Semimechanistic Physiologically-Based Pharmacokinetic/Pharmacodynamic Model Informing Epcoritamab Dose Selection for Patients With B-Cell Lymphomas

Epcoritamab is a CD3xCD20 bispecific antibody (bsAb) that induces T-cell-mediated cytotoxicity against CD20-positive B cells. Target engagement and crosslinking of CD3 and CD20 (trimer formation) leads to activation and expansion of T cells and killing of malignant B cells. The primary objective of the dose-escalation part of the phase I/II trial of epcoritamab was to determine the maximum tolerated dose, recommended phase II dose (RP2D), or both. For bsAbs, high target saturation can negatively affect trimer formation. The unique properties and mechanisms of action of bsAbs require novel pharmacokinetic (PK) modeling methods to predict clinical activity and inform RP2D selection. Traditional PK/pharmacodynamic (PD) modeling approaches are inappropriate because they may not adequately predict exposure-response relationships. We developed a semimechanistic, physiologically-based PK/PD model to quantitatively describe biodistribution, trimer formation, and tumor response using preclinical, clinical PK, biomarker, tumor, and response data from the dose-escalation part of the phase I/II trial. Clinical trial simulations were performed to predict trimer formation and tumor response in patients with diffuse large B-cell lymphoma (DLBCL) or follicular lymphoma (FL). Model-predicted trimer formation plateaued at doses of 48 to 96 mg. Simulation results suggest that the 48-mg dose may achieve optimal response rates in DLBCL and FL. Exposure-safety analyses showed a flat relationship between epcoritamab exposure and risk of cytokine release syndrome in the dose range evaluated. This novel PK/PD modeling approach guided selection of 48 mg as the RP2D and provides a framework that may be applied to other CD3 bsAbs.

863 In vitro and in vivo studies establish DuoBody®-CD3xB7H4 as a novel drug candidate for the treatment of solid cancers

Background

The immune checkpoint protein B7H4 is expressed on malignant cells in various solid cancers, whereas its expression is highly restricted in normal tissue. B7H4 is therefore an attractive target for a CD3 bispecific antibody (bsAb) therapeutic. Moreover, its expression is reported to be inversely correlated with PD-L1. Here, we describe the preclinical characterization of two B7H4-targeting CD3 bsAbs with different CD3 affinities, supporting the selection of our clinical lead, DuoBody-CD3xB7H4 (GEN1047).

Methods

B7H4 protein expression in patient-derived samples was determined by immunohistochemistry. Controlled Fab-arm exchange of an Fc-silenced B7H4 antibody with two Fc-silenced CD3ε-binding antibodies generated two CD3xB7H4 bsAbs that differ in CD3 binding affinity by approximately 30-fold. In vitro T-cell mediated cytotoxicity, T-cell activation, and cytokine release were assayed using cocultures of B7H4-expressing tumor cells and healthy donor T cells. Nonclinical safety (NCS) of the two CD3xB7H4 bsAbs was assessed in cynomolgus monkeys, and antitumor activity of the clinical lead in vivo was tested in a patient-derived xenograft (PDX) screen in mice with a humanized immune system (HIS).

Results

B7H4 protein expression was confirmed in tumor biopsies from multiple indications, including breast, ovarian and lung cancer. Both bsAbs induced target-specific and dose-dependent tumor cell kill in vitro. Maximal kill and T-cell activation were comparable for both variants, although the potency of the high CD3 affinity bsAb was higher. However, production of inflammatory cytokines at comparable effective concentrations (IC90) was lower for the low CD3 affinity bsAb. Single dose NCS studies in cynomolgus monkeys showed that both CD3xB7H4 bsAbs were well-tolerated. A dose-dependent increase in plasma cytokines IL-6 and MCP-1 2 hours after dosing was observed only with the high CD3 affinity bsAb. Based on these findings, the low CD3 affinity bsAb was selected for follow-up studies and named DuoBody-CD3xB7H4 (GEN1047). DuoBody-CD3xB7H4 demonstrated antitumor activity in vivo in a PDX screen in HIS mice. Repeated dosing of DuoBody-CD3xB7H4 in cynomolgus monkeys confirmed an acceptable safety profile up to the maximal dose tested (30 mg/kg).

