Teclistamab, a B-cell maturation antigen × CD3 bispecific antibody, in patients with relapsed or refractory multiple myeloma (MajesTEC-1): a multicentre, open-label, single-arm, phase 1 study

BACKGROUND

There is a need for novel therapies for relapsed or refractory multiple myeloma, and B-cell maturation antigen (BCMA) is a validated target. Teclistamab is a bispecific antibody that binds BCMA and CD3 to redirect T cells to multiple myeloma cells. The aim of the MajesTEC-1 study was to evaluate the safety, tolerability, and preliminary efficacy of teclistamab in patients with relapsed or refractory multiple myeloma.

METHODS

This open-label, single-arm, phase 1 study enrolled patients with multiple myeloma who were relapsed, refractory, or intolerant to established therapies. Teclistamab was administered intravenously (range 0·3-19·2 μg/kg [once every 2 weeks] or 19·2-720 μg/kg [once per week]) or subcutaneously (range 80-3000 μg/kg [once per week]) in different cohorts, with step-up dosing for 38·4 μg/kg or higher doses. The primary objectives were to identify the recommended phase 2 dose (part one) and characterise teclistamab safety and tolerability at the recommended phase 2 dose (part two). Safety was assessed in all patients treated with at least one dose of teclistamab. Efficacy was analysed in response-evaluable patients (ie, patients who received at least one dose of teclistamab and had at least one post-baseline response evaluation). This ongoing trial is registered with ClinicalTrials.gov, NCT03145181.

FINDINGS

Between June 8, 2017, and March 29, 2021, 219 patients were screened for study inclusion, and 157 patients (median six previous therapy lines) were enrolled and received at least one dose of teclistamab (intravenous n=84; subcutaneous n=73). 40 patients were administered the recommended phase 2 dose, identified as once per week subcutaneous administration of teclistamab at 1500 μg/kg, after 60 μg/kg and 300 μg/kg step-up doses (median follow-up 6·1 months, IQR 3·6-8·2). There were no dose-limiting toxicities at the recommended phase 2 dose in part one. In the 40 patients treated at the recommended phase 2 dose, the most common treatment-emergent adverse events were cytokine release syndrome in 28 (70%; all grade 1 or 2 events) and neutropenia in 26 (65%) patients (grade 3 or 4 in 16 [40%]). The overall response rate in response-evaluable patients treated at the recommended phase 2 dose (n=40) was 65% (95% CI 48-79); 58% achieved a very good partial response or better. At the recommended phase 2 dose, the median duration of response was not reached. 22 (85%) of 26 responders were alive and continuing treatment after 7·1 months' median follow-up (IQR 5·1-9·1). At the recommended phase 2 dose, teclistamab exposure was maintained above target exposure levels, and consistent T-cell activation was reported.

INTERPRETATION

Teclistamab is a novel treatment approach for relapsed or refractory multiple myeloma. At the recommended phase 2 dose, teclistamab showed promising efficacy, with durable responses that deepened over time, and was well tolerated, supporting further clinical development.

FUNDING

Janssen Research & Development.

Abstract 1267: Combination therapy of JNJ-67856633, a novel, first-in-class MALT1 protease inhibitor, and JNJ-64264681, a novel BTK inhibitor, for the treatment of B-cell lymphomas

Background: Constitutive activation of the classical nuclear factor kappa-light-chain-enhancer of activated B-cells (NF-κB) pathway is a clear driver of B-cell non-Hodgkin lymphomas (NHL). Bruton's Tyrosine Kinase (BTK) and Mucosa-associated lymphoid tissue lymphoma translocation protein 1 (MALT1), which lies downstream of BTK, are key mediators of the classical NF-κB signaling pathway activated by BCR and TCR receptors. JNJ-67856633 is a first-in-class MALT1 protease inhibitor. JNJ-64264681 is a BTK inhibitor with improved selectivity against BTK. Blocking the BCR pathway at multiple points using these two orally bioavailable compounds could enhance clinical activity in B-cell lymphoma patients.

Methods: JNJ-67856633 and JNJ-64264681 are currently being evaluated in phase 1 clinical trials designed to establish safety, PK, PD and the Recommended Phase 2 Dose (RP2D) of each agent.

