From Genome to Medicine - Acute Myeloid Leukemia

Transcription

1 From Genome to Medicine - Acute Myeloid Leukemia Hartmut Döhner Medical Director, Department of Internal Medicine III Director, Comprehensive Cancer Center Ulm Ulm University, Germany DGIM Opinion Leader Meeting Schloss Reichartshausen, 16./

2 Incidence of AML in Sweden ( ) Cases per inhabitants Median age at diagnosis: 72 years Juliusson G, et al. Blood. 2009:113(18):

3 Improving Outcome in AML Remains a Major Challenge Survival (%) yrs, n=1, yrs, n=2, yrs, n=963 >70 yrs, n= Time (years) No. of pts: n=5,130; only pts considered eligible for intensive induction therapy

4 Genomic Landscape of De Novo Adult AML (whole genome [n=50) and whole exome [150] sequencing) The Cancer Genome Atlas (TCGA) Research Network. N Engl J Med. 2013;368(22):

5 Functional Categories of Genes Myeloid transcriptionfactor genes RUNX1, CEBPA 22% 18% Transcription-factor fusion genes RUNX1-RUNX1T1, MYH11-CBFB 59% Signaling genes FLT3, KIT, NRAS

6 Functional Categories of Genes Myeloid transcriptionfactor genes RUNX1, CEBPA NPM1 DNA-methylationrelated genes DNMT3A, TET2, IDH1/2 22% Chromatinmodifying genes MLL-X, ASXL1, EZH2 44% 27% 18% 30% Transcription-factor fusion genes RUNX1-RUNX1T1, MYH11-CBFB 59% 16% Signaling genes FLT3, KIT, NRAS Tumor-suppressor genes TP53, WT1, PHF6 14% Spliceosomecomplex genes SRFS2, SF3B1, U2AF1 Cohesin-complex genes SMC1A, SMC3, RAD21 13%

7 Targeted Sequencing of Adult AML 1579 adult patients with AML Enrolled in 3 trials of the German-Austrian AML Study Group Targeted re-sequencing of 111 genes involved in pathogenesis of myeloid neoplasms (SureSelect target enrichment) Objectives: Frequency of gene mutations Secondary structure: patterns of cooperativity and exclusivity Prognostic, predictive impact of mutation signatures E. Papaemmanuil, M. Gerstung, P. Campbell R. Schlenk, K. Döhner, A. Ganser, L. Bullinger, H. Döhner

8 Genomic Landscape of AML 3992 mutations; 1249 cytogenetic alterations 4 genes >10% pts 13 genes 5-10% 24 genes 2-5% 37 genes <2% ELN classification

9 Secondary Structure of Mutations (n=1579) FLT3 DNMT3A SFRS2 RUNX1 SF3B1 KRAS RUNX1 / ASXL1 ETV6 JAK2 KDM6A EP300 NF1 MLL2 Identify KDM5A MYC previously unreported interactions CBL PHF6 ZRSR2 U2AF1 Define EZH2 BCOR tertiary interactions CEBPA for / GATA2 frequent mutations ASXL1 STAG2 GATA2 WT1 t(8;21)/kit Map TET2into pathways / patterns of biological relevance KIT IDH2 IDH1 RAD21 Model PTPN11 NRAS gene / 5q-/TP53 gene interaction effects with phenotype CEBPA NPM1 TP53 and plus13 plus8_8qoutcome plus21 plus22 plus11_11q Inf mono4_4q_abn.4q. minus9q Papaemmanuil minusy E, et al. Manuscript in preparation. minus20_20q mono12_12p_abn12p OR=1 abn3q_other Co mutated minus18_18q 82 minus7_7q mono17_17p_abn17p minus5_5q 0.03 inv3_t3_3 t_6_9 OR=1 t_mll MLL_PTD t_15_17 inv16_t16_16 t_8_21 Mutually0.02 exclusive t_8_21 inv16_t16_16 t_15_17 MLL_PTD t_mll t_6_9 inv3_t3_3 minus5_5q 7_17p_abn17p minus7_7q minus18_18q abn3q_other 2_12p_abn12p minus20_20q minusy minus9q o4_4q_abn.4q. plus11_11q plus22 plus21 plus8_8q plus13 TP53 NPM1 CEBPA NRAS PTPN11 RAD21 IDH1 IDH2 TET2 KIT WT1 GATA2 STAG2 ASXL1 BCOR EZH2 U2AF1 ZRSR2 PHF6 MYC CBL KDM5A MLL2 NF1 EP300 KDM6A JAK2 ETV6 KRAS SF3B1 RUNX1 SFRS2 DNMT3A FLT3 NPM1 / FLT3, DNMT3A Co-mutated Mutually exclusive

