Identifying New Targeted Therapies for Malignant Pleural Mesothelioma

Transcription

1 Identifying New Targeted Therapies for Malignant Pleural Mesothelioma Anne S. Tsao, M.D. Assistant Professor June 27, 2008 The University of Texas MD ANDERSON CANCER CENTER Department of Thoracic/Head & Neck Medical Oncology

2 Outline: Mesothelioma Background MDACC Clinical Infrastructure Translational Infrastructure Tissue and Serum-Plasma Collection Unresectable Mesothelioma Protocol cisplatin-pemetrexed-imatinib Protocol cisplatin-pemetrexed-azd2171 Protocol LBH589 Resectable Mesothelioma Protocol Induction Dasatinib Adjuvant therapy WT1 vaccine Translational Research EMT ADH compounds Future targets under investigation

3 Multidisciplinary Mesothelioma Group Pathology Conduct clinical trials with translational correlates Identify new targets for Tx Medical Oncology Thoracic Surgery Radiology Pulmonary Radiation Oncology Translational Team Archival Tissue Bank Plasma-Serum Bank Pleural Effusion Bank MPM Cell Line Bank Wistuba Biomarker Lab

4 Mesothelioma Focus Group (MFG) Multidisciplinary committee that meets every 1-2 months to discuss the mesothelioma laboratory translational projects and clinical trials. Mesothelioma patient cases weekly Tuesday Thoracic multidisciplinary meeting.

5 Thoracic Medical Oncology Anne S. Tsao Vassiliki Papadimitrakopoulou Charles Lu George Blumenschein Scott Lippman Roy Herbst Dan Karp Kathy Pisters John Heymach Thoracic Surgery Reza Mehran David Rice Steve Swisher Jack Roth Radiology Jeremy Erasmus Greg Gladish MFG Members Thoracic Radiation Oncology Zhongxing Liao Mary McAleer Kara Bucci Joe Chang Ritsuko Komaki Pulmonary Carlos Jimenez George Eapen Pathology Ignacio Wistuba Nelson Ordonez Ceaser Moran Administrative support: Bich Tran, Brenda Robinson Research RNs and LVNs James Gil (Research RN) Christine Alden (Research RN) Bethancort (Pulm Research RN) Natasha Pappas (LVN) Patricia (serum collection LVN) PharmD: Hai Tran Additional members: Milind Suraokar (Post-doc PhD) Adam Cantu (RA) Dandan He (RA)

6 Translational Mesothelioma Group Clinical Anne S. Tsao Jack Roth David Rice Reza Mehran Statistics Jack Lee Heather Lin Pathology Core Ignacio Wistuba Dandan He Basic Science Milind Suraokar Faye Johnson John Heymach Hai Tran Murine Model Milind Suraokar Anne S. Tsao Murine Radiology Dianna Cody

7 Translational Infrastructure Archival Tissue Bank (paraffin and frozen) 89 patient tissues collected with clinical outcome information 89 paraffin, 56 frozen as of Corresponding clinical data for all archived tumors has been collected - MPM tissue microarrays have been created for IHC - DNA, RNA, protein collection underway for the specimens Serum/Plasma bank MPM cell lines Bank - 4 MPM cell lines, 2 mesothelial tissue lines (controls SV40 transformed, htert transformed/cdk4) obtained from ATCC and Adi Gazdar labs **Research proposals are reviewed for scientific merit and approved by MDACC Thoracic Translational Research Committee.

8 Serum/Blood and Pleural Effusion Protocols For ALL Mesothelioma patients Protocol LAB Blood/Serum obtained by LVN (Patricia Hutchinson) and stored in Thoracic Plasma and Serum Bank (Hai Tran, John Heymach) Pleural effusion obtained by Pulmonary or in the clinic from Denver catheters and taken by RA (Adam) to Ignacio Wistuba s laboratory for processing and freezing. Protocol LAB (Rice/Wistuba) Archival tissue collection study Purpose develop cell lines Facilitate research investigation into archival tumor specimens

9 Outline: Mesothelioma Background MDACC Clinical Infrastructure Translational Infrastructure Tissue and Serum-Plasma Collection Unresectable Mesothelioma Protocol cisplatin-pemetrexed-imatinib Protocol cisplatin-pemetrexed-azd2171 Protocol LBH589 Resectable Mesothelioma Protocol Induction Dasatinib Adjuvant therapy WT1 vaccine Translational Research EMT ADH compounds Future targets under investigation

