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