Conclusions

These studies describe the preclinical development of DuoBody-CD3xB7H4, a bsAb that induces T-cell mediated cytotoxicity of B7H4-positive tumor cells, which may provide an alternative therapeutic modality in the immune-oncology space for patients with solid cancers.

Ethics Approval

Animal experiments were performed according to the guidelines of the Institutional Animal Care and Use Committee (IACUC) and in accordance with the regulations of the Association for Assessment and Accreditation of Laboratory Animal Care (AAALAC). NCS studies were conducted at Citoxlab (Evreux, France) and Charles River Laboratories (Tranent, UK) in accordance with the European Convention for the Protection of Vertebrate Animals Used for Experimental and Other Scientific Purposes (Council of Europe).

PPARalpha and PPARgamma are co-expressed, functional and show positive interactions in the rat urinary bladder urothelium

Some dual-acting PPARalpha + gamma agonists cause cancer in the rat urinary bladder, in some cases overrepresented in males, by a mechanism suggested to involve chronic stimulation of PPARalpha and PPARgamma, i.e. exaggerated pharmacology. By western blotting, we found that the rat urinary bladder urothelium expressed PPARalpha at higher levels than the liver and heart, and comparable to kidney. Urothelial expression of PPARgamma was above that of fat, heart, skeletal muscle and kidney. Male rats exhibited a higher PPARalpha/PPARgamma expression balance in the bladder urothelium than did female rats. Rats were treated by gastric gavage with rosiglitazone (PPARgamma agonist), fenofibrate (PPARalpha agonist) or a combination of rosiglitazone and fenofibrate for 7 days. In the urothelium, the transcription factor Egr-1 was induced to significantly higher levels in rats co-administered rosiglitazone and fenofibrate than in rats administered either rosiglitazone or fenofibrate alone. Egr-1 was also induced in the heart and liver of rats treated with fenofibrate, but a positive interaction between rosiglitazone and fenofibrate with regards to Egr-1 induction was only seen in the urothelium. Thus, in the rat urinary bladder urothelium, PPARalpha and PPARgamma were expressed at high levels, were functional and exhibited positive interactions. Interestingly, fenofibrate induced the peroxisome membrane protein PMP70 not only in liver, but also in the bladder urothelium, opening the possibility that oxidative stress may contribute to rat urothelial carcinogenesis by dual-acting PPARalpha + gamma agonists.

Glucagon-like Peptide-1 receptor agonists activate rodent thyroid C-cells causing calcitonin release and C-cell proliferation

Liraglutide is a glucagon-like peptide-1 (GLP-1) analog developed for type 2 diabetes. Long-term liraglutide exposure in rodents was associated with thyroid C-cell hyperplasia and tumors. Here, we report data supporting a GLP-1 receptor-mediated mechanism for these changes in rodents. The GLP-1 receptor was localized to rodent C-cells. GLP-1 receptor agonists stimulated calcitonin release, up-regulation of calcitonin gene expression, and subsequently C-cell hyperplasia in rats and, to a lesser extent, in mice. In contrast, humans and/or cynomolgus monkeys had low GLP-1 receptor expression in thyroid C-cells, and GLP-1 receptor agonists did not activate adenylate cyclase or generate calcitonin release in primates. Moreover, 20 months of liraglutide treatment (at >60 times human exposure levels) did not lead to C-cell hyperplasia in monkeys. Mean calcitonin levels in patients exposed to liraglutide for 2 yr remained at the lower end of the normal range, and there was no difference in the proportion of patients with calcitonin levels increasing above the clinically relevant cutoff level of 20 pg/ml. Our findings delineate important species-specific differences in GLP-1 receptor expression and action in the thyroid. Nevertheless, the long-term consequences of sustained GLP-1 receptor activation in the human thyroid remain unknown and merit further investigation.

