Post on 14-Jan-2016
LBH589 e altri inibitori delle istone-deacetilasi nel Mieloma
Multiplo
Claudia Polloni
Clinica di EmatologiaAzienda Ospedaliero-Universitaria
Ospedali Riuniti Ancona
Introduction to Deacetylases (DACs)
• Deacetylases (DACs) are enzymes that remove the acetyl groups from target proteins, leading to regulation of gene transcription and other cellular processes
• Histones are one of the target proteins, which is why the class is sometimes referred to as histone deacetylases (HDACs)
• DACs also target non-histone proteins, which include transcription factors, -tubulin, and HSP90
There are 4 Classes of DACs (I and II), Which Act on Different Target Proteins
HDAC4
Class II DACs act on NON-HISTONE proteins located in the cytoplasm (e.g. HDAC6)
Class I DACsact on
HISTONES andTRANSCRIPTION
FACTORS located
in the nucleus
There are 2 main classes of DACs
HDAC1
HDAC2HDAC3
HDAC8
HDAC5
HDAC7
HDAC9
HDAC6
HDAC10
HDAC7
Pan-DAC Inhibitors Target Both Classes of DACs, Modulating Histone and Non-Histone
Proteins
Specific DACinhibitors maytarget Class I
DACs only
There are 2 main types of DAC inhibitors
HDAC1
HDAC2HDAC3
HDAC8
Pan-DAC inhibitors target both Class I and Class II DACs – interfering with both histone and non-histone proteinsHDAC4
HDAC5
HDAC9
HDAC6
HDAC10
HDAC7
Isoenzyme-selectivity of pan-HDACi:
DNA
Mutations/translocations
Replication errors
Genetic Variations and Epigenetic Changes Can Both Contribute to Oncogenesis
GENETIC
Chromatin
EPIGENETIC
Transformed cells
Open/closed chromatin
Enzyme modification errors
Altered DNA/mRNA/proteins
DNA sequence altered
Altered mRNA/proteins
DNA sequencenot altered
Oncogenesis
Can be caused by:
• Abnormal modifications to histone proteins
• Abnormal DNA methylation
Can be caused by:
• Abnormal modifications to histone proteins
• Abnormal DNA methylation
Altered Expression of DACs is Found in Several Malignancies
DAC expression can increase cell-cycle progression and prevent cell death, which leads to increased cell proliferation
DAC expression can correlate with estrogen and progesterone receptor expression
DACs can be upregulated in malignant prostate cancer, with the highest levels found in HRPC
DAC expression can be associated with tumor aggressiveness
MULTIPLE MYELOMAMULTIPLE MYELOMA
BREAST CANCERBREAST CANCER
PROSTATE CANCERPROSTATE CANCER
GASTRIC CANCERGASTRIC CANCER
Histone
-tubulin HSP90
HIF-1
Pan-DAC Inhibition May Have Potential in Several Cancers
DACsDACs
Hematologic & Solid Tumors
Breast, Multiple Myeloma RCC,
Melanoma
CML, Breast, Prostate, NSCLC
50% of CancersDAC
InhibitorDAC
Inhibitor
p53
• Epigenetic changes, such as histone modifications and DNA methylation, play key roles in chromatin structure and gene activity
• Altered patterns of epigenetic modifications are common in many human diseases, including cancer
• Silencing of tumor suppressor genes by abnormal histone modifications is a key feature of cancer cells
• DAC inhibitors were developed when they were found to reactivate genes that had been epigenetically silenced
Epigenetic Changes Can Drive Cancer
Acetylation of Histones by HAT Allows Gene Expression
Acetylation by histone acetyltransferases (HATs) allows transcription and gene expression
Acetylated Histone
Open chromatin Transcription factors can access DNA
Deacetylated Histone
Closed chromatin Transcription factors cannot access DNA
HATHAT
HISTONE ACETYLATION
Ac: acetyl group
Transcription factors –Ac
Ac–
Ac– Ac–
Deacetylation of Histones by HDAC Can Prevent Gene Expression
Acetylation by histone acetyltransferases (HATs) allows transcription and gene expression