10 Clonal Heterogeneity and Clonal Evolution -> one subclone within the founding clone evolved to become the dominant clone at relapse by acquiring additional mutations Ding L, et al. Nature. 2012;481(7382):

11 Clonal Evolution in NPM1-mutated AML n=53 Time to relapse (mo) 2 nd CR NPM1 mut maintained (n=85) 9.1 ( ) 33/58 (57%) NPM1 mut lost (n=12) 30.6 ( ) 2/10 (20%) p<0.001 p=0.04 D, diagnosis R, relapse Krönke J, et al. Blood. 2013;122(1):100-8.

12 Exome Sequencing of NPM1 mut Loss Cases Diagnosis Remission Relapse pre-leukemic HSC? pre-leukemic HSC 2000 persistence? 2010 time (years)? DNMT3A DNMT3A DNMT3A DNMT3A? GXYLT1 GXYLT1? GXYLT1 GXYLT1? ZNF543 ZNF543? ZNF543 ZNF543 NPM1 Loss of NPM1 BHMT2, CDH26, FSD1, KAT6B, PDLIM1, PSTPIP2, TOP2B, ZBTB47 ARID4B, BRAF, CACNA1E, CHUK, COL5A2, DDX58, FAT2, LINGO4, MDN1, NF1, NPAT, PARS2, PTPRO SureSelect Human All Exon 50Mb Average coverage: diagnosis sample, 73.6 fold; relapse sample, 88.9 fold L. Bullinger, K. Döhner, et al. Unpublished data

13 MRD of NPM1 mut and DNMT3A mut -R882H DNMT3A/ABL1x DNMT3A mut (BM) DNMT3A mut (PB) NPM1/ABL1x NPM1 mut (BM) 1 MRD-positivity for DNMT3A: Persistence of pre-leukemic stem cells; predictive for relapse? AMLSG trial, pt. alive, in hematologic CR (03/2014)

14 Preleukemic Hematopoietic Stem Cells in AML Clinical Implications These data support a model in which mutations in epigenetic landscaping genes (e.g., DNMT3A, TET2) arise in pre-leukemic hematopoietic stem cells and occur early in the evolution of AML Ancestral cells bearing, e.g., DNMT3A mut may survive chemotherapy, expand during remission, and may serve as a reservoire for clonal evolution and disease recurrence, or for a novel leukemia If MRD-positivity for such pre-leukemic mutations predicts for relapse, this could be a clinical situation for a molecularly targeted approach or possibly for immune intervention to prevent relapse

15 Selected Novel Agents in Clinical Development Epigenetic modifiers Hypomethylating agents IDH1 / IDH2 inhibitors DOT1L inhibitor Bromodomain inhibitors Histone deacetylase inhibitors Tyrosine kinase inhibitors FLT3 inhibitors KIT inhibitors Cell cycle / signaling inhibitors MDM2 inhibitor PLK inhibitor CDK inhibitor PI3K inhibitor PIM kinase inhibitor mtor inhibitors Decitabine, azacitidine, SGI-110 AG-120, AG-221 EPZ-5676 OTX015, GSK Vorinostat, panobinostat, pracinostat Midostaurin, lestaurtinib, sorafenib, quizartinib, crenolanib, PLX3397, ASP2215 Dasatinib, midostaurin RO Volasertib Alvocidib; palbociclib Rigosertib LGH447 Everolimus, temserolimus

16 Selected Novel Agents in Clinical Development Nuclear export inhibitor CRM1/XPO1 inhibitor Antibody-based therapy Antibody-drug conjugates Bispecific antibody Stem cell targeting Cytotoxic agents Quinolone derivative Nucleoside analoga New drug formulation Various Immunomodulatory drug BCL2 inhibitor Aminopeptidase inhibitor Retinoic acid CXCR4 antagonist Homoharringtonine derivative Selinexor (KPT-330) Gemtuzumab ozogamicin, SGN-CD33A AMG330 (anti-cd33x3) CSL362 (anti-cd123) Vosaroxin Sapacitabine, clofarabine, cladribine CPX-351 Lenalidomide ABT-199/GDC-0199 Tosedostat All-trans retinoic acid Plerixafor Omacetaxine

