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.)