10 Front-line Systemic Therapy Almost every chemotherapy known to man has been tried in mesothelioma Mesothelioma was largely chemo-resistant with RR <15% Combination regimens are better Historically, the most efficacious agents in combination: doxorubicin, epirubicin, mitomycin, cyclophosphamide, ifosfamide, platinum agents Current standard in the USA Cisplatin 75 mg/m 2 + Pemetrexed 500 mg/m 2 Q3 weeks Ellis et al. JTO 1: , 2006

11 Phase III Cisplatin-Pemetrexed vs Cisplatin Unresectable Mesothelioma Chemo-naive KPS > 70 N= 456 Stratified Center PS Pain/dyspnea on entry Histology Gender WBC Homocysteine level R A N D O M I Z E Cisplatin 75 mg/m 2 Pemetrexed 500 mg/m 2 IV every 3 weeks N=226 Cisplatin 75 mg/m 2 IV every 3 weeks N=222 Primary endpoint: Overall survival Secondary endpoints: TTP, RR, QOL, toxicity Vogelzang et al. JCO 21: , 2003

12 Efficacy Analysis Cisplatin Pemetrexed Cisplatin HR P- value Response Rate 41.3% 16.7% <0.001 Median TTP 5.7 months 3.9 months 0.68 <0.001 Median OS 12.1 months 9.3 months Global QoL Improved Symptom Distress Vogelzang et al. JCO 21: , 2003; Gralla et al, ASCO abstract :621, 2003

13 Main Toxicity Adverse Grade 3/4 Cisplatin-Pemetrexed (n=226) # pts % # pts Cisplatin (n=222) % Neutropenia Anemia Nausea Vomiting Fatigue Diarrhea Dehydration Stomatitis Febrile neutropenia Rash Vogelzang et al. JCO 21: , 2003

14 Other platinum-antifolate regimens Carboplatin-pemetrexed (phase II) RR is less - RR18.6% SD 47% TTP 6.5 mo Overall survival may be similar months Fewer symptoms Cisplatin-raltitrexed (3 mg/m 2 ) Studied in Europe as a phase III RR 24%, median PFS 5.3 months (p=0.058) Median OS 11.4 months (p=0.048) 1-year OS rate 46% Van Meerbeeck et al. JCO 23: , Ceresoli JCO 24: , 2006

15 MDACC Frontline Studies A phase I trial of cisplatin-pemetrexed-imatinib mesylate in patients with unresectable MPM. Funding: Novartis Investigator Initiated Study (IIS), NIH K12 (Tsao), ASCO Young Investigator Award (Tsao) Status: open, accruing patients (NCI 9172, SWOG# pending) Phase I/II Study of Cediranib (Recentin, AZD2171), Cisplatin, and Pemetrexed in Chemonaive Patients with Malignant Pleural Mesothelioma Funding: CTEP, ASCO CDA (Tsao), SWOG Translational correlates: Serum/plasma This trial will be the first study that will utilize the SWOG Serum/Plasma Kits Status: NCI approval obtained, SWOG approval pending, MDACC IRB approval pending. Anticipate opening August-September 2008

16 PDGF-R Isoforms: α, β Natural ligand is PDGF (AA, BB, CC, DD) Tyrosine kinase receptor Normal cells Smooth muscle cells Pericytes Fibroblasts Neurons Macrophages T cells Malignant Cells Glioblastoma Neuroendocrine Malignant fibrous histiocytoma Dermatofibroma Medulloblastomas PNETs Chondrosarcomas GIST

17 PDGF-Rβ in MPM MPM PDGF-BB PDGF-Rβ PDGF-Rβ Angiogenesis EC survival Cell migration Proliferation PI3K VEGF Pericyte Capillary Endothelial Cell J Pathology 178: , 1996; Seminars in Oncology 29:82-96, 2002

18 Mesothelioma Autocrine loop mechanism PDGF-Rβ PDGF-BB Increased MPM Cell Proliferation, Invasion, Metastasis Pericyte Capillary Endothelial Cell J Pathology 178: , 1996; Seminars in Oncology 29:82-96, 2002

