LL’’Uso del CD33 nelle leucemieUso del CD33 nelle leucemie

MartinelliMartinelli Giovanni Giovanni

IstitutoIstituto didi EmatologiaEmatologia ed ed OncologiaOncologiaMedicaMedica ““ L. e A. L. e A. SeragnoliSeragnoli””

UniversitaUniversita’’ didi Bologna, Bologna,

Targeting treatment in AMLTargeting treatment in AML

•• Targeting Targeting leukemialeukemia-associated antigens-associated antigens-- CD33 as modelCD33 as model

•• Targeting molecular lesionsTargeting molecular lesions-- FLT3 as modelFLT3 as model

•• Targeting protein functionTargeting protein function-- RASRAS

-- P-P-gpgp

-- Bcl-2Bcl-2

•• Other targetsOther targets-- AngiogenesisAngiogenesis

-- ProteasomeProteasome

TargetingTargeting leukemia-associatedleukemia-associated antigens antigens

•• Myeloid cell surface antigen, 67 Myeloid cell surface antigen, 67 kDkD

•• SiglecSiglec protein protein

•• Contains two Contains two IgIg-like domains-like domains-- TransmembraneTransmembrane region region

-- CytoplasmicCytoplasmic tail with two ITIM sequences tail with two ITIM sequences

•• SialicSialic acid-binding receptor acid-binding receptor

•• Its precise function unknownIts precise function unknown

•• Downstream steps involves Downstream steps involves SykSyk, , c-Cblc-Cbl, , VavVav, Zap-70, Zap-70

CD33

SIGLEC

TargetingTargeting leukemia-associatedleukemia-associated antigens antigens

•• Ab-CD33 Ag complex rapidly internalizes and Ab-CD33 Ag complex rapidly internalizes and translocatestranslocatesinto into lysosomeslysosomes

•• Expressed in 90% of Expressed in 90% of AMLsAMLs

•• Down-regulated with maturation of myeloid lineageDown-regulated with maturation of myeloid lineage

•• Not expressed on primitive Not expressed on primitive HSCsHSCs and non- and non-hematopoietichematopoietictissuestissues

•• > 10,000 copies/cell and modulates> 10,000 copies/cell and modulates

Suitable Target

CD33

GemtuzumabGemtuzumab OzogamicinOzogamicin (GO) (GO)

Targets the Targets the cytotoxiccytotoxic

moleculemolecule

to to hematopoietichematopoietic cells that cells that

express the CD33 antigenexpress the CD33 antigen

GemtuzumabGemtuzumab OzogamicinOzogamicin

Linker

OH

CH3 CH2

OCH3

O

Me

O

O

NH

NHN

O

S

H

HOO

OCH3

NH O

O

OCH3

N

O

OCH3

HO

CH3

O

CH3

HNHO

OO

OH

CH3

S

CH3

OCH3

I

O

O

O

S

Me Me

OCH3

DNA minor grooveDNA minor groove

bindingbinding

Mylotarg® Prescribing Information. Wyeth Laboratories. Philadelphia, PA; 2002.

IgG4 anti-CD33IgG4 anti-CD33

CalicheamicinCalicheamicin derivative derivative

Anti-CD33-Calicheamicin Anti-CD33-Calicheamicin immunoconjugateimmunoconjugate

GemtuzumabGemtuzumab OzogamicinOzogamicin

••MechanismMechanism of action of action

-- BindsBinds toto CD33 and CD33 and getsgets internalizedinternalized

-- LinkerLinker cleavedcleaved intracellularlyintracellularly

-- CalicheamicinCalicheamicin bindsbinds toto DNA DNA

-- DoubleDouble strandstrand breaksbreaks apoptosisapoptosis

MechanismMechanism of action of GO of action of GO

MechanismMechanism of action of GO of action of GO

MechanismMechanism of action of GO of action of GO

MechanismMechanism of action of GO of action of GO

MechanismMechanism of action of GO of action of GO

MechanismMechanism of action of GO of action of GO

MechanismMechanism of action of GO of action of GO

MechanismMechanism of action of GO of action of GO

MechanismMechanism of action of GO of action of GO

MechanismMechanism of action of GO of action of GO

MechanismMechanism of action of GO of action of GO

PharmacokineticsPharmacokinetics

••Distribution to a relatively limited spaceDistribution to a relatively limited space