Deacetylation by histone deacetylases (HDACs) can prevent transcription and gene expression
HATHAT
HISTONE ACETYLATION
HISTONE DEACETYLATION
HDACHDAC
Acetylated Histone
Open chromatin Transcription factors can access DNA
Deacetylated Histone
Closed chromatin Transcription factors cannot access DNA
Ac: acetyl group
HDAC depicts a class I deacetylase
Transcription factors –Ac
Ac–
Ac– Ac–
In Tumor Cells, Imbalanced HAT and HDAC Activity Can Result in Deregulated Gene Expression
TumorCell
Unchecked CellGrowth and Survival
Decreased Tumor Suppressor Gene Activity (p21, p27)
IncreasedHDAC Activity
Decreased HAT Activity
HDACHDAC
HDACHDACHDACHDAC
HATHAT
Ac: acetyl group
TF: transcription factors
HDAC depicts a class I deacetylase
TF–Ac
Ac–
HDAC Inhibition Restores Gene Expression in Tumor Cells
HDACHDAC
HDACHDACHDACHDACDAC Inhibition Increases Acetylation of Histones HATHAT
DAC Inhibitor
DAC Inhibitor
Increased Tumor Suppressor Gene Activity (p21, p27)
Cell-Cycle Arrest and Differentiation
Normalized Cell
Ac: acetyl group
TF: transcription factors
HDAC depicts a class I deacetylase
–Ac
Ac–
Ac– Ac–
TF
DACs are Implicated in Cancer by Modulating Histone and Non-Histone Proteins Involved in
Oncogenesis
Non-histone proteins are implicated in multiple oncogenic pathways
Histone
p53
Histone proteins are implicated in epigenetic modifications that could
cause cancer
Proteins modulated
by DACs
DACDAC
DAC DAC DAC
-tubulinHSP90HIF-1
DACDAC DACDAC DACDAC
Pan-DAC Inhibition Interferes with the Multiple Hallmarks of Cancer
Proteins modulated
by DACs
DAC depicts individual deacetylases, e.g. HDAC1, HDAC4, HDAC6
Histone
DACDAC DACDAC
-tubulin HSP90HIF-1
Cell-cycle arrest
Apoptosis
Cell motility and Invasion
Cell proliferation and survival
Angiogenesis
Tumor effects
DAC Inhibitor
DAC Inhibitor
Tumor suppressor gene activity
Loss of tumor suppressor
function
Microtubule depolymerization/
aggresome formation
VEGF Oncoproteins Downstream
effects
p53
HSP90
HDAC6HDAC6
DAC Inhibitor
DAC Inhibitor
Growth and survival proteins
Growth and survival proteins
Acetylated HSP90 – binding to growth and survival
proteins prevented
HSP90
Deacetylated HSP90 – binds growth and survival proteins
HDAC6HDAC6
Growth and survival proteins
Growth and survival proteins
DAC Inhibition can Control Myeloma Cell Proliferation and Survival Through HSP90DAC Activity through HSP90
Overexpression of growth and
survival proteins
Proliferation and survival
DAC inhibition through HSP90
Overexpression of growth and
survival proteins
Proteins protected from degradation
Proteins degraded
Proliferation and survival
Acetylated α-tubulin
HDAC6HDAC6
DAC Inhibitor
DAC InhibitorDeacetylated
α-tubulin
HDAC6HDAC6
DAC Inhibition can Induce Apoptosis in Myeloma Cells Through the Aggresome
Pathway
Protein degradation
Cell survival Apoptosis
Aggresomeformation
DAC Activity through aggresomes DAC inhibition through aggresomes
No aggresome formation
Misfolded proteins recruited to aggresomes
Protein degradation
Accumulation of cytotoxic misfolded proteins
HDAC6HDAC6
Acytelated α-tubulin
DAC Inhibition can Synergize with Proteasome Inhibition to Induce Increased
Apoptosis in Myeloma Cells
Protein degradation
Apoptosis
Multiple Myeloma cell
Protein degradation
Proteasome Inhibitor
(Bortezomib)
DAC Inhibitor
DAC Inhibitor
Proteasome No aggresome
formation
Misfolded proteins
Accumulation of misfolded proteins
DAC Inhibition Can Lead To Decreased Angiogenesis in Tumor Cells Through HIF-1
ImplicatedImplicated in RCC, in RCC, melanoma and other melanoma and other
solid tumorssolid tumors
HIF-1HIF-1
Deacetylated HIF-1α•Stabilized
HDAC4HDAC4
HDAC6HDAC6 Acetylated HIF-1α•Destabilized•Degraded
