Terapia della malattia fludarabina-resistente: Università degli studi di Perugia Facoltà di Medicina e Chirurgia Azienda Ospedaliera S. Maria di Terni S.C. Oncoematologia-autotrapianto, Direttore Prof. A.M. Liberati Terapia della malattia fludarabina-resistente: ruolo delle mutazioni di TP53 Marco Gunnellini

CLL outcome Del (17p) patients outcome is worse than others cytogentic abnormalities p<0,001 Abnormalities N(%) Median TTF Median OS Del(17p) 7 9 32 Del(11q) 18 13 79 12q Trisomy 16 33 114 Normal 92 111 Del(13q) 55 49 133 Treatment-free interval (mesi) Doner et Al. N Engl J Med, 2000; 343: 1910-6

CLL guidelines Treatment-free interval (mesi)

Prospective clinical studies Fludarabine plus Cyclophosphamide Multidrug-resistent CLL Prospective clinical studies Fludarabine Fludarabine plus Cyclophosphamide 235 pts. PFS p=0,0006 Del11q = perdita del gene ATM Grever et Al; J Clin Oncol, 2007; 25:799-804

CLL guidelines Treatment-free interval (mesi)

28 chemotherapy-naive pts Role of Steroids 28 chemotherapy-naive pts ORR= 96% (27/28) CR= 32% (9/28) MRD negative = 22% (2/9) MRD positive = 78% (7/9) 30 mg 3 times weekly In realtà il gruppo 2 è stato ulteriormente suddiviso in 2A: schedula nella figura e 2B: rituximab al G1-8-15 il primo ciclo e come da figura per il secondo e terzo ciclo. I pazienti con malattia minima residua sono stati arruolati in un protocollo di consolidamento con Alemtuzumab. Treatment with HDMPrituximab was well tolerated, notably in elderly patients who are frequently less tolerant to combination chemoimmunotherapy. This regimen is of particular interest for the treatment of patients who are older, or have poor myeloid reserve, pretreatment cytopenias, bulky disease or adverse cytogenetics. RR = 83% Median PFS = 30,3 mesi 3-ys OS = 96% Castro et Al, Leukemia, 2009; 23: 1779-89 Castro et Al, Leukemia, 2008; 22: 2048-53

CLL guidelines Treatment-free interval (mesi)

CAM 307: Alemtuzumab vs Chlorambucil Role of Alemtuzumab CAM 307: Alemtuzumab vs Chlorambucil Hillmen et Al, J Clin Oncol, 2007; 25: 5616-23

Reduced-dose Alemtuzumab Role of Alemtuzumab Reduced-dose Alemtuzumab the median time to the maximum tumour reduction was 5.5 weeks for blood, 6 weeks for lymph nodes, 9 weeks for spleen and 15 weeks for bone marrow. Alemtuzumab è efficace e ben tollerato con questa schedula, anche nei pazienti con citogenetica sfavorevole. Purtroppo però le remissioni sono di solito temporanee e la maggior parte dei pazienti vanno incontro a recidiva anche se responders Relapse in 61,5% of CR Cortelezzi et Al; Leukemia, 2009; 1-7

(3-6, median 3 previous agents) Combination therapy CAM-PRED Alemtuzumab → eradication from the blood and bone marrow. HDMP → regression of bulky lymphadenopathy 3 pre-treated pts (3-6, median 3 previous agents) 2 untreated pts substantial lymphadenopathy p53 abnormalities ORR= 100% CR= 60% (3/5 pts) (40% MDR negative) → 1 relapsed after 1 year PR= 40% (2/5 pts) (20% nPR) → early relapse (4-6 months) Although alemtuzumab is effective at eradicating detectable CLL from the blood and bone marrow, it is ineffective in patients with substantial lymph node enlargement. CAM-PRED regimen appears to be a highly effective treatment option for CLL patients with p53 defects Pettitt et Al, Leukemia, 2006; 20: 1441–5

Role of Alemtuzumab CLL2H Study - GCLLSG del(11q) ORR = 30% PFS = 9 months OS = 22,7 months Alemtuzumab SC in heavily pre-treated 106 pts (1-10, median 3 previous agents) 31 (30%) → del(17p) 20 (19%) → del(11q) del(17p) ORR = 39% PFS = 5,8 months OS = 18,3 months ORR = 34% (only 4% of CR) PFS = 7,7 months OS = 19,1 months CONCLUSIONI DEGLI AUTORI: Although alemtuzumab is efficacious in inducing remissions in fludarabine-refractory CLL, the disease will eventually relapse and progress. Currently, the only potentially curative therapy for fludarabine-refractory CLL is alloSCT “Altough Alemtuzumab is efficacious in inducing remissions in fludarabine-refractory CLL, the disease will eventually relapse and progress. Currently the only potentially curative therapy for fludarabine-refractory CLL is allo-SCT” Stilgenbauer et Al, J Clin Oncol, 2009; 27: 3994-4001

