Targeted Therapies in Hematology & Oncology

Mark B Juckett MD
Section of Hematology/BMT
University of Wisconsin
Classical Drug Discovery
 Targeted Therapy

Therapeutics directed at specific molecular

lesions responsible for carcinogenesis
Examples:
tyrosine kinase pathway (bcr-abl, PDGF)
proteosomal pathways
survival signals (MCL1, BCL2)
heat shock proteins
immunological activation/tolerance
 Chronic Myeloid Leukemia (CML)
and Targeted Therapy

CML
Cancer of the hematopoietic stem cell
Well-characterized molecular pathogenesis
Philadelphia (Ph) chromosome
First abnormality associated with cancer
Bcr-Abl tyrosine kinase
A single molecular abnormality that causes
transformation of a hematopoietic progenitor
into a malignant clone
 Epidemiology of CML

Median age range at presentation: 45 to 55 years

Incidence increases with age
12%30% of patients are >60 years old
Male-to-female ratio1.3:1
At presentation
50% diagnosed by routine laboratory tests
85% diagnosed during chronic phase
CML - Age specific incidence

BMT Candidates
 Clinical Course: Phases of CML

Advanced phases
Chronic phase
Accelerated phase Blast crisis

Median 56 years Median duration Median survival

stabilization 69 months 36 months
 Therapies for Advanced Stages of CML

Usual therapy Hematologic Cytogenetic Survival

response response
(complete)
Accelerated phase Various single-agent or <50% anecdotal <18 months
combination
chemotherapy, IFN-
Blast crisis Acute leukemia type 20%40% anecdotal 36 months
multiagent (5%30%)
chemotherapy

Essentially, NO effective treatment

 Therapeutic Options for CML

Allogeneic stem cell transplantation (SCT)

Interferon - alpha

hydroxyurea (busulfan, 32P)

Imatinib mesylate (formerly STI571)

 Allogeneic Stem Cell Transplant in CML

Only Curative Treatment

100
International Bone Marrow Transplant Registry: 19901995
Leukemia-Free Survival

80
Probability (%) of

Chronic Phase (N=1756)

60

40 Chronic Phase (MUD) (N=391)

Accelerated Phase (N=262)

20 Blast Phase (N=72)
P=.0001
0
1 2 3 4 5
Years From BMT

HLA-identical siblings
MUDs
HLA = human leukocyte antigen; MUDs = matched unrelated donors.
www.bmtinfo.org. Accessed June 11, 2000.
 IFN-: Clinical Results in CML

IFN- IFN- + Ara-C

Response (results from 7 (results from 4
1-7 8-11
clinical trials) clinical trials)
CHR (%) 3180 6492

Cytogenetic responses (%)

Any 1858 4174
Major 638 1050

3-year survival rates (%) 79 86

Complete Cytogeneic response 10 15%
CHR = complete hematologic response.
1.Kantarjian HM et al. Ann Intern Med. 1995;122:254-261; 2. Ozer H et al. Blood. 1993;82:2975-2984; 3. Mahon F et al. Blood. 1994;84:3592; 4. Hehlmann R
et al. Blood. 1994; 84:4064-4077; 5. Italian Cooperative Study Group on CML. N Engl J Med. 1994;330:820; 6. Allan NC et al. Lancet. 1995;345:1392-1397; 7.
Ohnishi K et al. Blood. 1995;86:906-916; 8. Silver RT et al. Blood. 1996;88 (suppl 1) 638a; 9. Tura S et al. Blood. 1998;92 (suppl 1) 317a; 10. Guilhot F et al. N
Engl J Med. 1997;337:223-229; 11. Kantarjian HM et al. J Clin Oncol. 1999;17:284-292.
 Cytogenetic Response and Survival With IFN-
Major response
1.0

0.9

0.8
Proportion Surviving

0.7
P < .001
0.6

0.5

0.4
Minor or no response
0.3

0.2

0.1

0.0
0.0 12 24 36 48 60

Months After Treatment

Guilhot F et al. N Engl J Med. 1997;337:223-229.
 Chemotherapy: Chronic Phase CML

Oral cytotoxic agents

Hydroxyurea - standard treatment for rapid control
Busulfan - rarely used, toxic, decreased survival
Hematologic response in up to 90% of patients

Well tolerated

No cytogenetic effects

Palliative careno effect on disease progression

 Cytogenetic Abnormality of CML:
The Philadelphia Chromosome

Discovered in 1960 by Nowell and Hungerford

First consistent genetic lesion in human cancer
 The Ph Chromosome:
t(9;22) Translocation