Results: JNJ-67856633 is a potent, selective, orally bioavailable, allosteric inhibitor of MALT1 protease activity. The compound inhibits proliferation of activated B-cell diffuse large B-cell lymphoma (ABC-DLBCL) cell lines bearing CD79b or CARD11 mutations as well as models mimicking resistance to covalent BTK inhibitors. JNJ-67856633 exhibits potent tumor growth inhibition in two human DLBCL xenograft models, OCI-Ly3 and OCI-Ly10, and mutation selected patient derived DLBCL xenografts. Furthermore, treatment with JNJ-67856633 leads to dose dependent inhibition of the generation of Tregs (CD4+CD25+FoxP3+) following CD3/28 stimulation in vitro, suggesting a potential immune modulatory role of MALT1 inhibition. JNJ-64264681 is an orally active small molecule that is a potent, selective, and irreversible covalent BTK inhibitor. JNJ-64264681 inhibits the growth of CD79b-mutant DLBCL cell lines in vitro and potently inhibits tumor growth in xenograft- or patient-derived DLBCL models in vivo. Treatment with JNJ-64264681 and JNJ-67856633 administered together demonstrated statistically significant tumor growth inhibition compared with vehicle control in two CD79b mutant mouse lymphoma models, one based on a DLBCL cell line (OCI-Ly10) and one based on a patient-derived DLBCL model (LY2298). In both models, the combination showed increased growth inhibition compared with single agents and tumor regression in the combination arm. Synergistic anti-proliferative activity was observed in three DLBCL cell lines carrying CD79b mutations and one MCL cell line.

Conclusions: Taken together, the in vitro and in vivo data for JNJ-67856633 and JNJ-64264681 suggest that combination therapy can increase the anti-tumor effect of the monotherapies and provide a more sustained response, offering strong support for clinical investigation of the combination of these two novel agents. A phase 1b combination study is scheduled to initiate.

Citation Format: Ulrike Philippar, Lorena Fontan, Ivo Cornelissen, Haopeng Rui, Sriram Balasubramanian, Marcello Gaudiano, Mariette Bekkers, Luc Van Nuffel, Tianbao Lu, Tianbao Lu, John Wiener, Mark Tichenor, Tony Greway, Kathryn Packman, Bie Verbist, Yusri Elsayed, Ricardo Attar, Jacqueline Bussolari, John Gerecitano. Combination therapy of JNJ-67856633, a novel, first-in-class MALT1 protease inhibitor, and JNJ-64264681, a novel BTK inhibitor, for the treatment of B-cell lymphomas [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1267.

Abstract 1256: JNJ-74856665, a novel DHODH inhibitor, mediates potent anti-leukemic activity and differentiation in vitro and in vivo

Acute myeloid leukemia (AML) is a heterogeneous disease characterized by uncontrolled clonal expansion of hematopoietic progenitor cells (myeloid blasts). Disease remission can be achieved with standard induction chemotherapy, but refractory and relapsed disease remains a challenge with a 5-year overall survival rate of approximately 25%. Induction of differentiation is an alternative approach to AML therapy. Dihydroorotate dehydrogenase (DHODH) catalyzes the ubiquinone-mediated oxidation of dihydroorotate (DHO) to orotate in the de novo pyrimidine synthesis pathway. Pre-clinical findings demonstrated that DHODH is a metabolic vulnerability in AML and a new target for differentiation therapy. Given the genetic complexity of myeloid malignancies, future use of DHODH inhibitors in combination with selected antineoplastic agents (e.g., azacitidine) with nonoverlapping mechanisms of action may address specific aspects of the complex pathogenesis of AML and MDS (myelodysplastic syndrome), ultimately improving patients' outcomes.JNJ74856665 is an orally available, potent and selective DHODH inhibitor. JNJ-74856665 inhibited the biochemical activity of human DHODH with a 50% inhibitory concentration (IC50) in the subnanomolar range and in vitro inhibited proliferation of MOLM-13, OCI-AML3, HL60 and THP-1 AML cell lines with low nanomolar IC50 values. Mechanism of action studies using these four cell lines demonstrated induction of CD11b and CD14 differentiation marker mRNA levels. Differentiation was accompanied by cell cycle arrest and apoptosis induction. Importantly, addition of excess uridine to the tissue culture conditions abrogated the anti-proliferative, differentiation and apoptosis inducing activity of JNJ-74856665, indicating on target activity. In vivo, JNJ-74856665 mediated significant activity in decreasing leukemic burden and increasing life span across subcutaneous (MOLM-13 and OCI-AML3) and disseminated (MOLM-13) xenografts, respectively. Pharmacodynamic investigations demonstrated target engagement as evidenced by upregulation of the DHODH substrate dihydroorotate in plasma and induction of differentiation markers in tumor. Combination of JNJ-74856665 with azacitidine in vivo demonstrated lack of antagonism in the anti-leukemic activity.The results described herein demonstrate that JNJ-74856665 exerts potent anti-leukemic activity in vitro and in vivo and warrant further investigation. To that end, a phase 1 clinical trial assessing the safety and efficacy of JNJ-74856665 in patients with AML and MDS is planned to initiate shortly.