DAC Activity
HIF-1HIF-1
DAC Inhibition
HDAC4HDAC4
HDAC6HDAC6
DAC Inhibitor
DAC Inhibitor
VEGFVEGF VEGFVEGF
AngiogenesisAngiogenesis AngiogenesisAngiogenesis
DAC Inhibition can Induce Apoptosis in Myeloma Cells
Studi in corso: Tab 3 Hematology review
STUDIO DI FASE II, MULTICENTRICO, IN APERTO DI
LBH589 ORALE IN ASSOCIAZIONE CON MELPHALAN, PREDNISONE E
TALIDOMIDE (LBH-MPT) IN PAZIENTI CON MIELOMA MULTIPLO AVANZATO O
REFRATTARIO
LBH-MPT
Rationale LBH589-MPT
• Activty of LBH589 in solid tumors and hematologic malignancies
• Combination treatments standard for MM (MPT)
• Each drug has different mechanisms of action
• Safety will be closely evaluated
QTcF prol: 27%
Nausea: 40%
Diarrhea: 33%
Vomiting: 33%
Hypokalemia: 27%
Anorexia: 13%
Thrombocytopenia: 13%
Safety of iv LBH-589
ARM ARM
ARM 1 (32 pts)ARM 1 (32 pts)15 mg MWF (3 pts)15 mg MWF (3 pts)20 mg MWF (19 pts)20 mg MWF (19 pts)30 mg MWF(10 pts)30 mg MWF(10 pts)
ARM 3 (22 pts)ARM 3 (22 pts)30 mg MWF eow(20 pts)30 mg MWF eow(20 pts)45 mg MWF eow(2 pts)45 mg MWF eow(2 pts)$$
ARM 5 (8 pts)ARM 5 (8 pts)30 mg MT (3 pts)30 mg MT (3 pts)45 mg MT ( 5 PTS)45 mg MT ( 5 PTS)
No grade 3No grade 3
0000
1 (diarrhea)1 (diarrhea)
001 (diarrhea)1 (diarrhea)
001 (fatigue)1 (fatigue)
1 (QTcF prol)1 (QTcF prol)
1 (PLTpenia)1 (PLTpenia)**
No grade 4No grade 4
0000
1 (PLTpenia)*1 (PLTpenia)*
1 (PLTpenia)1 (PLTpenia)**1 (PLTpenia)1 (PLTpenia)**
0000
Prot CLBH589B2101: safety of oral LBH589
* Transient and reverseble; $ 1 pt grade 2 anemia and 1 pt grade 2 fatigueTransient and reverseble; $ 1 pt grade 2 anemia and 1 pt grade 2 fatigue
Prot CLBH589B2101: cardiac toxicity
ARM (dose)ARM (dose)
30 mg 30 mg 20 mg 20 mg 30 mg 30 mg
QTc prol.QTc prol.
111111
notesnotes
4 days later, sepsis4 days later, sepsisBBDBBD
msecmsec
10010058 (QTc:503)58 (QTc:503)
7777
ARM (dose)ARM (dose)
20 mg 20 mg 30 mg 30 mg
FAFA
2222
AFlutterAFlutter
1100
1046 post dose ECG: median prolongation <10 msec
T-wave flattening in 25 patients
CK in 2 patients (not clinically relevant)
6 cicli da 28 giorni 1 3 5 8 10 12 15 17 191 3 5 8 10 12 15 17 19
Melphalan 0,18 mg/kg Melphalan 0,18 mg/kg
Prednisone 1,5 mg/kgPrednisone 1,5 mg/kg
LBH 589 per os Livello 0: 15 mg, Livello -1: 10 mg, Livello +1: 20 mgLBH 589 per os Livello 0: 15 mg, Livello -1: 10 mg, Livello +1: 20 mg
Talidomide 50 mg continuativamente
TREATMENT
G 1- 4
G 1- 4
cicli da 28 giorni fino a progressione o tossicità intollerabilecicli da 28 giorni fino a progressione o tossicità intollerabile
1 3 5 8 10 12 15 17 191 3 5 8 10 12 15 17 19
LBH 589 per os alla dose utilizzata per LB-MPTLBH 589 per os alla dose utilizzata per LB-MPT
Mantenimento:(pazienti con risposta ≥ malattia stabile)
Prednisone 25 mg nei giorni 1, 3, 5 di ogni Prednisone 25 mg nei giorni 1, 3, 5 di ogni settimana fino a progressionesettimana fino a progressione
LBH-MPT: type of study and population
• Phase I-II, multicenter, non-comparative, non-randomized, open-label
• Adult patients with relapsed MM with any sign of PD during melphalan or thalidomide and who have not received melphalan or thalidomide in the last six months suitable for treatment or re-treatment with melphalan and thalidomide
Endpoints
Primary• The safety profile will be assessed by showing:
– Any grade 3 non-hematologic toxicity
– Grade 4 neutropenia ≥ a week, or any grade 4 hematologic toxicity except neutropenia
The efficacy will be assessed by showing a significant PR rate
Secondary
- Determine the progression-free survival (PFS)
- Determine the overall survival (OS)
- Determine whether responses are associated with a prolongation of PFS, in comparison with that of non-responding patients.
