Proteasome inhibition in Hodgkins Lymphoma

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Proteasome inhibition in Hodgkins Lymphoma

• By Kristie Blum, M.D.
• Third-year hematology/oncology fellow
• Washington University, St. Louis
• Siteman Cancer Center

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Background

• 20-30 Patients with HD relapse after first line
  therapy for HD, the majority of these patients
  either with advanced age or stage
• Salvage therapy with high dose therapy and
  autologous stem cell transplant can cure an
  additional 40-60 of these patients
• Refractory disease, first remission durations of
  lt 12 months, B-symptoms at relapse, and poor
  response to cytoreductive/salvage therapy all
  associated with poor outcomes with high dose
  therapy
• Yuen AR, et al. Blood 89 814-822, 1997.

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Salvage therapy for Hodgkins lymphoma

• For those who fail transplant or are ineligible
  for transplant, numerous single agent regimens
  can palliate patients for months or years
• Oral etoposide
• Chlorambucil
• Vinblastine
• Gemcitabine 1250 mg/m2 d 1, 8, 15 every 28 days
• CR - 9, PR 30, duration of response 6.7
  months
• Santoro A, et. al. JCO 18 2615-2619, 2000.
• Vinorelbine 30 mg/m2 weekly for 10 weeks
• CR 14, PR 36, duration of response 6 months
• Devizzi L, et. al. Annals of Oncology 5 817-820,
  1994.

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Newer salvage strategies

• Proteasome inhibition
• Anti-CD30 antibodies
• Combination regimens
• Doxil, navelbine, gemcitabine

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Proteasome-Ubiquitin pathway

• Method of degrading defective proteins or those
  involved in cell cycle progression or apoptosis
• This role in regulation cell cycle progression
  and apoptosis has led to the investigation of
  proteasome inhibition in various malignancies

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Targets of the Proteasome

• Cyclins A, B, D, E
• CDK inhibitors
• p53
• p21
• C-myc
• I?B
• Ki-67
• Bcl-2

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NF-?B

• Transcription factor present in most cells
• Binding to I?-B proteins (I?B?, I?B?, I?B?, and
  I?B?) keeps NF-?B inactive in the cytoplasm
• Phosphorylation of I?B by the I?B kinases (IKK?
  and IKK?) targets I?B for ubiquitination and
  subsequent degradation by the proteasome
• This releases NF-?B into the nucleus where it
  then affects cell cycle progression and apoptosis

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NF-?B family

• 5 proteins identified to date in the NF-?B family
• NF- ?B1 (p50)
• p52 and its precursor p100
• p65 (RelA)
• c-Rel
• RelB
• In mature B-cells see p50/c-Rel complexes
• p50/p65 heterodimers commonly seen after cellular
  stimulation

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NF-?B in Hodgkins lymphoma

• Constitutive nuclear activity is present in HD
  cell lines and in cultured RS from patients with
  HD
• Consists of p50/p65 (NF-?B/rel-A) heterodimers,
  normally seen only after cellular stimulation
• Bargou RC, et. al. Blood 87 4340-4347, 1996.
• May result from either
• Loss of I?B
• Mutation of NF-?B so it cant bind I?B
• Constitutive activity of I?B kinases

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Mechanisms of Constitutive NF-?B activity in HD
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NF-?B in Hodgkins lymphoma (cont.)

• A few patients (1/10) with HD had truncating
  mutations of I?B in at least one allele in the
  COOH-terminal end of the protein, making it
  unable to associate with NF-?B
• Emmerich FM, et. al. Blood 94 3129-3134, 1999.
• However, most patients have wild-type I?B and
  NF-?B, making increased activation of the I?B
  kinases more likely
• Krappmann D, et. al. Oncogene 18 943-953, 1999.
• THEREFORE, PROTEASOME INHIBITION MAY HAVE A
  THERAPEUTIC ROLE IN THE TREATMENT OF HD, BY
  INCREASING THE AMOUNT OF I?B BOUND TO NF-?B

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Proteasome inhibition in vitro

• Diffuse large B cell lymphoma
• Treatment with PS-341 (a proteasome inhibitor) or
  Bay 11 (a phospho-I?B? inhibitor) inhibits
  p50/p65 NF-?B heterodimer activity, thereby,
  inducing rapid apoptosis of DLBCL cells
• Pham L., et. al. Blood 100 Abstract 758, 2002.
• CLL
• Proteasome inhibition has been shown to induce
  apoptosis and DNA fragmentation in CLL cell lines
• CLL cells more sensitive to proteasome inhibition
  than normal lymphocytes
• Chandra J., et. al. Blood 92 4220-4229, 1998.