Citation Format: Christine Pietsch, Scott Kuduk, Xiaochun Zhang, Tammy Bush, Faraz Kazmi, Edgar Jacoby, Zhuming Zhang, Lindsey DeRatt, Weixue Wang, Aaron Patrick, Andrew Steele, Friedericke Pastore, Tony Greway, Nikki Daskalakis, Kathryn Bradford, Kathryn Packman, Gilles Bignan, James Edwards, Ricardo Attar, Yusri Elsayed, Jacqueline Bussolari, Ulrike Philippar. JNJ-74856665, a novel DHODH inhibitor, mediates potent anti-leukemic activity and differentiation in vitro and in vivo [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1256.

Delayed cord clamping: Time for physiologic implementation

Delayed cord clamping has been shown to be beneficial in both preterm and term babies. Practice guidelines have not been consistent between centers and the practice of delayed cord clamping has not been standardized. The concept of physiologic-based cord clamping emerged into practice as well. Cord milking has different physiological effect and might be harmful in preterm babies.

The impact of targeted oxygen reduction test in preterm infants on reducing the oxygen exposure

BACKGROUND

Caring for infants on respiratory support is a challenge in the middle-income countries, applying a protocol of targeted oxygen reduction test (tORT) guided by daily assessment of oxygen histograms is novel and practical approach.

OBJECTIVE

To study the impact of tORT guided by daily assessment of oxygen histograms as a quality improvement project aiming to decrease days on oxygen support, and duration of hospital admission in preterm infants.

STUDY DESIGN

A quality project conducted in neonatal intensive care units (NICU) of two hospitals, from 2017- 2018 (Epochs II). After a period of observation of a cohort of preterm Infants, 2016-2017 (Epoch I). The main aims were to reduce days on oxygen and hospital admission days. All infants in Epoch II underwent daily assessment of oxygen histograms and a trial of oxygen reduction if applicable as per a predefined protocol. Comparison was made between these two Epochs, and the primary outcome was the time to successful discontinuation of oxygen support.

RESULTS

Fifty-nine infants were included; 30 underwent the protocolized tORT (Epoch II) with a median (IQR) of 4 (2-6) tORC per infant. Postanal age at presentation (time of initial tORT assessment was performed at the postnatal age of 8 (5, 13) days. Days on oxygen and total numbers of hospital days were significantly less in Epoch II. Oxygen histograms significantly improved after tORT.

CONCLUSIONS

Applying tORT guided by oxygen histograms may have a significant impact on oxygen exposure and hospitalization days of patients admitted to the NICU.

Abstract 5662: JNJ-67571244: A novel anti-CD33 C2 domain binding bispecific antibody with potent T cell redirection activity