19 Imatinib mesylate (Glivec, STI-571) Tyrosine kinase inhibitor BCR-ABL protein c-kit receptor PDGF-R CML GIST tumors Dermatofibrosarcoma protuberans J. Biological Chem 278 (7): , Nov 2002

20 Tumor Interstitial Fluid Pressure Abnormal capillary architecture Increased capillary resistance Poor lymphatic drainage Increased interstitial fluid pressure (IFP) PDGF-Rβ regulates IFP Poor transvascular transport and drug delivery

21 Inhibition of PDGF-R decreases IFP Inhibition of PDGF-Rβ on vascular stroma Contraction of pericytes around endothelial cells Decreased capillary pressure Pericyte Capillary Endothelial Cell X X X Decreased IFP Cancer Research 62: , 2002

22 Tumor IFP (mmhg) Tumor uptake of [ 3 H]Taxol PBS STI571 Taxol Taxol + STI-571 Control aptamer 8 STI-571 Control aptamer 24 STI-571 Time after injection [ 3 H]Taxol (h) Imatinib mesylate inhibition of PDGF-Rβ decreases Tumor IFP Drug uptake into tumors Imatinib mesylate and taxane chemo had an additive anti-tumor effect Cancer Research 62: , 2002

23 Phase I Cisplatin-Pemetrexed-Imatinib mesylate Unresectable Mesothelioma Chemo-naive KPS > 70 Dose Escalation of Imatinib Mesylate Cohort 1: 300 mg Cohort 2: 400 mg Cohort 3: 600 mg Cisplatin 75 mg/m 2 Pemetrexed 500 mg/m 2 IV every 3 weeks Imatinib mesylate orally daily Primary endpoint: Safety/Toxicity, DLT/MTD Secondary endpoints: OS, TTP, RR, QOL

24 Preliminary Results Cohort 2 currently accruing No DLT reached, no MTD reached Main side effects in addition to cisplatinpemetrexed toxicity: fatigue, periorbital edema

25 Pivotal Role of VEGF in Tumor Angiogenesis 1. Tumor secretes VEGF 4. Microvascular networking promoted by VEGF 2. VEGF increases endothelial protease expression 3. Endothelial cell migration and proliferation promoted by VEGF 25

26 MET Ephrin receptor Novel Therapies P Trastuzumab ErbB3 Cetuximab FGFR2 Her2 IGF-1R PDGFRα/ β P P P P SU5402 P Dasatinib P C-KIT Imatinib Sunitinib P AZD2171 Gefitinib Erlotinib PP1/Dasatinib HK1272 AZD2171 AG1024 LY / PP1 Imatinib Src P Dasatinib Sunitinib RET P Sunitinib Sorafenib ZD6474 P Pfizer MET inhibitor Dasatinib GSK3α/ β P Proteosome BCR- Ab1 PI3K AKT P mtor P p70 S6K P pten RAD001 ERK1/ 2 P RAS B-RAF P MEK Sorafenib PD / CI-1040 p38map K P Cytokine Receptors STAT1, 3,6 P Preibe VEGFs VEGFR2 VEGFR1 STAT P AZD2171 sunitinib Endothelial cells sorafenib Bevacizumab Bevacizumab Bortezomib Chemotherapeutic agents Cell cycle G1 G2 ERK1/2 p70 S6K P P STAT1, 3,6 R P VEGF S HIF-1α 17-AAG/PX478 M Tumor cells P AZD2171 sorafenib sunitinib ZD6474 P AZD2171 VEGFR3 sunitinib

27 Phase I/II Cisplatin-Pemetrexed-AZD2171 Unresectable Mesothelioma Chemo-naive KPS > 70 Phase I Cisplatin + Pemetrexed + AZD2171 Randomized Phase II Cisplatin 75 mg/m 2 Pemetrexed 500 mg/m 2 IV every 3 weeks AZD2171 orally daily Cisplatin 75 mg/m 2 Pemetrexed 500 mg/m 2 IV every 3 weeks AZD2171 Doses: Cohort 1: 30 mg Cohort 2: 20 mg Chemo maximum 6 cycles of therapy Primary endpoint: PFS Secondary endpoints: Safety, OS, RR, QOL Anticipated at MDACC, SWOG: 8-9/2008