9 9 q+

22 Ph ( or 22q-)

bcr
bcr-abl

abl FUSION PROTEIN

WITH TYROSINE
KINASE ACTIVITY
 p210Bcr-Abl Fusion Protein Tyrosine Kinase

Extracellular
space
Cytoplasm

Y177 SH3 SH2 SH1

BAP-1 GRB2
CBL SHC CRKL

Faderl S et al. N Engl J Med. 1999;341:164-172.

bcr-abl Gene and Fusion Protein Tyrosine Kinases

Chromosome 22 Chromosome 9
c-bcr 1 2-11 c-abl

2-11 p210Bcr-Abl

2-11 p185Bcr-Abl
Exons
Introns
CML Breakpoints
ALL Breakpoints Adapted from Melo JV. Blood. 1996;88:2375-2384.
 Bcr-Abl as a Therapeutic Target for CML

Bcr-Abl translocation is detected in all patients with CML

Bcr-Abl tyrosine kinase is the causative abnormality of
CML
Bcr-Abl tyrosine kinase is constitutively activated in CML
cells, and activation is necessary for growth
Inhibitors of Bcr-Abl inhibit the growth of CML cells
Imatinib mesylate specifically blocks the function of Bcr-Abl
 Steps to Develop Imatinib mesylate

Study and understand the Bcr-Abl tyrosine kinase

homologous to abl, PDGF, c-kit proteins
Design a molecule that blocks the activation site
i.e. the ATP binding site
Refine the molecule to enhance specificity
Add a chemical group to allow it to work as a pill
Test the compound on CML cells in the lab
Determine whether it is safe
Test the new drug in patients
 Structure of Imatinib Mesylate

CH3SO3H

C29H31N7OCH4SO3

Class: Phenylaminopyrimidines, 589.7 mw

 Mechanism of Action of Imatinib Mesylate

Goldman JM, Melo JV. N Engl J Med. 344:1084-1086.

 Cellular Selectivity of Imatinib Mesylate: IC50 M

Kinases Inhibited Kinases Not Inhibited

v-ABL 0.10.3 Flt-3 >10

p210Bcr-Abl 0.25 c-Fms, v-Fms >10
p185Bcr-Abl 0.25 EGF receptor >100
TEL-Abl 0.35 c-erbB2 >100
PDGF-R 0.1 Insulin receptor >100
TEL-PDGF-R 0.15 IGF-I receptor >100
c-Kit 0.1 v-Src >10
JAK-2 >100

PDGF-R = platelet-derived growth factor receptor; EGF = epidermal growth factor; IGF-I = insulin-like growth factor-I.
Druker BJ et al. Nat Med. 1996;2:561-566.
 Effect of Imatinib Mesylate on Growth of
Bcr-AblPositive and Bcr-AblNegative Cell Lines

U937*
KG1*
SU DHL1*
KCL22
K562
KU812

Imatinib Mesylate Concentration (M)

*Bcr-Ablnegative cell lines.
Bcr-Ablpositive cell lines.
Gambacorti-Passerini C et al. Blood Cells Mol Dis. 1997;23:380-394.
 Imatinib Mesylate: Rapid Hematologic Response

100
WBC x 103

10

1
0 30 60 90 120 150

Days on Imatinib Mesylate

Imatinib Mesylate: Steady-State Pharmacokinetics

Rapidly and completely absorbed after oral administration

Absolute bioavailability 98%
Terminal half-life (t1/2) 1822 h; volume of distribution
435 L; and clearance 14 L/h
Linear and dose-proportional increase in AUC with doses
25 mg to 1000 mg
 Clinical Trials
Phase I Conclusions

Well tolerated with a mild side-effects profile

In all phases of CML, imatinib mesylate achieved

Hematologic responses
Cytogenetic responses

Time to response was rapid

 Phase II Studies With Imatinib Mesylate

3 large international trials have been conducted

0110: Patients with CML in chronic phase
after failure of IFN- therapy
0109: Patients with CML in accelerated phase
0102: Patients with CML in myeloid blast crisis

Study design and objectives

Open-label, multicenter, noncontrolled
Imatinib mesylate dose: 400 mg to 600 mg
Assess safety, efficacy, and survival rate
 Phase II Study Patients With CML
Kantarjian, et al, 2002

Patients with CML Chronic phase after IFN failure

Accrual time: December 1999 to May 2000
Patients with CML in chronic phase:
Hematologic failure
Cytogenetic failure
IFN- intolerant
Primary endpoint: cytogenetic response

NEJM 346:645, 2002

Chronic Phase: Patient Demographics (n=532)

Median age [yrs] (range) 57 (1890)

IFN- failure
Hematologic failure 152 (29%)
Cytogenetic failure 186 (35%)
IFN- intolerance 194 (36%)

Months from diagnosis (range) 32 (3218)

Months of prior IFN-* (range) 14 (>1135)