CD33 is expressed in 90% of acute myeloid leukemia (AML) patients with expression in both blasts and leukemic stem cells. The extracellular portion of CD33 consists of a V and a C2 Ig-like domain. A recent study showed that a single nucleotide polymorphism (SNP) rs12459419 (C >T; Ala14Val in exon 2 of CD33) was present in ~50% of the Western AML population and is associated with preferential expression of an alternatively spliced CD33 isoform lacking exon2, resulting in the deletion of the CD33 V domain. Interestingly, several CD33-antibody-based therapies, including gemtuzumab ozogamicin (GO), the only approved anti-CD33 antibody drug conjugate for AML, bind and recognize the V domain of CD33. Recent data demonstrated that patients with SNP rs12459419 CC genotype receiving GO had a significantly lower risk of relapse and increased event-free survival compared to patients with the CT or TT genotypes. Given the data with GO, it is reasonable to hypothesize that the activity of other V binding CD33 antibodies maybe limited to a subset (~50%, rs12459419 CC genotype) of AML patients. On the other hand, since the C2 domain is shared by all CD33 isoforms in AML patients, we hypothesized that a C2 binding anti-CD33 antibody could target AML cells more broadly regardless of their SNP status. Additionally, we reasoned that targeting the membrane proximal C2 domain would be a beneficial strategy for a CD3 redirection bispecific antibody as targeting epitopes closer to the membrane have been reported to mediate efficient synapse formation between T cells and target cells leading to potent anti-tumor responses. We developed JNJ-67571244, a novel human bispecific antibody capable of binding to the C2 domain of CD33, and to CD3 to induce T-cell recruitment and tumor cell cytotoxicity independently of their SNP status. JNJ-67571244 specifically binds to CD33-expressing target cells and induces cytotoxicity of CD33+ AML cell lines in vitro at 48 hours (EC50 values: KG-1=0.168 nM, MOLM-13=0.131 nM, Kasumi-1=0.05 nM and OCI-AML3=0.183 nM) with concomitant T cell activation (EC50 values: KG-1=0.066 nM, MOLM-13=0.028 nM, Kasumi-1=0.043 nM and OCI-AML3=0.05 nM) along with cytokine release. In contrast, JNJ-67571244 was unable to kill CD33- cancer cell lines (CARNAVAL and KG-1 cells with a genetic deletion of CD33), demonstrating the specificity of the cytotoxicity. JNJ-67571244 demonstrated statistically significant anti-tumor activity in vivo in established disseminated and subcutaneous mouse models of human AML (MOLM-13Luc and KG-1: up to 100% and 92% tumor growth inhibition respectively) through T cell redirection activity. Furthermore, this antibody could deplete CD33+ blasts (EC50=0.549 nM) in AML patient blood samples (n=7) in an ex-vivo assay at 48 hours with concurrent T cell activation (EC50=0.355 nM). JNJ-67571244 also cross-reacts with cyno CD33 and CD3 and was well-tolerated in cynomolgus monkeys up to 30 mg/kg along with a sustained reduction in CD33+ leukocyte populations. Lastly, JNJ-67571244 mediated efficient cytotoxicity of cell lines and primary samples regardless of their genotype status (SNP rs12459419 CC, CT and TT), suggesting a potential therapeutic advantage over competitor V-binding antibodies. JNJ-67571244 is currently in Phase 1 clinical trials to treat relapsed/refractory AML and high risk myelodysplastic syndrome (MDS) patients (NCT03915379).

Citation Format: Priyanka Nair-Gupta, Michael Diem, Dara Reeves, Weirong Wang, Robert Schulingkamp, Katrin Sproesser, Bethany Mattson, Bradley Heidrich, Jocelin Joseph, Jocelyn Sendecki, Brad Foulk, Gerald Chu, Damien Fink, Qun Jiao, Sheng-Jiun Wu, Kathryn Packman, Yusri Elsayed, Ricardo Attar, Francois Gaudet. JNJ-67571244: A novel anti-CD33 C2 domain binding bispecific antibody with potent T cell redirection activity [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5662.

Abstract 5690: Discovery of JNJ-67856633: A novel, first-in-class MALT1 protease inhibitor for the treatment of B cell lymphomas

Introduction: Constitutive activation of the classical nuclear factor kappa-light-chain-enhancer of activated B-cells (NF-κB) pathway is a clear driver of B-cell lymphomas, especially the aggressive activated B-cell (ABC) subtype of diffuse large B-cell lymphoma (DLBCL). Mucosa-associated lymphoid tissue lymphoma translocation protein 1 (MALT1) is a key mediator of the classical NF-κB signaling pathway downstream of B-cell receptor and T-cell receptor. MALT1 possesses 2 functions: a scaffolding function to recruit NF-κB signaling proteins and a protease function to cleave and inactivate inhibitors of the NF-κB signaling pathway.

Methods: Using a high-throughput screen followed by iterative structure-activity relationship (SAR) analyses, the MALT1 inhibitor JNJ-67856633 was identified. The lead compound was evaluated using biochemical, in vitro cellular and in vivo tumor efficacy and safety models.