28 Second-line and Beyond A phase IB, open-label, multicenter study to investigate the effect of oral LBH589 on dextromethorphan, a CYP2D6 substrate, and to assess the efficacy and safety of oral LBH589 in patients with advanced solid tumors (LBH2109) Funding: Novartis Translational correlates: Pharmacokinetic analysis Status: Recently opened study. LBH589 is an oral histone deactylase inhibitor. Tentative Studies under Planning: Integrin inhibitor, N- cadherin inhibitors

29 Outline: Mesothelioma Background MDACC Clinical Infrastructure Translational Infrastructure Tissue and Serum-Plasma Collection Unresectable Mesothelioma Protocol cisplatin-pemetrexed-imatinib Protocol cisplatin-pemetrexed-azd2171 Protocol LBH589 Resectable Mesothelioma Protocol Induction Dasatinib Adjuvant therapy WT1 vaccine Translational Research EMT ADH compounds Future targets under investigation

30 MPM Background Mesothelioma needs more effective therapies EPP and IMRT provides good local control Median survival is 15 months and 3-year overall survival is 28% Distant recurrence is the highest relapse site

31 ID EPP + IMRT Overall Survival n = Survival Probability Median survival 15 mo 2 year survival 25% 3 year survival 25%

32 Systemic Therapy MPM Cisplatin + pemetrexed yield ~40% response rate and improve survival by 3 months over cisplatin alone in unresectable advanced MPM. Few other systemic chemotherapy options Novel agents and improved understanding of MPM are needed

33 Induction MPM Chemo Trials Trial Regimen # pts # EPP % RR Median OS (months) Weder et al JCO 22: , 2004 Cisplatin-gemcitabine Flores et al JTO 1: , 2006 Cisplatin-gemcitabine Rea et al MARF abstract 2006 Carboplatin-gemcitabine Krug et al MARF abstract 2006 Cisplatin-pemetrexed Pending Analysis

34 Protocol BMS CA A phase I study of induction dasatinib in patients with resectable malignant pleural mesothelioma Funding: DOD Program Project 4 Grant, ASCO Career Development Award, Donor Funds, BMS (drug).

35 Promotes proliferation via EGFR Promotes migration via Integrins Promotes metastasis via vascular permability Promotes proliferation and chemotaxis via PDGFR Src Increases invasion via E-cadherin Promotes angiogenesis via induction of VEGF Promotes antiapoptosis via STAT3 and PI3K

36 Preclinical Data: MPM express Src IHC and have activated Src expression at Tyr 419/530 Src p-src Tyr 419 p-src Tyr 530 Epitheliod Mesothelioma Biphasic Mesothelioma Activated Src kinase was associated with higher invasion and metastasis but not survival Tsao et al. MCT 2007

37 Aminothiazole analogue Dasatinib (BMS ) ATP competitive inhibitor against Src kinase, BCR- ABL, c-kit, PDGFR, and ephrin receptor kinases Src kinase may be a new target PDGF/PDGFR: cell proliferation and possible autocrine loop mechanism C-Kit/Slug pathway may be involved in MPM multidrug resistance EphB4 overexpression promotes angiogenesis and tumorcell motility, invasion, metastasis Low toxicity profile : fluid retention, pleural/pericardial effusion, prolonged QTc, skin rash, TLS (CML)

38 Dasatinib has cytotoxic and inhibitory effects on MPM cell line migration/invasion Cell Number (% control) BMS (um) H2052 H28 H2452 MSTO-211H IC50 (nm) H2452 epithial 980 H2052 meso 80 H28 meso H biphasic 25 control dasatinib O hrs 24 hrs Tsao et al. MCT 2007

39 Dasatinib inhibits MPM migration in all 4 cells lines after 24 hrs of treatment with target specificity Control Dasatinib MSTO-H211 NCI-H28 NCI-H2052 NCI-H2452 Tsao et al. MCT 2007

40 MDACC Protocol Funding: DOD, BMS (drug) ESS: Mediastinoscopy Laparoscopy VATS or US Bx Day Weeks Oral Dasatinib Therapy EPP or Pleurectomy Assess eligibility Patients with a pathologic or radiographic response will receive dasatinib as maintenance therapy after surgery. CT +/-MRI PET-CT Labs Pre-op cardiac PFT Informed Consent Day -5 Blood/ Tissue Platelets/ Pleural Effusion collection in OR Day 7 Visit Blood collection Clinical Exam Day 14 Visit Blood collection Clinical Exam Day 21 Visit Blood collection Clinical Exam Day Blood/ Tissue Platelets/ Pleural Effusion Collection in OR Radiology Correlate