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Proteasome inhibition in vitro

• HD
• Gliotoxin and MG132, chemical inhibitors of
  proteasome-mediated I?B degradation, both lead to
  a decrease in p65 (RelA) levels and induced
  apoptosis in HD cell lines
• Adenoviral expression of the NF-?B
  super-repressor I?B?N leads to p-53 independent
  apoptosis and decreases the expression of the
  anti-apoptotic proteins Bfl-1/A1, c-IAP2, TRAF1,
  and Bcl-XL
• Izban KF, et. al. Modern Pathology 14 297-310,
  2001.
• Hinz M, et. al.. Blood 97 2798-2807, 2001.

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Phase I PS-341 in hematologic malignancies

• 27 patients with refractory hematologic
  malignancies enrolled
• 3 prior therapies
• 4 HD
• 10 NHL (2 SLL/CLL, 3 FL, 2 DLCL, 3 MC)
• 11 MM and 1 Waldenstroms
• 1 MDS
• Doses of 0.4, 1.04, 1.20, and 1.38 mg/m2 given
  biweekly for 4 weeks with 2-week rest for up to 3
  cycles
• DLT seen at 1.38 mg/m2 grade 3 hyponatremia and
  grade 3 fatigue
• 1.20 mg/m2 level expanded to 6 patients, but 2
  more DLTs (grade 3 fatigue and grade 3
  hypokalemia) observed
• MTD 1.04 mg/m2
• Orlowski RZ, et. al. JCO 20 4430-4427, 2002

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Phase I PS-341 in hematologic malignancies
(cont.)

• Toxicities
• Thrombocytopenia 74, anemia 48, leukopenia 48,
  neutropenia 37
• Fatigue 59
• Nausea 52, diarrhea 37, vomiting 30
• Hyponatremia 26, hypocalcemia 22, hypokalemia
  11
• Peripheral neuropathy in 19 - all patients had
  received prior neurotoxic agents vinca
  alkaloids or thalidomide
• Efficacy
• MM - 1 CR, 8 patients with decreased paraproteins
• NHL - 2 PRs (MCL and FCL)
• Pharmacodynamics
• 0.4, 1.04, 1.2, and 1.38 doses led to 36, 60,
  65, and 74 20S proteasome inhibition,
  respectively
• Orlowski RZ, et. al. JCO 20 4430-4427, 2002

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Phase I PS-341 (Bortezomib) trials

• Phase I trials
• Schedules
• Twice weekly x 2 weeks every 21 days MTD 1.3
  mg/m2 with DLTs consisting of neuropathy,
  fatigue, diarrhea
• Aghajanian, Proc. ASCO 2001, Abstract 338
• Biweekly x 4 weeks with 2 week rest MTD 1.04
  mg/m2 in hematologic malignancies and 1.7 mg/m2
  in solid tumors, DLTs consisting of fatigue,
  diarrhea, nausea, and vomiting
• Stinchombe T, Blood 2000, Abstract 2119
• Erlichman C, Proc ASCO 2001, Abstract 337
• Weekly x 4 week schedule MTD 2.0 mg/m2
• Papandreou CN, Proc. ASCO 2000, Abstract A738
• Responses noted in NHL, MM, prostate CA, NSCLC

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Phase II PS-341 trials

• NHL
• 13 patients with relapsed/refractory indolent NHL
• 2 SLL, 6 FL, 5 MCL
• 1.5 mg/m2 biweekly for 2 weeks, with 1 week rest
• Average of 3 cycles per patient given
• Toxicities
• Grade 3 thrombocytopenia 14, grade 3 neuropathy
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• Efficacy
• OConnor O., et. al. Blood 100, Abstract No. 3063

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Phase II PS-341 trials (cont.)