- Quality of Life assessment (QoL)
- Assessment of common chromosomal abnormalities in multiplemyeloma by FISH
19 pts19 pts
Livello 0Livello 0
19 pts livello +119 pts livello +1RP RP ≤ 4≤ 4
Tox g 3-4 ≤ 3Tox g 3-4 ≤ 3
STUDY DESIGN(Briant and Day method)
RP RP ≥ 5≥ 5
Tox g 3-4 >10Tox g 3-4 >10
RP RP ≥ 5≥ 5
Tox g 3-4 ≤10Tox g 3-4 ≤10
19 pts livello -119 pts livello -1
23 pts livello 023 pts livello 0
RP RP ≤ 4≤ 4
Tox g 3-4 Tox g 3-4 ≥ ≥ 44STOPSTOP
2323 ptspts
STOP STOP
STOPSTOP
Wolf et. Al, ASH 2008
Siegel, San Miguel et al, ASH 2009
Phase Ib study: Panobinostat combined with bortezomib ± dexamethasone in
relapsed MM (B2207)Study design
• International, open-label, phase Ib, dose-escalation study
Treatment
• 21-day cycles:– Escalating doses of oral panobinostat (cohorts 1–3: 10 mg, 20 mg, 20 mg)
TIW– Escalating doses of bortezomib (cohorts 1–3: 1.0 mg/m2, 1.0 mg/m2,
1.3 mg/m2) given on days 1, 4, 8, 11 – Optional dexamethasone (20 mg on day of and day after bortezomib) in
cycle 2 onwards (i.e. after the DLT observation period)
Patient characteristics (n=22)
• Median 3 previous lines of therapy (range 1–6), 11pts had previously received bortezomib
• Disease status at baseline: 10 relapsed and refractory, 11 relapsed, 1 unknown
• Median age 61 years (range 46–78), 19 had previously undergone SCT
Sezer O et al. IMW 2009, Abstract 337 (data updated in oral presentation)
Safety of panobinostat combined with bortezomib ± dexamethasone in relapsed
MM (B2207)• MTD for panobinostat not reached at 20 mg TIW
– Accrual ongoing for cohort 4 (panobinostat 30 mg, bortezomib 1.3 mg/m2)
• Assessment of DLTs (cycle 1):– Cohort 1 (panobinostat 10 mg, bortezomib 1.0 mg/m2): no DLTs– Cohort 2 (panobinostat 20 mg, bortezomib 1.0 mg/m2): 1 DLT
(grade 4 febrile neutropenia)– Cohort 3 (panobinostat 20 mg, bortezomib 1.3 mg/m2: no DLTs
• After 1035 post-baseline ECGs:– No dose-related increase in QTcF time– No QTcF >500 ms or increase in QTcF from baseline >60ms
Sezer O et al. IMW 2009, Abstract 337 - data update at ASH09
Preliminary efficacy of panobinostat combined with bortezomib ±
dexamethasone in relapsed MM (B2207)
• 11 responses to date: 3 CRs, 1 VGPR and 7 PRs, across cohorts 1–3
• 5 of these responders were refractory (a, b) to their last bortezomib-based therapy
Three of 22 treated patients were not evaluable for efficacy as they discontinued treatment in cycle 1
Cohort 1panobinostat 10 mg
bortezomib 1.0 mg/m2
Cohort 2panobinostat 20 mg
bortezomib 1.0 mg/m2
Cohort 3panobinostat 20 mg
bortezomib 1.3 mg/m2
All responders
0
1
23
4
5
6
7
89
10
11
CR VGPR PR Other
b
a b
ab
a: Non-responder to prior bortezomib (i.e. best response SD (IMWG 2006)
b: Disease progression on prior bortezomib-based therapy
Sezer O et al. IMW 2009, Abstract 337 - data update at ASH09
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Phase Ib study: Panobinostat combined with lenalidomide and dexamethasone in relapsed
MM (B2206)Study design
• Multicentre, international open-label phase Ib dose-escalation study
Patients
• Adults with active MM (IMWG criteria) whose disease has relapsed after at least 1 previous line of therapy
• primary refractory MM, grade >2 peripheral neuropathy, or cardiac diseases/factors associated with QT prolongation were excluded
Treatment
• Patients were treated on 28-day cycles until PD or unacceptable toxicity
– Escalating doses of oral panobinostat (cohorts 1–3: 5, 10, 20 mg) TIW
– Lenalidomide 25 mg given orally on days 1–21