* IFN- at doses >25 MIU/week. NEJM 346:645, 2002

Cytogeneic and Hematologic Responses

All Patients Patients intolerant

to interferon
Cytogenetic
Response
Complete 41% 47%
Partial 19% 19%

Hematologic 95% 93%

Response

Median time on treatment was 17.5 months

NEJM 346:645, 2002
 Time to Progression to Advanced disease

Rate of progression-free survival was 89% at 18 months

NEJM 346:645, 2002

 Time to Progression According to
Cytogenetic Response

Major cytogenetic response includes complete and partial

responders
NEJM 346:645, 2002
Prognostic Factors associated with Major
Cytogenetic Response

Response to interferon therapy

Time since diagnosis of CML
Presence of anemia at diagnosis
Presence of Blasts in peripheral blood
Presence of Blasts in the bone marrow

NEJM 346:645, 2002

Adverse Events related to Treatment

Event Any Grd 3 or 4

Edema 60 1.1
Nausea 55 1.5
Muscle Cramps 49 0.9
Rash 32 3
Diarrhea 29 0.9
Neutropenia 27 8.1
Weight gain 26 4.3
Vomiting 23 0.6
Myalgia 20 0.2
NEJM 346:645, 2002
 Accelerated Disease Study: Responses
Talpaz, et al, 2002

400mg dose 600 mg dose

Cytogenetic
Response
Complete 11% 19%
Partial 5% 5%

Complete 27% 37%

Hematologic
Response
Blood 99: 1928, 2002
Time to Hematologic and Cytogeneic Response

Blood 99: 1928, 2002

Overall Survival

P = 0.01

Blood 99: 1928, 2002

 Blast Crisis Study: Responses

Sawyers et al Kantarjian et al
Blood 99:3530 Blood 99:3547
Cytogenetic N = 260 N = 75
Response
Complete 7% 7%
Partial 9% 4%

Any Hematologic 31% 46%

Response ( 4 wks)
Median time to major cytogenetic response was 3 months
Most patients treated with 600mg
Hematologic Response Duration

Median duration of response 10 months

 Overall survival (229 pts)

Median survival time 6.9 months

 Gleevec vs. Interferon for new CML

International Randomized Study Phase III

1,106 patients, 177 center, 16 countries
Gleevec 400 mg/day
vs
INF 5 MIU/M2/day with Ara-C 20mg/M2/day
10 days per month
Median follow-up 14 months
 Gleevec vs. Interferon for new CML

Gleevec INF/ARAC

Cytogenetic
Response
Complete 69% 12%
Partial 15% 30%

Complete 96% 67%

Hematologic
Response

Interim analysis presented at ASCO 2002

 Considerations When Using Imatinib Mesylate

Imatinib mesylate should be taken with food and a large

glass of water
Exposure to imatinib mesylate may increase if liver function
is impaired
Effect of renal or liver insufficiency not well studied
Use in pregnancy unknown
Potential for drug interactions
P450-CYP3A4 or CYP2D6 inhibitors and substrates
 Cytochrome p450 - CYP2D6

Substrates Inhibitors
Amitriptyline Amiodarone
captopril Celecoxib
Beta-blockers Chlopromazine
Morphine derv. Cimetidine
Cyclophosphamide Fluoxetine
Antiarrhythmics Ritonavir
Tamoxifen Valproic acid
Nicotine Methadone

Substrates - concentration increases when given with Gleevec

Inhibitors - concentration of Gleevec increases when given with Inhibitor
 Cytochrome p450 - CYP3A4

Substrates Inhibitors
Acetaminophen Amiodarone
Amiodarone Azithromycin
Nifedipine Cyclosporine
Cyclosporin Metronidazole
Corticosteroids Itraconazole
Warfarin Ranitidine
Cannabinoids Troglitazone
Estradiol
Pantoprazole

Substrates - concentration increases when given with Gleevec

Inhibitors - concentration of Gleevec increases when given with Inhibitor
 Imatinib MesylateUse in CML
Practical Considerations

Side Effect Possible Management

Cytopenia Dose reduction, interruption, or discontinuation

Diarrhea Supportive care
Edema Diuretics, supportive or localized care
Fluid retention Diuretics, supportive measures, dose
reduction, interruption, or discontinuation
GI upset Take with a meal and a large glass of water
Muscle cramps Ca2+ supplementation, tonic (quinine) water
Rash Topical or systemic steroids, dose interruption
or discontinuation
 Imatinib Mesylate: Dosing