• MM
• 1.0 or 1.3 mg/m2 dose biweekly x 2 weeks every 21
  days
• In 54 patients with median of 5 prior therapies,
  85 have responded or stabilized after 2 cycles
• Richardson, Proc ASCO 2002, Abstract 40
• Several trials ongoing combining PS 341 with 5
  FU/LV, irinotecan, gemcitabine, and doxorubicin
  in solid malignancies

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Phase II study of the proteasome inhibitor,
PS-341 in relapsed/refractory Hodgkins lymphoma

• Primary Objectives
• To evaluate the overall response rate of PS-341
  in relapsed/refractory HD patients
• Secondary Objectives
• To assess 2-year progression-free and overall
  survivals after therapy with PS-341
• Evaluate the safety and tolerability of PS-341 in
  heavily pre-treated HD patients

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Eligibility Criteria

• Histologically confirmed classic Hodgkins
  disease that is recurrent or refractory after
  standard chemotherapy
• Measurable disease.
• Greater than 3 weeks since completion of
  radiotherapy or chemotherapy.
• Prior autologous or allogeneic PBSC transplant
  permitted.
• Bili ? 1.5 x ULN, AST and ALT ? 2.5 x ULN, and Cr
  ? 2.5 mg/dL.
• WBC ? 2000, ANC ? 1000, Platelets ? 50,000, Hgb ?
  7.5 without transfusion support in the last 7
  days.
• No existing peripheral neuropathy of grade 2 or
  greater.
• No prior treatment with PS-341.

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Treatment Plan
  Response should be assessed Q3 cycles.
Patients who have stable disease or continued
response may continue until evidence of
progression.
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Statistical considerations

• Simons two stage design
• Expect to see 25-30 response rate, similar to
  other single agents in HD
• 18 patients enrolled in first stage, will
  continue to stage two if ? 3 responses observed
• 25 patients will then be added in stage two, for
  a maximum of 43 patients
• If ? 8 responses seen, will conclude PS-341 has
  at least a 25 response rate in
  relapsed/refractory HD

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Future directions

• Combinations with Anti-CD30 antibodies
• Combinations with chemotherapy

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CD30

• Limited only to activated T, B, and NK cells in
  normal patients
• Present on most Hodgkin and Reed-Sternberg cells,
  except LPHD
• Increased surface expression or elevated serum
  levels of soluble CD30 associated with advanced
  disease, B symptoms, and poor prognosis
• Nadali G, et. al. JCO 12 793, 1994
• Belongs to the TNF receptor superfamily
• Homologous with other members of this family
• Type I and Type II TNF receptor
• CD27
• CD40
• CD95
• Actions
• Increases ICAM-1 expression
• Induces secretion of IL-6, IL-2, TNF-?, and IFN-?

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CD30 and its connection to NF-?B

• Activation of CD30 by a specific agonist
  monoclonal Ab leads to nuclear translocation of
  NF-?B and increases IL-6 production
• Removal of the NF-KB binding site in the IL-6
  promoter blocks IL-6 production when H-RS are
  activated by CD30 moAb
• The NF-?B complex induced by CD30 consists of p65
  (Rel-A), p50, and c-Rel subunits
• Gruss HJ, et. al. Blood 87 2443-2449, 1996
• Overexpression of CD30 in H-RS cells leads to
  self-aggregation, recruitment of TRAF2 and TRAF5,
  and NF-?B activation independent of CD30 ligand
• Truncated CD30 lacking the cytoplasmic domain or
  I?B inhibition block NF-?B activity and induces
  apoptosis
• Horie R, et. al. Oncogene 21 2493-2503, 2002.

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Annunziata CM, et. al. Blood 96 2841-2848 Horie
R, et. al. Oncogene 21 2493-2503, 2002
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Anti-CD30 antibodies

• I 131 labeled murine anti-CD30 (Ki-4) antibody
• 5 mg Ki-4 to block soluble CD30
• Performed dosimetry at 1, 24, 48, 72, and 144h
  after infusion of I131 Ki-4
• 5/21 patients had enhancement of involved areas
  on dosimetry
• Only lesions gt 5 cm seen
• Gave therapeutic total body doses on day 8
  equaling 0.125 Gy, 0.25 Gy, and 0.35 Gy
• Schnell R., et. al. Blood 100 Abstract 762, 2002.

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Anti-CD30 antibodies (cont.)