41 First Surgical Time Point - ESS Multiple biopsies from the primary tumor - Tru-cut or U/S guided core biopsies biopsies optimal from different sites of the primary Even if it is a few mm to the side - At least ½ centimeter in length - Research RN (James Gil) will document where the biopsies are taken from so a direct comparison came be made with tissue taken from the same area after induction therapy. Purpose: 1) Document and assess tumor heterogeneity 2) Each core biopsy will be divided in half paraffin and fresh frozen for future genomic/proteomic, microrna analysis 3) Compare SrcTyr419 phosphorylation status after dasatinib induction therapy from tissue removed from the same areas at the first and second surgical time points

42 Statistical Trial Design Based preclinical studies, the primary endpoint analysis will evaluate IHC levels Src Tyr 419 pre and post induction dasatinib therapy A weighted score (0-300) uses both intensity and % positive expression will measure the extent of receptor phosphorylation Assumptions: 67% of subjects will have positive p-src expression (score >100 or 2-3+) After dasatinib therapy, positive p-src will be reduced by 33% (approximately 50% relative reduction, chosen based on preclinical murine data Power 80% with type 1 error rate 10% Sample Size = 24 patients Accrual 1.5 patients/month for Total = 16 months Trevino et al. Am J Pathology 168:962-72, 2006

43 Translational Objectives Funding: ASCO CDA 1A Determine the effects of induction dasatinib therapy on activated Src kinase (phosphorylated-src Tyr419) levels in patients with resectable MPM in a phase I clinical trial. 1B Determine the modulatory effects of dasatinib on selected mechanismbased molecular biomarkers of tumor-cell survival and apoptosis (PI3K/AKT, bcl-xl, caspases), proliferation (IGFR, Ki-67), angiogenesis (IL-8, bfgf, VEGFR, PDGFR, TNF-α), epithelial-mesenchymal transition (TNF-β, E-cadherin, c-kit/slug) and invasion/migration (Ephrin, matrix metalloproteinases [MMPs]) in tumor specimens before and after induction therapy. 1C Determine the effects of induction dasatinib therapy on cellular biomarkers including tumor mean vessel density (MVD), cell apoptosis (TUNEL), and the proliferation index (PCNA) of tumor cells. 1D Conduct gene expression array analysis on pre- and post- induction therapy MPM tissue

44 Translational Objectives Surrogate Peripheral Biomarkers for Response/Outcome 1E Determine drug concentration levels of dasatinib contained within the surgically resected tumor extract and blood samples. 1F Determine the modulatory effects of dasatinib on markers of cell survival (PI3K/AKT, bcl-xl, caspases), proliferation (IGFR, Src), angiogenesis (soluble VEGFR, VEGF, PDGF, IL-8, bfgf,tnf-α), and invasion/migration (Ephrin) in serum, platelet, and pleural effusion samples. 1G Assess the effect of dasatinib and cytoreductive surgery on serum mesothelin-related peptide (SMRP) levels.

45 Specific Aim 2 Conduct radiographic correlates of tumor response and clinical outcome with PET-CT

46 Specific Aim 3 Determine new therapeutic targets by conducting gene array and drug sensitivity analysis on MPM tumor cell lines In vitro cell line gene array and drug sensitivity Generate New Biomarker Panel for Potential Therapeutic Target Validate biomarker panel in archived tumor tissue specimens Murine xenograft studies using systemic agent that targets the new potential therapeutic pathway Confirm Data Analysis with Specific Aim 3B Establish Scientific Rationale for Systemic Therapy in Future Clinical Trials

47 Adjuvant Therapy Potential Trial: WT1 vaccine PI: Lee Krug, MSKCC ASCO 2008 Abstract Pilot Trial of a Wilm s tumor-1 (WT-1) peptide vaccine in patients with thoracic and myeloid neoplasms. WT1, a transcription factor, is processed and presented to the immune system and may be a target for immunotherapy. Peptide vaccines derived from WT1 protein can induce T cell recognition and attack WT1expressing mesothelioma cell lines. Pilot Study using WT1 vaccine in 20 patients (AML/MDS, MPM, NSCLC) Results: Injection site reaction grade 1, one allergic reaction grade 2 WT1 vaccine induces CD4 and CD8 T cell responses Mesothelioma has high WT1 expression Plan: Adjuvant study after multimodality treatment in MPM