CLL guidelines CHOP: ciclofosfamide, doxorubicina, vincristina, prednisone CFAR: RFC + alemtuzumab Hyper-CVAD: ciclofosfamide, doxorubicina, vincristina, prednisone alternati a R+ metotrexate e citarabina ad alte dosi OFAR: oxaliplatino, fludarabina, citarabina, rituximab R-CHOP CFAR R-Hyper-CVAD OFAR Alemtuzumab + Rituximab

Allogenic SCT in pre-treated 44 del(17p) pts Role of Allo-SCT Allogenic SCT in pre-treated 44 del(17p) pts Median 3 pre-treatment (range 2-7) Graft-versus-leukemia effects may overcome the negative prognostic impact of 17p deletions in CLL 43 (98%) → Fludarabine 19 (43%) → Alemtuzumab 13 (30%) → Auto-SCT ORR = 84% PFS 3ys = 44% OS 3ys = 37% Early death in 2/44 (5%) Schetelig et Al; J Clin Oncol, 2008; 26: 5094-100

Flavopiridol in refractory, high-risk CLL Novel therapy Flavopiridol in refractory, high-risk CLL n= 20 30 mg/m2 + PR= 40% n= 3 40 mg/m2 + PR= 33% PRtot= 45% PR17p-= 42% No CR n= 19 30 mg/m2 + 50 mg/m2 PR= 52% leukocyte counts greater than 200 109/L represents the most important risk factor for TLS Hyperacute Tumor Lysis Syndrome Median PFS for responders → 6 pts (14%) → 13 months Byrd et Al; Blood, 2007; 109: 399-404

GIMEMA LLC0405     RC,RP MS-PM  Alemtuzumab FLU+Cy (2 cicli) (multicenter, < 60 years, advanced/progressive CLL) Basso Rischio: assenza delle caratteristiche dell’alto rischio Alto Rischio: del17p in >20%, del11q + IgVH germline o ZAP70+ >10% o CD38+ >7% IgVH germline (o mutated VH3-21) + (almeno 2) ZAP70+ >10%, CD38+ >7%, del6q o tri12.  FLU 30mg/mq/ev+ Cy 250 mg/mq/ev gg 1,2,3 (4 cicli)  FLU 30mg/mq/ev+ Campath1H 30 mg ev gg 1,2,3 (4 cicli)   RC,RP MS-PM  Alemtuzumab FLU+Cy (2 cicli) RC, RC-cy, b-RP RC-mol 30mg/w (6+6 w) no donor donor nb-RP, MS, PM   RP,RC, RC-cy, RC-mol Mobilizzazione CSP Ara-C(800 mg/mq/12h x 3 gg)+G-CSF MS-PM Off-Study Off-Study   Watch&Wait No CS Si CS W&W   Mini Allo Fam alemtuzumab AutoBEAM (Thio/CTX/Flu)

Ongoing Study Identification Drugs Phase State NCT00022880 Iodine-131 Anti-B1 Antibody I not recruiting NCT00829647 Dasatinib plus Lenalidomide I/II recruiting NCT00002838 Allo-SCT NCT00292760 Alemtuzumab plus HDMP II not yet recruiting NCT00558181 HDMP plus Rituximab NCT00562328 Alemtuzumab plus Rituximab plus GM-CSF NCT00343447 RC plus vaccine therapy NCT00436904 Alemtuzumab plus Rituximab NCT00525603 CFAR NCT00513747 Rituximab plus Fludarabine (early vs delayed treatment) III http://www.clinicaltrial.gov

Take-home message An optimal treatment of del(17p) B-CLL still awaits to be defined Del(17p) B-CLL results in poor response to fludarabine and rituximab Alemtuzumab with or without HDMP can partially overcome p53-dependent resistance but duration of responses is short Allogeneic HCT has the potential to induce long term disease-free survival in patients with 17p– CLL but prospective confirmation is needed New agents and more effective regimens are in pre-clinical or early clinical study in del(17p) CLL patients

Grazie per l’attenzione Terapia della malattia fludarabina-resistente: ruolo delle mutazioni di TP53 Marco Gunnellini

Multidrug-resistent CLL In-vitro studies P<0.0001 P= 0.03 P= 0.0001 p53 mutated cases conserve response to steroids, anthracyclines and vincristine SX: La perdita di funzione di p53 determina, nelle cellule di CLL una significativa maggior resistenza al killing da parte della fludarabina e delle radiazioni ionizzanti. DX: (DA RIVEDERE BENE CON L’ARTICOLO IN MANO) maggiore sensibilità alla fludarabina delle linee cellulari di CLL con gene p53 wild-type (linea tratteggiata) rispetto al gruppo con p53 mutato. In questo studio è stato inoltre dimostrato ma in modo non statisticamente significativo che le mutazioni introniche comportano una resistenza ancora più marcata rispetto alle Fludarabine γ-radiation Pettitt et Al, Br J Haematol 1999:;106: 1049-51 Sturm et Al, Cell Death Differ 2003; 10: 477-84