••Mean half-life of Mean half-life of 67 hours67 hours

••Significant increase in plasma level afterSignificant increase in plasma level afterthe second dose infusionthe second dose infusion

••UnconjugatedUnconjugated calicheamicincalicheamicin < 4% < 4% ininplasmaplasma

••Transient detection of Transient detection of calicheamicincalicheamicinmetabolitesmetabolites

Resistance and MDRResistance and MDR

••Resistance to GO correlated with aResistance to GO correlated with aMDR phenotypeMDR phenotype

•• Efficacy restored by MDR Efficacy restored by MDRmodulatorsmodulators

•• Inverse correlation between CD33Inverse correlation between CD33and and PgpPgp expression expression

Efficacy and PB CD33-ag loadEfficacy and PB CD33-ag load

••Peripheral consumption of GOPeripheral consumption of GO

••Reduced BM CD33 saturationReduced BM CD33 saturation

••Reduced BM cell killReduced BM cell kill

ActionsActions

••Higher or repeated doses of GOHigher or repeated doses of GO

••Reduction of Reduction of leukemicleukemic burden burden

Phase II trials in AML (1st relapse)

• 9 mg/m2 2-hr infusion, day 1 and 15

• ORR 31%; 1-yr OS 27%

• Predictable myelosuppression

• Minimal mucositis

• Moderate liver dysfunction

• Reduced toxic mortality in older pts (13%)

188 188 patientspatients

Areas of investigation in AML

• Frontline therapy- Combination therapy (simultaneous/sequential)

- Single agent (elderly unfit)

• Consolidation- Single agent & combination therapy

• Maintenance- Single agent (AML, APL)

• Relapsed/refractory- Single agent & combination therapy

• Transplant- conditioning

- in vitro purging

Anziano AMLas front line therapy

AML-15 trial

• Gemtuzumab Ozogamicin (GO) followed or not byintensive chemotherapy as initial treatment for elderlypatients with AML

- Phase II (06993)

- EORTC-LG

- GIMEMA

- Activated 09/2000

Dual-treatment strategy

• “Fit” patients

- Age 61-75 + PS 0-1

• “Frail” patients

- Age >75 + PS 0-2

- Age <76 + PS 2

AML-15A AML-15B

AML-15° (“FIT”): diagram

mini-ICE (1course)"recommended"

CR/CRp < CR/CRpoff treatment

MICE(1/2 courses)

Response assessment

GOdays 1 and 15

Induction results

• Response to GO- Evaluable 57

- CR 13 (22.8%)

- CRp 7 (12.3%)

- PR 6 (10.5%)

- RD 28 (49.1%)

- ID 3 (5.3%)

• Overall Response- Evaluable 57

- CR 20 (35.1%)

- CRp 11 (19.3%)

- PR 1 (1.8%)

- RD 17 (29.9%)

- ID 8(14.1%)

CR+CRp 35.1% CR+CRp 35.1%

(95% CI, 24% - 48.1%)(95% CI, 24% - 48.1%)CR+CRp 54.4% CR+CRp 54.4%

(95% CI, 41.6% - 66.6%)(95% CI, 41.6% - 66.6%)

Safety summary

• Manageable toxicity- Overall TRM 14.1%

- GO-related mortality 5.3%

- Dropout rate (toxicity) @GO 21%

• Prolonged myelosuppression after GO- Median time to PMN > 0.5K: 37 days

- Median time to PLT > 50K: 32 days

• VOD in 8.8% (5/57)- Fatality rate 80%

AML-17 Trial

• EORTC-LG

• Age 61-75 yrs; PS 0-2

• Randomized phase III

GO (6+6)+MICE x inductionGO (6+6)+MICE x induction

GO (3)+mini-ICE x consolid (2)GO (3)+mini-ICE x consolid (2)