17 Molecular Markers Guiding Therapy: CBF-AML Associated with KIT mutations (30-35%) exon 8 In vitro and in vivo evidence for mutant Kit as sufficient co-operative event Impact on prognosis: in general poor High KIT expression exon 17 Dasatinib Inhibition of wild-type and mutant KIT Schittenhelm et al. Cancer Res. 2006; Wang et al. PNAS Inhibition of human AML stem/progenitor cells Dos Santos et al. Blood in vitro differentiation of AML cells Fang et al. PLoS One in vivo differentiation of t(8;21)+ AML blasts Chevalier et al. Leukemia

18 Phase Ib Study of Chemotherapy + Dasatinib in Patients with Newly Diagnosed Core-Binding Factor (CBF) AML - AMLSG Induction Consolidation x 4 Maintenance Daunorubicin Cytarabine + Dasatinib High-Dose Cytarabine* + Dasatinib Dasatinib 1 year Phase Ib n=89 *Cytarabine: 18-60yrs: 3g/m 2, q12hr, d1-3; >60yrs: 1g/m 2, q12hr, d1-3 ClinicalTrials.gov Identifier: NCT (AMLSG), NCT (CALGB) PI: H. Döhner; supported by BMS

19 Event-free survival, % AMLSG vs. Historical Control 100 Event-Free Survival 75 AMLSG 11-08, n=89, CR: 93% median age: 49.5 yrs Control, n=325, CR: 91% median age: 45 yrs 0 P= Years Preliminary data 05/2014; ClinicalTrials.gov Identifier: NCT Median follow-up: 26.2 months

20 Phase III Study of Chemotherapy with or without Dasatinib in Patients with Core-Binding Factor AML AMLSG Induction Consolidation x3 Maintenance CBF Mutation Screening Within 48 Hours R Daunorubicin Cytarabine n=277 Daunorubicin Cytarabine +Dasatinib High-Dose Cytarabine* MRD assessment by RQ-PCR High-Dose Cytarabine* +Dasatinib 1-yr Dasatinib Salvage / transplantation if MRD persists or recurs All adult patients eligible for intensive therapy, no upper age limit * Cytarabine: 18-60yrs: 3g/m 2, q12hr, d1-3; >60yrs: 1g/m 2, q12hr, d1-3 PI: H. Döhner; supported by Bristol-Myers Squibb

21 Molecular Markers Guiding Therapy: FLT3 PLX3397 ASP2215 Galanis A, et al. Cancer Res 2012;72:#3660. Midostaurin Chemo +/- midostaurin in younger pts. (n=719) with activating FLT3 mutations (RATIFY) Lestaurtinib Chemo +/- lestaurtinib in relapsed/refractory AML with FLT3 mutation (Levis M, et al. Blood 2011) Sorafenib Chemo +/- sorafenib in older pts. with AML (Serve H, et al. JCO 2013) Quizartinib (AC220) Quizartinib monotherapy vs. salvage chemotherapy in relapsed / refractory AML with FLT3-ITD Crenolanib MC +/- crenolanib in relapsed / refractory AML with FLT3 mutations (AMLSG 20-13)

22 Phase III Study of Chemotherapy + Midostaurin (PKC412) or Placebo in Newly Diagnosed Patients 60 Years of Age with FLT3 Mutated Acute Myeloid Leukemia (RATIFY) CALGB, AMLSG, CETLAM, ECOG, EORTC, GIMEMA, NCIC, OSHO, PETHEMA, SAL, SWOG Induction Consolidation x4** Maintenance FLT3 ITD/TKD Mutation Screening Within 48 Hours* R Daunorubicin Cytarabine + Placebo Daunorubicin Cytarabine + PKC412 High-Dose Cytarabine + Placebo n=719; screened: 3,291 (May 2008 Sept 2011) High-Dose Cytarabine + PKC412 Placebo PKC412 * Patients may receive hydroxyurea during screening phase ** Patients with an HLA-compatible family donor may proceed to allogeneic HSCT PI: Dr. R. Stone, CALGB