Retrospective clinical studies Fludarabine plus Rituximab Multidrug-resistent CLL Retrospective clinical studies 88 pts 54 pts Significant correlation between non-response to treatment and the presence of p53 aberrations (P=0.0065) SX: OS dei pazienti trattati con FR. Differenza tra casi del17 e tutti gli altri DX: delezioni o metilazioni con perdita di espressione di p53 correlano con una scarsa risposta al trattamento con fludarabina Fludarabine plus Rituximab Fludarabine Byrd et Al, J Clin Oncol 2006; 24: 437-43 Valganon et Al, Br J Haematol 2005; 129: 53-9

Retrospective clinical studies Multidrug-resistent CLL Retrospective clinical studies p=0,001 Il rischio di progressione dopo terapia aumenta all’aumentare della percentuale di nuclei portatori della del(17p) Tam et Al; Blood, 2009; 114: 957-64

(1-6, median 3 previous agents) Role of Steroids 25 pre-treated pts (1-6, median 3 previous agents) HDMP can induce regression of bulky lymphadenopathy in CLL patients with p53 abnormalities Pts with p53 losses still fared worse than those with normal p53 Other drugs: vinblastina, vincristina, mitoxantrone, ara-c, cisplatino, doxorubicina Mild toxicity. Gli effetti avversi più seri sono risultate le infezioni (7/22 - 32%) Thornton et Al, Ann Hematol, 2003; 82: 759-65

Role of Alemtuzumab Alemtuzumab SC in heavily pre-treated 46 pts del(17p) Heavily pre-treated (1-7, median 4 previous agents) 13 (29%) → del(17p) 13 (29%) → del(11q) 27 (59%) → VH um del(11q) ORR = 36% PFS = 9,7 months OS = 13,1 months PD in 9/46 (20%) Early stop of treatment for toxicity in 13/46 (28%) pts Stilgenbauer et Al, Blood, 2004;104: a478

Role of Alemtuzumab Alemtuzumab in heavily pre-treated 36 pts (1-12, median 3 previous agents) 81% → Fludarabine ORR → 11 (31%) 15 (42%) → p53 mutation or del(17p) Pazienti fortemente pretrattati (in media 3 linee terapeutiche) 81% precedentemente trattati con fludarabina 15 su 36 pts (42%) presentavano la del(17p) 11 responders (2 complete e 9 parziali), 6 su 15 pts (40%) con del(17p) hanno risposto al trattamento Nei pazienti con p53 mutato o deleto è preferibile una terapia con campath alla fludarabina È giustificabile uno screening alla diagnosi dei pazienti affetti da CLL per evitare di somministrare terapie inefficaci in quelli ad alto rischio Cytogenetic screening of all B-CLL patients at diagnosis can avoid administration of ineffective therapy for this disease Lozanski et Al; Blood , 2004; 103: 3278-81

Role of Alemtuzumab Alemtuzumab in heavily pre-treated 23 pts (1-11, median 4 previous agents) 92% → Fludarabine 8% → ASCT 7 (30%) → del(17p) Toxicity in 10/23 (43%) pts: 4 asymptomatic CMV reactivation 4 cytopenias with infection 1 anorexia 1 death for pulmonary CMV In realtà 26 pazienti ma la risposta era valutabile solo in 23 Pazienti fortemente pretrattati (in media 4 linee terapeutiche) 92% precedentemente trattati con fludarabina, l’8% con trapianto autologo di cellule staminali 7 su 23 pts (30%) presentavano la del(17p) 12 responders (5 complete e 7 parziali), 3 responders nel sottogruppo di pazienti con del(17p) Tossicità accettabile (solo un caso di polmonite da CMV che ha determinato la morte del paziente) 2 morti per PD Osuji et Al; Blood, 2004; a2510

Novel therapy Drugs Phase References OFAR I/II Tsimberidou et Al., J Clin Oncol, 2008; 26:196-203 Lenalidomide II Ferrajoli et Al.; Blood, 2008; 111: 5291-7. Gossypol Pre-clinic Balakrishnan et A.; Blood, 2008; 112: 1971-80. ABT-737 Paoluzzi et Al.; Blood, 2008; 112: 2906-16. microRNA106b activators Sampath et Al.; Blood, 2008; PMID 19096009 CD40L gene-therapy Kato et Al.; J Clin Invest, 1998; 101: 1133-41. Kipps; ASCO EDUCATIONAL BOOK.2009; 2009: 385-93