MICE x inductionMICE x induction

mini-ICE x consolid (2)mini-ICE x consolid (2)

Activated 09/02Activated 09/02

AML-15B (“frail”): diagram

No further therapy

GO Consolidation

(2 monthly doses)

CR/CRp < CR/CRp

off treatment

Response assessment

GO

days 1 and 15

Induction results

• No. patients 40- CR 4 (10%)

- CRp 3 (7.5%)

- Resistant disease 24 (60%)

PD @GO-1PD @GO-1 88- Induction death 7 (17.5%)

Early deathEarly death 55

Hypopl deathHypopl death 22- NA (toxicity) 2 (5%)

CR+CRp 17.5% (95% CI, 8.7% - 32.0%)CR+CRp 17.5% (95% CI, 8.7% - 32.0%)

Efficacy/Safety summary

• Antileukemic activity- ORR (CR+CRp) 17.5%- 1-yr OS rate 27%

• Prolonged myelosuppression- Grade 3-4 infection 40%- Grade 3-4 febrile neutropenia 52.5%- Overall TRM 17.5%

31.8% in pts >75 yrs31.8% in pts >75 yrs- Dropouts (toxicity) 18%

• Grade 3-4 liver toxicity 10%- VOD in 1 pt @GO-1 (fatal)

AML 15 B …..… AML-19 Trial

• Target population- Age >75 + PS 0-2 (Frail patients)

• Phase II-III trial- Palliative HU (control arm)- GO monotherapy

Lower dose x inductionLower dose x inductionCondensed schedule (1,8; 1,3,5))Condensed schedule (1,8; 1,3,5))MaintenanceMaintenance

• Primary end-point: survival

• EORTC-LG + GIMEMA

AML-19: phase II

Randomize

Control Arm

Supportive care

Regimen 1

GO 6 mg/m2 d 1

GO 3 mg/m2 d 8

Regimen 2

GO 3 mg/m2

d 1, 3, 5

CR/CRp/PR/NC CR/CRp/PR/NCDay 36

Day 50 Continuation

GO 2 mg/m2 every 4 weeks x 8

AML-19: phase III

Randomize

Control Arm

Supportive care Best GO regimen

CR/CRp/PR/NCDay 36

Continuation

GO 2 mg/m2 every 4 weeks x 8Day 50

Giovane “de novo” AMLas front line therapy

The addition of Gemtuzumab Ozogamicin toInduction Chemotherapy for AML ImprovesDisease Free Survival without Extra Toxicity:Preliminary Analysis of 1113 Patients in MRCAML15 Trial

A K Burnett, W J Kell, A H Goldstone,

D Milligan, A Hunter, A G Prentice,

N Russell, B Gibson, K Wheatley, R K Hills

on behalf of the NCRI Leukaemia Working Party

Patient Demographics

Induction Consolidation

Number

Age (years)

Sex (M:F)

De Novo/Secondary

Presenting WBC x 109/l

Cytogenetic Risk

Group(19) Favourable/

Standard/Unfavourable/

not available

64

46.5 (18-59)

37:27

61/3

9.5

(0.54-305.8)

13/39/7/5

31*

46 (17-58)

17:14

30/1

9.19

(0-305.8)