PPAR alpha and PPAR gamma coactivation rapidly induces Egr-1 in the nuclei of the dorsal and ventral urinary bladder and kidney pelvis urothelium of rats

To facilitate studies of the rat bladder carcinogenicity of dual-acting PPAR alpha+gamma agonists, we previously identified the Egr-1 transcription factor as a candidate carcinogenicity biomarker and developed rat models based on coadministration of commercially available specific PPAR alpha and PPAR gamma agonists. Immunohistochemistry for Egr-1 with a rabbit monoclonal antibody demonstrated that male vehicle-treated rats exhibited minimal urothelial expression and specifically, no nuclear signal. In contrast, Egr-1 was induced in the nuclei of bladder, as well as kidney pelvis, urothelia within one day (2 doses) of oral dosing of rats with a combination of 8 mg/kg rosiglitazone and 200 mg/kg fenofibrate (specific PPAR gamma and PPAR alpha agonists, respectively). These findings were confirmed by Western blotting using a different Egr-1 antibody. Egr-1 was induced to similar levels in the dorsal and ventral bladder urothelium, arguing against involvement of urinary solids. Egr-1 induction sometimes occurred in a localized fashion, indicating physiological microheterogeneity in the urothelium. The rapid kinetics supported that Egr-1 induction occurred as a result of pharmacological activation of PPAR alpha and PPAR gamma, which are coexpressed at high levels in the rat urothelium. Finally, our demonstration of a nuclear localization supports that the Egr-1 induced by PPAR alpha and PPAR gamma coactivation in the rat urothelium may be biologically active.

High frequency of tumor cells with nuclear Egr-1 protein expression in human bladder cancer is associated with disease progression

Background

Egr-1 (early growth response-1 transcription factor) has been proposed to be involved in invasion and metastasis processes of human bladder cancer, but Egr-1 protein expression levels in human bladder cancer have not been investigated. In the present study we investigated the expression levels of Egr-1 protein in early stages of human bladder cancer and correlated it to later progression.

Methods

Expression of Egr-1 protein in human bladder cancer was examined by immunohistochemistry, on a tissue microarray constructed from tumors from 289 patients with non-muscle invasive urothelial bladder cancer.

Results

The frequency of tumor cells with nuclear Egr-1 immunolabelling correlated to bladder cancer stage, grade and to later progression to muscle-invasive bladder cancer (T2-4). Stage T1 tumors exhibited significantly higher frequencies of tumor cells with nuclear Egr-1 immunolabelling than Ta tumors (P = 0.001). Furthermore, Kaplan-Meier survival analysis showed that a high frequency of tumor cells with nuclear Egr-1 immunolabelling was significantly associated with a higher risk of progression to stage T2-4 (log-rank test, P = 0.035). Tumor cells with nuclear Egr-1 immunolabelling were found to localize at the tumor front in some of the tumor biopsies.

Conclusion

The results from this study support a potential involvement of Egr-1 in the progression from non-muscle invasive bladder cancers to muscle invasive bladder cancer.

Biomarkers for early effects of carcinogenic dual-acting PPAR agonists in rat urinary bladder urotheliumin vivo

Small-molecule agonists of the peroxisome proliferator-activated receptor (PPAR) alpha and gamma isoforms (dual-acting PPAR agonists) can cause urothelial cancers in rodents. Rats were dosed orally for 16 days with bladder carcinogenic (ragaglitazar) as well as non-bladder carcinogenic (fenofibrate and rosiglitazone) PPAR agonists and protein changes were assayed in the urinary bladder urothelium by Western blotting. Dose levels reflected 10-20 x human exposure, and the ragaglitazar dose was in the carcinogenic range. Ragaglitazar induced expression of the transcription factor Egr-1, phosphorylation of the c-Jun transcription factor and phosphorylation of the ribosomal S6 protein were observed. These changes were also observed in rats dosed with either rosiglitazone or fenofibrate. However, the protein changes were stronger (Egr-1 induction) or of a longer duration (S6 phosphorylation) in ragaglitazar-treated animals. Animals co-administered fenofibrate (a specific PPARalpha agonist) and rosiglitazone (a specific PPARgamma agonist) exhibited Egr-1 and S6 protein changes more similar to those induced by ragaglitazar (a dual-acting PPARalpha/gamma agonist) than either fenofibrate or rosiglitazone alone. The findings suggest that ragaglitazar causes Egr-1, c-Jun and S6 protein changes in the urothelium by a mechanism involving PPARalpha as well as PPARgamma, and that the Egr-1, c-Jun and S6 protein changes might have potential biomarker value.