Results: JNJ-67856633 is a potent, selective, allosteric inhibitor of MALT1 protease activity as measured by biochemical assays or downstream cellular cytokine readouts (IL 6/10) or direct MALT1 substrate cleavage (RelB, BCL10). The compound inhibits proliferation of activated B-cell diffuse large B-cell lymphoma (ABC-DLBCL) cell lines bearing CD79b or CARD11 mutations as well as models mimicking resistance to covalent Bruton's Tyrosine Kinase (BTK) inhibitors. Furthermore, combination effects were observed in CD79b cellular ABC-DLBCL models when JNJ-67856633 was combined with a BTK inhibitor. JNJ-67856633 leads to potent in vivo pharmacodynamic shutdown in CD79b- as well as CARD11-mutant ABC-DLBCL models as measured by serum IL10 or uncleaved BCL10 levels in tumors. JNJ-67856633 exhibits potent tumor growth inhibition in two human DLBCL xenograft models, OCI Ly3 and OCI Ly10, and mutation selection patient derived DLBCL xenografts. To address the role of MALT1 inhibition in T cells, primary human T cells derived from normal healthy volunteers were treated with JNJ-67856633 in vitro. Dose dependent inhibition of the generation of Tregs (CD4+CD25+FoxP3+) following CD3/28 stimulation was observed upon treatment with JNJ-67856633 suggesting a potential immune modulatory role of MALT1 inhibition.

Conclusions: Phase 1 clinical trials assessing the safety and efficacy of JNJ-67856633 initiated in 2019. JNJ-67856633 is a combination partner for BTK inhibitors and a promising treatment option for BTKi-resistant tumors, with demonstrated preclinical activity in CARD11 mutant tumors. In addition to ABC-DLBCL, a MALT1 inhibitor is a promising treatment option for patients with CLL, MCL, WM, and FL whose tumors have been shown to be sensitive to inhibition of BTK. MALT lymphomas, characterized by MALT1 and BCL10 translocation, represent another attractive target for MALT1 inhibition.

Citation Format: Ulrike Philippar, Tianbao Lu, Nele Vloemans, Mariette Bekkers, Luc Van Nuffel, Marcello Gaudiano, Katarzyna Wnuk-Lipinska, Bas-jan Van Der Leede, Katie Amssoms, Kristof Kimpe, Bart Medaer, Tony Greway, Yann Abraham, Max Cummings, Emanuele Trella, Greet Vanhoof, Weimei Sun, Jan Willem Thuring, Peter Connolly, Jan Linders, Haopeng Rui, Sriram Balasubramanian, Amy Johnson, John Gerecitano, Jenna Goldberg, James P. Edwards, Yusri Elsayed, Jennifer Smit, Jaqueline Bussolari, Jaqueline Bussolari, Ricardo Attar. Discovery of JNJ-67856633: A novel, first-in-class MALT1 protease inhibitor for the treatment of B cell lymphomas [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5690.

Abstract 1492: Development of a CD123xCD3 bispecific antibody to treat acute myeloid leukemia (AML)

AML is a heterogeneous disease characterized by uncontrolled clonal expansion of leukemic stem cells (LSCs). Current therapies for AML are not curative, in part due to their inability to eradicate LSCs from the bone marrow. T cell redirection has been shown to be effective in heme malignancies and represents a promising approach to treat AML by targeting markers differentially expressed on the cell surface of cancer cells. One marker, CD123 (α-chain of the interleukin-3 receptor) is often present on AML LSCs and blasts. We developed a human bispecific antibody (CD123xCD3; Ab-178) capable of binding to the extracellular domain of CD123 and the ϵ chain of CD3 on T cells to induce T cell–mediated tumor cell killing. This bispecific IgG4 antibody can recruit T cells to CD123+ AML cells (MOLM-13, KG-1 and OCI-AML5) and induce T cell activation as evidenced by CD69 and CD25 up-regulation on T cells. Ab-178 potently killed these CD123+ AML cell lines in vitro (EC50 = 0.51-0.91 nM) but not a CD123− cell line (JIM3). Ab-178 was also able to induce tumor inhibition (MOLM-13 cells) and regression (KG-1 cells) in murine xenograft CD123+ AML models in the presence of human PBMCs. Furthermore, this antibody was able to kill AML blasts in primary AML blood samples ex vivo in the absence of exogenous T cells (autologous setting; EC50 = 0.83 nM). Related bispecific antibodies directed against a viral epitope (nullxCD3 or CD123xnull) did not activate T cells or cause tumor cell killing in the various assays tested. Ab-178 had no impact on T cell activation when incubated with T cells alone. These results indicate that Ab-178 can potently and specifically activate T cells in the presence of CD123+ AML cells and induce their killing. Furthermore, because of the antibody format, this molecule is expected to have a longer half-life compared to smaller bispecific biologic scaffolds. Ab-178 is currently being evaluated pre-clinically for its potential to treat patients with AML.