5/20/4/2

*23 patients also treated with GO induction

Study Cohorts

Cohort Number Schedule

1

2

3

4

5

6

7

8

9

22

9

9

10

7

14

17*

8**

18

H-DAT + GO 3mg/m2

H-DAT + GO 6mg/m2

H-DAT + GO 3mg/m2 courses 1 and 2

S-DAT + GO 3mg/m2

S-DA + GO 3mg/m2

FLAG-Ida + GO 3mg/m2

MACE + GO 3mg/m2

MidAc + GO 3mg/m2

GO 3mg/m2 in induction and

consolidation

*12/17 had GO with induction **6/8 had GO with induction

Response to Induction

Schedule No CR CR% ID RD

DAT + 3mgs 32 27 84% 4 1

DAT + 6mgs 9 8 89% 1 -

DA + 3mgs 7 7 100% - -

FLAG-Ida + 3mgs 14 12 86% 1 1

62 54 87% 6 2

Pilot Trial: Conclusions

- 3mgs/m2 well tolerated with all schedules

- Combination with thioguanine associated with livertoxicity

- 6mgs/m2 caused liver and haematological toxicity

- Consecutive courses associated with haem and livertoxicity

- Remission rate >80%

MACE

or

Mini Allo SCT

MidAC

Ara-C 3g/m2

Ara-C 1.5g/m2

MACE ± MylotargADE

8 + 3+5

DA 3+10± Mylotarg

Standard/poor risk adultspoor risk childrendonor available,

suitable for Allo SCT

Course 2

FLAG-Ida

DA 3+8

Risk group assessmentof status. If poor risk,

OPTIONAL tocontinue in AML15 or toenter an NCRI high risk

trial if available

No CR

CR

Course 1

R

FLAG-Ida± Mylotarg

ADE 10+3+5± Mylotarg

Good risk orstandard /poorrisk & not for

Allo SCT

Elect

R

E

Randomise

Ara-C 1.5g/m2

E

Standard AlloSCT

Course 4 Course 5

R

No furthertreatment

Course 3

Ara-C 3g/m2

± Mylotarg

Ara-C 1.5g/m2

± MylotargR

MRC AML 15 Schema

Flow chart

ADE8+3+5

DA 3+10± Mylotarg

DA 3+8

FLAG-Ida± Mylotarg

FLAG-Ida

MACE± Mylotarg

Ara-C 1.5g/m2

± Mylotarg

Ara-C 3g/m2

± Mylotarg

Ara-C 1.5g/m2

Ara-C 3g/m2

MidAC

Standard AlloSCT

MACEMini Allo

SCT

To compare threeinduction schedules(namely ADE, DA and

FLAG-Ida)

To assess the value ofMylotarg during

induction when used incombination with ADE or

DA or FLAG-Ida

AML15: Trial: Recruitment till 30/06/06

Entry 2009

225 APL

WBC>30 (01/03/04)

Abnormal LFTs (01/03/04)

ADE Therapy (01/06/05)

Children (19/12/05)

1113 Randomised

Remission Induction:

Mylotarg No Mylotarg

Complete

Remission

84% 86%

Induction Death 8% 7%

Resistant Disease 8% 7%

CR/CRi Course 1 79% 76%

CR Course 1 75% 73%

Resource usage

Resource Mylotarg No mylotarg p-value

Blood units 12.7 12.2 0.8

Platelet units 19.1 13.8 <0.0001

Days IV antibiotics 20.4 18.6 0.002

Days in hospital 32.2 (median 31) 30.9 (median 30) 0.07

Differences assessed using Wilcoxonrank-sum test

OS

ICE vs FLAI vs FLAIE vs MyAIERisposta alla terapia di induzione

Istituto Seràgnoli

ICE FLAI FLAIE MyAIE

Pz arruolati 55 57 44 22

RC post

induzione

28 (51%) 42 (74%) 33 (75%) 13 (59%)

Decesso in

induzione

5 (9%) 1 (2%) 2 (4%) 0

RES/RP 22 (40%) 14 (25%) 9 (20%) 9 (41%)

RC post I

consolidamento

10

(45%)

4 (29%) 2 (22%) 3 (34%)

OR 38 (69%) 46 (81%) 35 (80%) 16 (73%)

Incidence and outcome of liver toxicity

Scenario Incidence Case fatality

rate

GO alone 15 - 25%1-3

(VOD <5%)

1 - 2%2

GO + other drugs >30%2,5

(VOD 5-10%)<33%2,5

HSCT after GO >31%2

(VOD 15%)<38%2

GO after HSCT 10 - 50%2,4

(VOD 20%)

