoglobinuria

CD59, CD90, CD109

CD55 CD58 CD59 CD48 CD52 PrPc CD16

CD24 CD55

CD58 CD59 CD48 PrPC CD73 CD108

CD55 CD58 CD59 CD109 PrPC GP500 Gova/b

CD55 CD58 CD59 PrPC AChE JMH Ag Dombroch HG Ag

CD55 CD58 CD59 CD14 CD16 CD24 CD48 CD66b CD66c CD87 CD109 CD157 LAPNB1 PrPC p50-80 GPI-80 ADP-RT NA1/NA2

CD14 CD55 CD58 CD59 CD48 CD52 CD87 CD109 CD157 Group 8 PrPC GPI-80 CD16*

CD55 CD58 CD59 CD48 CD52 CD87 CD108 PrPc ADP-RT CD73 CD90 CD109 CD16

Haematopoietic Stem Cell

Platelets

RBC

Granulocytes

B cells

Monocytes

T cells

NK cells

Proteins deficient on PNH blood cells

Courtesy L. Del Vecchio

Granulocyte Lymphocyte

Monocyte Erythrocyte

CD66b

CD24

CD59 CD14

CD48

T

B

NK

Panel for cytometric analysis in patients with suspected PNH

Studio midollare in corso di EPN: procedura errata a fini diagnostici

FLAER Alexa-488

ERITROCITI

13.3%

FSC e SSC log

EPN: Monociti 3 popolazioni

CD33 CD45

CD14 CD14

I II III

CD64

The  gold  standard  diagnos9c  test  for  PNH  is  high  sensi9vity  flow  cytometry  performed  on  peripheral  blood    

• Tes%ng  for  PNH  Iden%fies  3  Popula%ons  of  PNH  Cells    Type  I:  Cells  with  normal  expression  of  CD59    Type  II:  PNH  cells  with  par%al  CD59  deficiency    Type  III:  PNH  cells  with  complete  CD59  deficiency  

• Granulocytes  provide  more  accurate  representa%on  of  PNH  clone  size  

  Percentages  of  PNH  RBCs  may  be  affected  by  hemolysis  or  blood  transfusions  

•  Evaluate  granulocytes  and  at  least  1  addi%onal  cell  line:  RBCs  and/or  monocytes  

 Borowitz  MJ  et  al;  Clinical  Cytometry  Society.  Cytom  B  Clin  Cytom.  2010;78:211-­‐230  

Standard Diagnostic Testing for PNH  

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Routine Testing Is Recommended for High-Risk Patient Populations  

Two  independent,  interna9onal  groups  recommend    tes9ng  of  high-­‐risk  pa9ents  for  PNH  

Interna9onal  Clinical  Cytometry  Society  (ICCS)  –  provides  laboratory  tes%ng  guidelines  for  rou%ne  diagnosis  of  PNH  

Interna9onal  PNH  Interest  Group  (I-­‐PIG)  –  provides  guidelines  on  diagnosis  and  management  of  PNH  

1.  Borowitz MJ et al; Clinical Cytometry Society. Cytometry B Clin Cytom. 2010;78:211-230.

2.  Parker C et al; International PNH Interest Group. Blood. 2005;106:3699-3709.

Advancements  in  treatment  op9ons  warrant  early  diagnosis  and  interven9on  Early  diagnosis  is  essen9al  for  improved  pa9ent  prognosis1-­‐2  

REFERTAZIONE CASO I

Rule PNH In or Out Using High Sensitivity Flow Cytometry

and Clinical Assessment

Early  Diagnosis  Is  Essen9al  for  Improved  Pa9ent    Management  and  Prognosis1-­‐2  

1. Borowitz MJ et al; Clinical Cytometry Society. Cytometry B Clin Cytom. 2010;78:211-230.

2. Parker C et al; International PNH Interest Group. Blood. 2005;106:3699-3709. 19

Unexplained Thrombosis

(venous or arterial)

Unexplained Cytopenia

RA-MDS (RCUD)

Aplastic Anemia Hemoglobinuria

Coombs-Negative Hemolytic

Anemia

RA-MDS= refractory anemia-myelodysplastic syndrome.

•  PNH  cells  detected  in  57%  to  70%  of  AA1,  2,  3  

•  PNH  cells  detected  in  20-­‐50%  of  MDS  pa9ents2,3  

•  PNH  cells  detected  in  50%  in  other  bone  marrow  

failure3  

20

1.  Sugimori C et al. BJH. 2009; 147: 102-12;

2.  2. Sugimori C et al. Blood. 2006 (107):1308-14; 3.  3. Galili N et al. JCO. 2009; Abstract 7082.