Citation Format: Francois Gaudet, Jennifer F. Nemeth, Ronan McDaid, Yingzhe Li, Benjamin Harman, Hillary Millar, Alexey Teplyakov, John Wheeler, Jinquan Luo, Susan Tam, Sheng-Jiun Wu, Emily Chen, Alexander Babich, Yusri Elsayed, Ricardo Attar. Development of a CD123xCD3 bispecific antibody to treat acute myeloid leukemia (AML). [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1492.

Phase II multicentre trial of oral quisinostat, a histone deacetylase inhibitor, in patients with previously treated stage IB-IVA mycosis fungoides/Sézary syndrome

BACKGROUND

Quisinostat is a hydroxamate, second-generation, orally available pan-histone deacetylase inhibitor.

OBJECTIVES

To evaluate the efficacy and safety of oral quisinostat in patients with previously treated cutaneous T-cell lymphoma (CTCL).

METHODS

Patients received quisinostat 8 mg or 12 mg on days 1, 3 and 5 of each week in 21-day treatment cycles. Primary efficacy end point was cutaneous response rate (RR) based on the modified Severity Weighted Assessment Tool (mSWAT). Secondary end points included global RR, duration of response (DOR) in skin, progression-free survival (PFS), pruritus relief, safety and pharmacodynamic markers.

RESULTS

Eight of 26 (25 evaluable) patients achieved ≥ 50% reduction in mSWAT score at least once, with confirmed cutaneous response in six (RR 24%). There was a low global RR of 8%. DOR in skin ranged from 2·8 to 6·9 months. Median PFS was 5·1 months. Pruritus relief was more frequent in cutaneous responders (67%) than nonresponders (32%). Serial tumour biopsies revealed an increase in acetylated tubulin, indicating a target effect of histone deacetylase 6. Twenty-one of 26 (81%) patients were withdrawn from the study before or at clinical cut-off; five (19%) continued to receive treatment with quisinostat. The most common drug-related adverse events were nausea, diarrhoea, asthenia, hypertension, thrombocytopenia and vomiting. Grade 3 drug-related adverse events included hypertension, lethargy, pruritus, chills, hyperkalaemia and pyrexia.

CONCLUSIONS

Quisinostat 12 mg three times weekly is active in the treatment of patients with relapsed or refractory CTCL, with an acceptable safety profile. Combination therapy with other drugs active in CTCL may be appropriate.

A phase I study of quisinostat (JNJ-26481585), an oral hydroxamate histone deacetylase inhibitor with evidence of target modulation and antitumor activity, in patients with advanced solid tumors

PURPOSE

To determine the maximum-tolerated dose (MTD), dose-limiting toxicities (DLT), and pharmacokinetic and pharmacodynamic profile of quisinostat, a novel hydroxamate, pan-histone deacetylase inhibitor (HDACi).

EXPERIMENTAL DESIGN

In this first-in-human phase I study, quisinostat was administered orally, once daily in three weekly cycles to patients with advanced malignancies, using a two-stage accelerated titration design. Three intermittent schedules were subsequently explored: four days on/three days off; every Monday, Wednesday, Friday (MWF); and every Monday and Thursday (M-Th). Toxicity, pharmacokinetics, pharmacodynamics, and clinical efficacy were evaluated at each schedule.

RESULTS

Ninety-two patients were treated in continuous daily (2-12 mg) and three intermittent dosing schedules (6-19 mg). Treatment-emergent adverse events included: fatigue, nausea, decreased appetite, lethargy, and vomiting. DLTs observed were predominantly cardiovascular, including nonsustained ventricular tachycardia, ST/T-wave abnormalities, and other tachyarhythmias. Noncardiac DLTs were fatigue and abnormal liver function tests. The maximum plasma concentration (Cmax) and area under the plasma concentration-time curve (AUC) of quisinostat increased proportionally with dose. Pharmacodynamic evaluation showed increased acetylated histone 3 in hair follicles, skin and tumor biopsies, and in peripheral blood mononuclear cells as well as decreased Ki67 in skin and tumor biopsies. A partial response lasting five months was seen in one patient with melanoma. Stable disease was seen in eight patients (duration 4-10.5 months).