In chronic phase CML

400 mg once daily
In advanced phase CML
600 mg once daily
Imatinib mesylate is supplied as 100-mg capsules
Dose escalation (400 mg to 600 mg or 600 mg to 800 mg)
may be considered:
Disease progression
Failure to achieve a hematologic response after
at least 3 months
Loss of a previously achieved hematologic response
 Conclusions: Imatinib Mesylate in CML
Therapy specifically designed to target the molecular
cause of CML
Potent and selective inhibitor of Bcr-Abl
Improved rates of hematologic and cytogenetic responses
in all stages of disease
Encouraging survival and time to progression - so far
Survival compared to IFN unknown
Favorable side-effects profile (compared to IFN)
Convenient once-daily oral dosing (but $$$)
 Imatinib Mesylate use in Solid Tumors

Additional molecular targets

c-Kit
PDGF-R
Relationship to prognosis and malignant transformation
is unknown
Tumors associated with these targets
Sarcomas
Lung cancer
Prostate cancer
Gliomas and neuroblastoma
Breast cancer
Seminomas and germ-cell tumors
Evidence for mutations leading to constitutive activation
KIT Expression in Human Malignancies

Tumor type KIT Protein c-kit Gene

expression mutation
Mastocytosis 100% >90%
GIST 100% >70%
Seminoma 78-100% 9%
Melanoma 90% ?
Thyroid 100% ?
Ovarian 70-90% ?

JCO 20:1692, 2002

Tyrosine Kinase Inhibitors to KIT

Compound KIT IC50 Other Targets

STI571 0.1 Bcr-abl, PDGFR

SU4984 <5 PDGFR, IR, FGFR

SU5416 0.1-1.0 KDR, PDGFR, FGFR

SU5614 0.05-0.1 KDR, PDGFR, FGFR

SU6577 <5 PDGFR, KDR

PTK787 0.73 KDR, FLT1, FMS

 Gastrointestinal Stromal Tumors (GIST)

Infrequent tumor (~0.2% of all GI tumors)

Occur primarily in stomach (60%70%) and small intestine
Therapeutic options
Surgery was only effective modality
Few respond to chemotherapy

Outcomes
For unresectable/metastatic disease

Estimated time to progression <2 months

Estimated survival <1 year
 Pathology of GIST
Distinguishing GIST from sarcomas is difficult
Arise from GI mesenchymal stem cells
Gain-of-function mutations in c-kit appear to be the most
important alteration leading to the formation of GIST
Abnormal KIT signaling in GIST may be the result of genetic
mutations in the DNA of the c-kit gene
GIST cells are positive for KIT (CD117) in 100% of cases
 Microscopic Appearance of GIST

H+E Stain CD117 (c-kit) Stain

GIST

Normal
Small
Intestine
 Normal Functions of c-KIT

KIT is tyrosine kinase found in many normal tissues and is

essential for
Hematopoiesis (blood cell development)
Melanogenesis (development of skin pigmentation)
Fertility
Activation of KIT plays a critical role in different
cell functions
Proliferation (cell multiplication)
Differentiation (cell maturation)
Apoptosis (programmed cell death)
Adhesion (cell attachment)
 First GIST Patient
After 4-Week Treatment With Imatinib Mesylate
3 March 2000 5 April 2000

June 27, 2000 Joensuu et al. N Engl J Med.

2001;344:1052-1056.
October 4, 2000
EORTC Phase I Study of Imatinib mesylate

Primary objective: Establish a maximum

tolerated dose (MTD) for GIST patients
Secondary objective: Determine
efficacy
40 patients, 36 with documented GIST
Dose administered at 400mg daily and
increased by 200mg increments, up to
1000mg
Proc ASCO 20:1a, abst 2, 2001
 EORTC Phase I Study: Results

MTD = 800mg daily dose with 1000mg leading to DLTs

Objective Response = 69.4%
PR = 52.7%
SD = 16.7%
Adverse events (AEs) were mild to moderate in severity
Most patients experienced relief of symptoms after one
week of treatment

Proc ASCO 20:1a, abst 2, 2001

 Phase II Study: Objectives

Primary objective: assessment of clinical

and biologic activity in GIST patients
Secondary objectives:
Time to onset of response
Duration of response
Time to treatment failure

JCO 20:1a, abst1, 2001

Phase II Study: Patient Characteristics

n (%)

Total 147 (100)

Age - median 54 (1883)
ECOG PS
0 62 (42)
Recurrent tumor 132 (90)
Liver 115 (78)
Peritoneum 56 (38)
Retroperitoneum 21 (14)
Previous therapy
Surgery 144 (98)
Chemotherapy 75 (51)

JCO 20:1a, abst1, 2001

 Phase II Study:
Best Confirmed Responses
All Doses
(N=147)
400mg n=73
600mg n=74
Best Response
Complete response (CR) 0
Partial response (PR) 40%
Stable disease (SD) 41%
Progressive disease (PD) 12%
Not evaluable 5%

JCO 20:1a, abst1, 2001