Co-­‐evolu9on  of  PNH  and  BMF  in  a  Hypoplas9c  Marrow    

Mutation of the PIG-A

AA / MDS

Suppor9ve  Care  Op9ons  Do  Not  Impact  Progression  and  Risk  for  Severe  Morbidi9es  and  Mortality1  

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Historical  care  op9ons  for  PNH  

• Transfusions1  –  risk  of  iron  overload  • An%coagulants1  –  ineffec%ve  in  many  pa%ents  

• Red  cell  supplements1  –  may  expand  clone  and  elevate  hemolysis  

• Steroids/androgen  hormones1  –  adverse  events  

1.  Parker  C  et  al;  Interna%onal  PNH  Interest  Group.  Blood.  2005;106:3699-­‐3709.  

THERAPY  OF  PNH    

Bone  Marrow  Transplant  (BMT)  Is  Associated  With  Significant  Morbidi9es  and  Mortality2,3  

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Although  it  is  the  only  poten9ally  cura9ve  therapy  for  PNH,  BMT  is  associated  with  significant  morbidi9es  and  mortality2,3    

•  In  a  study  examining  PNH  pa%ents  (n=23)2:  

– 50%  chronic  grad-­‐versus-­‐host-­‐disease  (GVHD);  42%  acute  GVHD3  

– 42%  transplant-­‐related  mortality2  – \  

• BMT  has  a  significant  impact  on  quality  of  life  post-­‐transplant4,5  

1.  Parker C et al; International PNH Interest Group. Blood. 2005;106:3699-3709. 2.  Santaraone S et al. Haematologica. 2010;95:983-988. 3.  de Latour PF et al. EBMT 2009:Abstract 316. 4.  Bieri S et al. Bone Marrow Transplant. 2008;42:819-827. 5.  Fraser CJ et al. Blood. 2006;108:2867-2873.

•  Eculizumab binds with high affinity to C51,2

•  Terminal complement - C5a and C5b-9 formation is blocked1,2

•  Proximal functions of complement remain intact1,2 –  Weak anaphylatoxin2,4

–  Immune complex clearance2

–  Microbial opsonization2

1.  Soliris®  (eculizumab)  Summary  of  Product  Characteris%cs.  Cheshire,  CT:  Alexion  Europe  SAS.    2.  Rother  RP  et  al.  Nature  Biotechnol.  2007;25:1256-­‐1264.    3.  Walport  MJ.  N  Engl  J  Med.  2001;344:1058-­‐1066.    4.  Figueroa  JE,  Densen  P.  Clin  Microbiol  Rev.  1991;4:359-­‐395  

Eculizumab  is  an  An9-­‐C5  An9body  That  Blocks    Complement-­‐Mediated  Hemolysis    

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Eculizumab Clinical Development Program

Eculizumab (n = 11)

Eculizumab (n = 43)

Placebo (n = 44)

Eculizumab (n = 97)

Entered long-term extension (up to 3 years;

n = 10)

Entered long-term extension (up to 3 years;

n = 41)

Entered long-term extension (up to 3 years;

n = 44)

Entered long-term extension (up to 3 years;

n = 92)

Phase II pilot study NEJM 20041

(12 weeks) + 2 extension studies (52 and 104 weeks) 11 patients

Phase III study Blood 20083

SHEPHERD

(52 weeks) 97 patients

187 patients entered long-term extension trial4

Investigation: Measure clinical and biochemical indicators of hemolysis

Primary end points: stabilization of hemoglobin levels and the number of units of packed red blood cells

transfused

Primary efficacy end point: hemolysis as assessed by LDH

AEGIS study

Int J Hematol 20115

(12 weeks) 29 patients

Eculizumab (n = 29)

Primary end point: reduction of hemolysis

Entered long-term extension (up to 2

years; n = 27)

Phase III study NEJM 20062 TRIUMPH (26 weeks) 87 patients

Overview  of  the  Eculizumab  Clinical  Development  Program:  Pilot  Study,  TRIUMPH,  SHEPHERD,  and  AEGIS  

1.  Hillmen P et al. N Engl J Med. 2004;350:552-559. 2.  Hillmen P et al. N Engl J Med. 2006;355:1233-1243. 3.  Brodsky RA et al. Blood. 2008;111:1840-1847. 4.  Hillmen P et al. Br J Haematol. 2013;162:62-73. 5.  Kanakura Y et al. Int J Hematol. 2011;93:36-46.

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1.  Hillmen  P  et  al.  N  Engl  J  Med.  2006;355:1233-­‐1243.    2.  Hillmen  P  et  al.  Blood.  2007;110:4123-­‐4128.    3.  Brodsky  RA  et  al.  Blood.  2008;111:1840-­‐1847.    4.  Hillmen  P  et  al.  Br  J  Haematol.  2013;162:62-­‐73.    5.  Socié  G  et  al.    49th  Annual  Mee%ng  of  the  American  Society  of  Hematology;  December  8-­‐11,  2007;  Atlanta,  GA.  Poster  891-­‐III  [Blood.007;110:3672.)    