50%2,4

1Tallman et al, Blood 2003 2Chako et al, Blood 2003 3McDonald, Unpublished obs.2004 4Rajvanshi et al, Blood 2002 5Giles et al, Cancer 2001

VOD (SOS) e Mylotarg

• SOS (synusoidal obstructive syndrome)is the preferred term forthe VOD-like syndrome

• Primary site of injury: the sinusoidal endothelium and NOT thehepatic venules

• The most important adverse effect , with an incidence ofapproximately 20%, is Grade 3 or 4 hyperbilirubinemia andhypertansaminasemia which can induce the development ofpotentially fatal hepatic veno-occlusive disease (VOD)

• Calicheamicin seems the most likely cause of GO-associatedVOD, possibly by causing damage to hepatic sinusoidalendothelial cells.

• Generally, the median time of occurrence of VOD is 25 days(range 10-35) after the first dose of Mylotarg.

Occurrence of VOD According to the Time Interval BetweenGemtuzumab Ozogamicin and HSCT Administration

Total HSCT procedures 14 (18) 66 (83) 80 (100)

HSCT after GO

Autologous

115 days after GO 1 (17) 5 (83) 6

> 115 days after GO 0 (0) 14 (100) 14

Allogeneic

115 days after GO 7 (27) 19 (73) 26

> 115 days after GO 0 (0) 6 (100) 6

Total 8 (15) 44 (85) 52

No. of HSCT procedures (%)

HSCT type With VOD Without VOD Total

DEFIBROTIDE

•anti-ischemic drug with multiple sites of action

•able to interfere with leukocyte adhesion toendothelial cells It produces profibrinolytic,cytoprotective actions by decreasing the PAI-1 levels.

•profibrinolytic effects and inhibition of fibrindeposition with selective activity on smallvessels.

•No significant effects on systemic coagulation

• it increases the synthesis of PGI2, that is astrong inhibitor of platelet aggregation and aninducer of vessel dilatation.

STUDY DESIGNSTUDY DESIGNG

rou

p B

(4

pts

) MylotargMylotarg 3mg/ m2 I.V. 3mg/ m2 I.V. day 1, 3, 5 day 1, 3, 5

MylotargMylotarg 3mg/ m2 I.V. 3mg/ m2 I.V.

every 28 days every 28 days

Defibrotide prophylaxisDefibrotide prophylaxis••10 mg/kilo/day I.V10 mg/kilo/day I.V day -1 +7 day -1 +7••400mg p.o.400mg p.o.

day +8 +15 day +8 +15

Defibrotide prophylaxisDefibrotide prophylaxis10 mg/kilo/day I.V.10 mg/kilo/day I.V.

day -1 +14day -1 +14

Gro

up

A (

8 p

ts)

MylotargMylotarg 6mg/ m2 I.V. 6mg/ m2 I.V. day 1 and 14 day 1 and 14

Defibrotide prophylaxisDefibrotide prophylaxis10 mg/kilo/day I.V.10 mg/kilo/day I.V.day -1 +30day -1 +30

Courtesy of Ada Quirino, SIE 2005

Ringraziamenti

• M. Fiacchini, N. Vianelli, C. Finelli, A. Curti, R. Lemoli, PPPiccaluga, Testoni N., Ottaviani E., Paolini S. PapayannidisC., Panagiota G., . Colarossi, ……Baccarani M. (Bologna)

• Russo D, Malagola M, (Brescia)

• PP, Damiani D, Candoni A, Michielutti A, Fanin R, (Udine)

• Castelli M, Pricolo G, Mazza P. (Taranto)

• Raspadori D, Bocchia M, Lauria F. (Siena)

• Bonini A, Avanzini P, Gugliotta L. (Reggio E.)

• Visani G. A. Isidori (Pesaro)

• Rondoni M, Zuffa E, Zaccaria A, (Ravenna)

• Pieri I., GobbiM. (Genova)

• Gallieni (Ascoli P.)