23 Phase III study of chemotherapy with or without crenolanib in relapsed / refractory AML with FLT3 mutations - AMLSG Induction Consolidation Maintenance Relapsed/ refractory AML with FLT3 mutations R MC + Placebo n=293, 1:1 MC + Crenolanib MC # + Placebo MC # + Crenolanib Allo HCT* HiDAC + Placebo Allo HCT* 3x HiDAC + Crenolanib 1-yr Placebo 1-yr Placebo 1-yr Crenolanib 1-yr Crenolanib # Optional second cycle of MC (mitoxantrone, intermediate-dose cytarabine) * First priority for consolidation is allogeneic HCT PIs: R.F. Schlenk, H. Döhner; supported by AROG Pharmaceuticals

24 Targeting IDH1 and IDH2 in AML IDH mutations in 15%-20% of AML Cluster: IDH1 R132, IDH2 R140 or IDH2 R172 Increasing incidence with age mainly due to IDH2 R140 Neomorphic enzyme activity D-2HG inhibits α-kg dependent enzymes, e.g. TET2 Conflicting data in terms of prognostic relevance Phase-I trials targeting mutant IDH enzymes NCT : AG-120 in AML/MDS with IDH1 mutation NCT : AG-221 in AML/MDS with IDH2 mutation ASH 2014: Stein et al., Blood. 2014;124(21): abstract #115 AG-221, an Oral, Selective, First-in-Class, Potent Inhibitor of the IDH2 Mutant Enzyme, Induces Durable Reponses in a Phase 1 Study of IDH2 Mutation Positive Advanced Hematologic Malignancies Induction of differentiation 75 mg (n=9) 100 mg (n=14) Response 150 mg (n=22) Total (n=45) CR CRp mcr CRi PR SD PD Not Evaluable Overall Response /9 (44%) 9/14 (64%) 12/22 (55%) 25/45 (56%)

25 Molecular Markers Guiding Targeted Therapy in AML Genotype APL [PML-RARA] NAPOLEON APOLLO Trial GIMEMA/AMLSG/SAL +/- ATO-ATRA-Ida Molecular Screening hrs CBF-AML [KIT] AML FLT3 mut AML NPM1 mut AML MLL rearr +/- Dasatinib AMLSG Midostaurin AMLSG /- Crenolanib AMLSG ATRA +/- GO AMLSG EPZ 5676 (DOT1L) Epizyme Palbociclib (CDK6) AMLSG AML IDH2 mut AG-221 Agios/Celgene Other subtypes, mainly high-risk +/- Volasertib (PLK1) AMLSG 20-13

26 AMLSG BiO Registry: Fast Biomarker Screening AMLSG Trial Center AMLSG BiO registry Informed Consent Courier Express BM&PB samples Reference Lab Molecular screening - PML-RARA - RUNX1-RUNX1T1 - CBFB-MYH11 - NPM1 - FLT3-ITD - FLT3-TKD - MLL-AF9 - CEBPA Web-based system Trial Center Clinical Trial Informed Consent Standard Care 0 Hours Overnight hrs / 7d week

27 Molecular Lesions Guiding Targeted Therapy We have entered a new era in leukemia genomics, however, large gene panel testing and whole exome/genome sequencing remain research tools. Currently, cytogenetics and NPM1, CEBPA, FLT3-ITD mutational screening are standard of care. WHO / ELN update in 2015 / 2016 The explosion of knowledge has yet to be translated into therapeutic benefit. However, few compounds are at the horizon that hold promise to enter the clinic. One of the major challenges remains the identification of predictive biomarkers that help selecting the appropriate therapy for an individual patient. integrate biosampling, companion studies Enter your patients, younger or older, on a clinical trial!

28 A. Corbacioglu A. Dolnik S. Kapp-Schwörer J. Krönke F. Kuchenbauer M. Kühn F. Rücker D. Späth F. Theis V. Teleanu L. Bullinger K. Döhner V. Gaidzik P. Paschka R.F. Schlenk Ulm University J. Krauter M. Heuser G. Göhring F. Thol B. Schlegelberger A. Ganser MHH, Hannover R. Delwel P. Valk B. Löwenberg Rotterdam R. Larson G. Marcucci C. Bloomfield CALGB E. Papaemmanuil M. Gestung P. Campbell Cambridge