• 21 patients treated
• 4 median prior therapies, 9 refractory to first
  line therapy, 19 with prior PBSC transplant
• Toxicity
• 7 patients with grade 4 hematologic toxicity,
  mainly thrombocytopenia, lasting up to 5 weeks
• Nausea/fatigue
• Efficacy
• 1 CRu, 5 PR, 3 minor or mixed response, 2 stable
• Schnell R, et. al. Blood 100 Abstract 762, 2002.

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Anti-CD30 antibodies (cont.)

• Phase I single dose study with SGN-30, a chimeric
  anti-CD30 antibody in development by Seattle
  Genetics
• 13 patients treated 9 with HD, 2 with ALCL, 2
  other NHL
• 5 median prior therapies, 9 prior PBSC transplant
• Dosing
• 6 patients received one of the following doses
  1, 2, 4, 7.5, 10, and 15 mg/kg
• 7 patients received 12.5 mg/kg
• Bartlett NL, et. al. Blood 100 Abstract 1403,
  2002.

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Anti-CD30 antibodies (cont.)

• Toxicity
• One patient Grade 2 allergic reaction, urticaria,
  30 minutes into infusion
• Efficacy
• 2 PRs one by RECIST and one by physical exam
  only
• Patient with ALCL had PR of skin lesions
• Patient with HD treated at 4 mg/kg dose had 39
  reduction in LN measurements
• Multi-Dose phase I/II trial now ongoing
• 6 patients will be treated at each dose level
  (2.0, 4.0, 8.0, and 12.0 mg/kg) weekly for 6
  weeks
• Once MTD determined, 40 patients will be enrolled
  in phase II portion
• Bartlett NL, et. al. Blood 100 Abstract 1403,
  2002.

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Anti-CD30 antibodies (cont.)

• ?Rapid progression of disease in a few patients
• One patient with 3 year history of stable
  mediastinal disease treated for years with
  alternating single agents etoposide,
  chlorambucil, etc. had rapidly progressive SOB
  after 1 dose SGN-30
• Second patient with also 1-2 year history of
  stable disease treated with a variety of agents
  including DNG had sudden onset of pancytopenia
  within one month of receiving SGN-30
• WBC 3, Hgb 4.4, Plt 19
• ? Could SGN-30 be acting as an activating
  antibody in these patient i.e. similar to CD30L

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? Combination therapy of SGN-30 and PS-341
I?B kinases
2.
5. NF-?B enters nucleus
PO4
4. Proteasome degradation of I?B
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Novel combination chemotherapy

• Doxil, Navelbine, Gemcitabine
• Patients who have not had a transplant
• Gemcitabine 1000 mg/m2 d1, d8 q21 days
• Navelbine 20 mg/m2 d1, d8 q21 days
• Doxil 15 mg/m2 d1, d8 q21 days
• Receive 2-3 cycles and then PBSC transplant
• Patients who have had a prior transplant
• Gemcitabine 800 mg/m2 d1,d8 q 21 days
• Navelbine 15 mg/m2 d1,d8 q 21 days
• Doxil 10 mg/m2 d1, d8 q21 days
• Receive maximum of 6 cycles

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Toxicities of DNG

• Primarily hematologic
• Neutropenia that leads to dose delays or
  reduction
• Rare hand/foot syndrome
• ? Of lung toxicity none identified to date
• Reports of ABVG leading to 5 cases of significant
  lung toxicity in 12 patients treated
• 2 with interstitial pneumonitis, 2 with DOE and
  DLCO decline, 1 with lobar pneumonia
• Friedberg JW, Blood 100 Abstract 596.

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Future directions

• Pursue phase I trials combining PS-341 with
  chemotherapy (either combination agents like DNG
  or single agents like gemcitabine) in HD
• Are some ongoing trials combining PS-341 with
  doxorubicin and gemcitabine in solid tumors
• Gem PS-341 MTD Gem 1000 mg/m2 d1, 8 and PS-341
  1.0 mg/m2 d1, 4, 8, and 11 every 21 days
• Ryan DP, et. al. Proceedings of ASCO, Abstract
  379, 2002
• Dox PS-341 Dox 15 0r 20 mg/m2 d1,8 and PS-341
  1.0 or 1.3 mg/m2 d1, 4, 8, and 11 every 21 days
• Thomas JP, et. al. Proceedings of ASCO, Abstract
  368, 2002