– Dexamethasone 40 mg given orally on days 1–4, 9–12 and 17–20 for cycles 1–4, and on days 1–4 for cycle 5 onwards
Spencer A et al. ASCO 2009 Abstract #8542 (data updated in the poster)
Safety of panobinostat combined with lenalidomide + dexamethasone in
relapsed MM (B2206)
Safety• MTD for panobinostat not reached at 20 mg TIW
– Study is now recruiting patients at the 25 mg dose level
• Assessment of DLTs (cycle 1):
– Cohort 1 (5 mg panobinostat): 7/8 evaluable, no DLT
– Cohort 2: (10 mg panobinostat): 6/8 evaluable, 1 DLT (grade 1 QTcF prolongation)
– Cohort 3: (20 mg panobinostat): 6/11 evaluable, 1 DLT (grade 4 neutropenia lasting for >5 days)
• Most frequent grade 3/4 AEs: neutropenia (5/23 pts), thrombocytopenia (5/23 pts), fatigue (4/23 pts), hyponatraemia (3/23 pts)
– High-dose dexamethasone may be responsible for many AEs
• After 1375 post-baseline ECGs: no QTcF >500 ms, no QTcF change >60 ms from baseline
Spencer A et al. ASCO 2009 Abstract #8542 (data updated in the poster)
Responses with panobinostat combined with lenalidomide + dexamethasone in relapsed
MM (B2206)• 20 patients evaluable for efficacy (cohorts 1–3 combined)
– 12/20 responded: 1 sCR, 1 CR, 5 VGPR, 4 PR, 1 MR– 1 responder was refractory to their last bortezomib-based regimen– 4 responders were refractory to their last thalidomide-based regimen
Spencer A et al. ASCO 2009 Abstract #8542 (data updated in the poster)NE, not evaluable; sCR, stringent CR
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Weber et al, ASH 2008
Siegel et al,
Harrison et al, ASH 2008
Pivotal Phase III Study: D2308
A multicentre, randomized, double-blind, placebo-controlled phase III
study of panobinostat in combination with bortezomib and dexamethasone in patients with
relapsed multiple myeloma
D2308 study design
Bortezomib 1.3 mg/m2 BIW, 2 weeks on, 1 week off+ dexamethasone on same
days as and 1 day after each bortezomib dose
Bortezomib 1.3 mg/m2 QW, 2 weeks on, 1 week off (x2)+ dexamethasone on same days
as and 1 day after each bortezomib dose
Bortezomib 1.3 mg/m2 BIW, 2 weeks on, 1 week off+ dexamethasone on same
days as and 1 day after each bortezomib dose
+ Placebo TIW 2 weeks on, 1 week off
Panobinostat 20 mg TIW2 weeks on, 1 week off
n = 672
Relapsed or
Relapsed & Refractory
MMa
(≥1 up to 3 lines of prior
therapy)
Treatment with panobinostat or placebo in combination with bortezomib +dexamethasone (phase 1, 24 weeks)
Patients with ‘no change‘ of disease status or response continue into treatment phase 2 (a further 24 weeks).
Continuation of combination therapy up to a total of 48 wks, or until PD, withdrawal of consent, or unacceptable toxicity.
Screening 3 weeks
Panobinostat 20 mg TIW 2 weeks on, 1 week off (x 2)
+ Placebo, TIW 2 weeks on, 1 week off (x2)
Bortezomib 1.3 mg/m2 QW, 2 weeks on, 1 week off (x2)+ dexamethasone on same days
as and 1 day after each bortezomib dose
RTreatment phase 1
8 cycles of 21 days each (weeks 1–24)
Treatment phase 2
4 cycles of 42 days each (weeks 25–48)
Follow-up after therapy:
1 year for PD, up to 4 years
for OS
aNot refractory to bortezomib
Worlwide recruitment
672 patients across 200 clinical sites
North America (n=90)
Latin America(n=168)
Europe (> 200 pts) Japan
(n=30)
Other countries(n=168)
Timelines• First patient, first visit: 21 Dec 2009
• Last patient, first visit: 21 June 2011
• Last patient, last visit: 21 June 2012
18-month 18-month enrolment periodenrolment period