TRIUMPH1,2

•  Patients not on Soliris (n = 44) •  Soliris (n = 43) •  Patients not on Soliris transitioned •  to Soliris (n = 44)

SHEPHERD2

•  Soliris (n = 97) EXTENSION  studies  • Hillmen  2013  (n  =  189  and  87  at  72  and  144  weeks,  respec%vely)4  • Socié  2007  (n  =  10)5    

Reduc9on  in  Hemolysis  as  Measured  by  LDH  Was  Sustained  With  Long-­‐Term  Soliris  Treatment  

Patients being treated with Soliris maintained an 86% reduction in hemolysis as measured by LDH over a 36-month treatment period4

Blood transfusion requirements in the 12 months before eculizumab therapy and the most recent 12 months on eculizumab treatment in 64 patients.

Kelly R J et al. Blood 2011;117:6786-6792 ©2011 by American Society of Hematology

Transfusion independence: 40 of 61 patients (66%)

Eculizumab Riduce l’Incidenza di Trombosi in Pazienti Trattati con Anticoagulanti1

!  94% di riduzione di incidenza di trombosi con SOLIRIS

(n=91)

P<0.001

*excludes patients on antiplatelet agents

1. Hillmen P, et al. Blood. 2007;110:4123-4128.

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Soliris  Treatment  Resulted  in  Significant  Improvements  in  Survival  for  Pa9ents  With  PNH  

Years  A[er  Diagnosis  

Pa9e

nts  S

urviving  (%

)  

Actuarial Survival From the Time of Diagnosis in 80 Patients With PNH1

100

80

60

40

20

0 0 5 10 15 20 25

Age- and Gender- Matched Controls

Patients With PNH

Pa9ents  With  PNH  on  Soliris  Compared  With  Age-­‐  and  Gender-­‐Matched  Controls2*  

Time,  (Years)  Pa

9ents  S

urviving,  (%)  

*Survival after 10-years is slightly inferior to controls with causes of

death related to bone marrow failure and not hemolysis or thrombosis

1.  Hillmen P et al. N Engl J Med. 1995;333:1253-1258 2.  Hill A et al. Presented at: 54th Annual Meeting of the American Society of Hematology (ASH); December 8-11, 2012; Atlanta, GA. Abstract 3472

Results  from  a  10-­‐year  mul9center    observa9onal  cohort  study    

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•  Treatment  with  Eculizumab  resulted  in  a  92%  reduc9on  in  thrombo9c  events1  

 

•  Pa%ents  being  treated  with  Eculizumab  reported  significant  improvement  in  evidence  of  pulmonary  hypertension  and  dyspnea3,4  

 

•  82%  of  pa%ents  being  treated  with  Eculizumab  achieved  transfusion  independence  at  36  months2  

•  Treatment  with  Eculizumab  resulted  in  clinically  meaningful  improvements  in  quality  of  life,  including  reduced  fa%gue  and  pain5  

1.  Hillmen P et al. Blood. 2007;110:4123-4128. 2.  Hillmen P et al. Br J Haematol. 2013;162:62-73. 3.  Hill A et al. Br J Haematol. 2012;158:409-414.

4.  Hill A et al. Br J Haematol. 2010;149:414-425. 5.  Hillmen P et al. N Engl J Med. 2006;355:1233-1243.

Clinical  Efficacy  of  Eculizumab  in  Pa9ents  With  PNH  

1. Hillmen P et al. N Engl J Med. 2006;355:1233-1243. 2. Brodsky RA et al. Blood. 2008;111:1840-1847. 3. Hillmen PD et al. Blood. 2007;110:4123-4128

4. Hill A et al. Br J Haematol. 2010;149:414-425. 5. Hillmen P et al. Am J Hematol. 2010;85:553-559. 6. Richards SJ et al. Blood. 2005;106:Abstract 1047.

7. Hillmen P et al. Br J Haematol. 2013;162:62-73. 8. Soliris® (eculizumab) summary of product characteristics. Cheshire, CT: Alexion Europe SAS. 9. Kelly RJ et al. Blood. 2011;117:6786-6792  

Soliris  Treatment  Expecta9ons    

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REGIONE LOMBARDIA

PRESIDI REGIONALI DI RIFERIMENTO PER L’EPN:

CREMONA  

MILANO  

BERGAMO  

BRESCIA  

PAVIA  

MONZA  

Percorso  Diagnos?co,  Terapeu?co  e  Assistenziale  (PDTA)  rela?vo  a:  EMOGLOBINURIA  PAROSSISTICA  

NOTTURNA  Codice  esenzione  RD0020  

12,5  6,1  8,3   9,3  

79,2  100,0   84,6  

0  

10  

20  

30  

40  

50  

60  

70  

80  

90  

100  

LOMBARDIA   EMILIA-­‐ROMAGNA   ITALIA  

%  

Distribuzione  della  dimensione  del  clone  

<1%  

1-­‐5%  

>5%