48 Outline: Mesothelioma Background MDACC Clinical Infrastructure Translational Infrastructure Tissue and Serum-Plasma Collection Unresectable Mesothelioma Protocol cisplatin-pemetrexed-imatinib Protocol cisplatin-pemetrexed-azd2171 Protocol LBH589 Resectable Mesothelioma Protocol Induction Dasatinib Adjuvant therapy WT1 vaccine Translational Research EMT ADH compounds Future targets under investigation

49 Epithelial-mesenchymal transition (EMT) EMT is a phenomenon seen in development and in cancer initiating migratory behavior in cells. B. Baum et al. Semin Cell Dev Biol (2008), J.M. Lee et al. J Cell Biol (2006), A. Peralta Soler, et al. Hum Pathol 26 (1995), E. Williams et al.j Biol Chem (2000),

50 EMT biomarkers are expressed in MPM tissue High membrane-localized N-cadherin expression and cytoplasmic vimentin had a worse overall survival [(HR=2.012, p=0.0089) and (HR=1.004, p=0.287) respectively]. High cytoplasmic expression of N-cadherin had a worse relapse-free survival (HR 3.215, p=0.0055) in patients. Also membrane E-cadherin expression inversely correlated with membrans and cytoplasmic N- cadherin expression. Suraokar et al. AACR 2008 Abstract #2816

51 EMT markers in MPM Cell Lines by Western Blot Analysis Western blot analysis confirmed that most of these EMT markers are expressed in MPM cell lines. Reduced expression of E- cadherin protein was seen in MSTO-211H cells with a corresponding increase in N- cadherin protein. Suraokar et al. AACR 2008 Abstract #2816

52 Cadherin Junction between Cells Illustration of Cadherins linking 2 cells together. The cadherin extracellular domains are the blue cylinders and the blue spheres represent calcium ions that ensure the correct molecular structure. The cytoplasmic domain of the cadherins are seen at the bottom of the image and interact with catenin family proteins, linking them to the filamentous actin of the cell cytoskeleton. Cadherins maintain structural integrity and are involved In cell signaling that regulate motility, growth, differentiation.

53 ADH-1 ADH-1 has a single molecular target, N-cadherin. N-cadherin appears to act as a tumor cell survival factor and coordinates cadherin-regulated cell survival signals. In cell culture studies, inhibition of N-cadherin binding between tumor cells has been shown to cause tumor cell apoptosis. ADH-1 also appears to disrupt the blood vessels that feed the tumors. This may directly effect the binding of cadherins between the endothelial cells of the tumor blood wall, or apoptosis in the tumor cells that form part of the cancerous blood vessel. This leads to leakage and rupture of the vessels which supply the tumor.

54 MTT assays ADH-1 and ADH Suraokar et al. AACR 2008 Abstract #2816

55 N-cad antagonists inhibit MPM cell migration Suraokar et al. AACR 2008 Abstract #2816

56 N-cad antagonist inhibit MPM cell invasion Suraokar et al. AACR 2008 Abstract #2816

57 EMT and mesothelioma We have identified that high expression of N-cadherin in MPM correlates with a worse overall and progression-free survival. Loss of E-cadherin expression directly correlates with gain of N-cadherin expression. In-vitro cell viability studies show that N-cadherin antagonist ADH may have potent anti-tumor activity against MPM cell lines with growth inhibitory action in the micromolar range. Targeting N-cadherin in MPM may be a potential therapeutic strategy. Suraokar et al. AACR 2008 Abstract #2816

58 Additional Targets for Therapy FUS1 is lost in malignant mesothelioma -Gene therapy replacing FUS1 PDGFR overexpression -mirna Src kinase-emt interaction -combination targeted therapy

59 Targets and Agents under active preclinical investigation Src kinase inhibitors HDAC inhibitors HSP90 inhibitors OSI-930 (c-kit/kdr TKI) OSI-906 (IGF-1R TKI) MAGE-3 and other CTA s EMT (N-cadherin inhibitors - Adherex) Integrin inhibitors