CONCLUSIONS

The adverse event profile of quisinostat was comparable with that of other HDACi. Intermittent schedules were better tolerated than continuous schedules. On the basis of tolerability, pharmacokinetic predictions, and pharmacodynamic effects, the recommended dose for phase II studies is 12 mg on the MWF schedule.

Phase 2 study of carlumab (CNTO 888), a human monoclonal antibody against CC-chemokine ligand 2 (CCL2), in metastatic castration-resistant prostate cancer

BACKGROUND

CC-chemokine ligand 2 (CCL2) promotes tumor growth by angiogenesis, macrophage infiltration and tumor invasion, and distant metastasis. Carlumab (CNTO 888) is a human IgG1κ mAb with high affinity and specificity for human CCL2. Preclinical data suggest carlumab may offer clinical benefit to cancer patients.

METHODS

In a phase 2, open-label study, patients with metastatic castration-resistant prostate cancer (CRPC) previously treated with docetaxel received a 90-min infusion of 15 mg/kg carlumab q2w. The primary endpoint was response rate: change from baseline in skeletal lesions, extraskeletal lesions, and PSA values. Secondary endpoints included overall response rate (CR + PR) by RECIST, OS, PSA response, safety, pharmacodynamics, pharmacokinetics, immunogenicity.

RESULTS

Forty-six patients were treated with 6 median (range 1, 26) doses. One patient had SD >6 months. There were no PSA or RECIST responses. Fourteen (34 %) patients had SD ≥ 3 months. Median OS was 10.2 (95 % CI: 5.2, not estimable) months. Twelve (39 %) patients reported improved pain scores. AEs occurred in 43 (93 %) patients, including 27 (59 %) with grade ≥ 3 AEs. Common grade ≥ 3 AEs were back (11 %) and bone (9 %) pain. Twenty (43 %) patients experienced SAEs, including pneumonia, spinal cord compression, back pain. No patient developed antibodies to carlumab. Steady-state serum concentrations were achieved after 3 repeated doses and were above the 10-μg/mL target concentration. Suppression of free CCL2 serum concentrations was briefly observed following each dose but was not sustained.

CONCLUSION

Carlumab was well-tolerated but did not block the CCL2/CCR2 axis or show antitumor activity as a single agent in metastatic CRPC.

Abstract A164: Cardiac effects in a first-in-human (FIH), pharmacokinetic (PK), pharmacodynamic (PD) phase I trial of JNJ-26481585, a second-generation oral hydroxamate histone deacetylase inhibitor (HDACi), in patients with refractory cancer

Background: HDACi have demonstrated activity as anticancer agents and are licensed for use in cutaneous and peripheral T cell lymphoma. Cardiac effects including arrhythmias and QTc prolongation have previously been associated with HDACi administration in humans. This report summarizes the cardiac adverse event (AE) profile observed during the recently completed FIH Phase I trial of JNJ26481585.

Methods: Continuous oral daily dosing (QD) of JNJ26481585 in 21-day (D) cycles (C) was investigated initially in 20 patients (pts) demonstrating activity (including 1 partial response, 1 minor response, 1 prolonged stable disease in melanoma) but ventricular arrhythmia (2 pt) and fatigue (1 pt) were dose-limiting. To improve tolerability, 3 intermittent schedules (QD Mon/Wed/Fri (MWF); QD Mon/Tue/Wed/Thu (MTWT); QD Mon/Thu (MT)) also in 21-D C were subsequently explored in 38 (including expansion cohort), 19 and 15 pts respectively. All pts had triplicate 12-lead ECG (tECG), 24 hour ECG (Holter) and echocardiography or MUGA scan for assessment of left ventricular ejection fraction (LVEF) at baseline and during treatment. Analysis of mean QTcF, categorical QTcF and preliminary assessment of cardiac rhythm/morphology was performed.

Results: 12mg QD MWF was identified as the recommended Phase II dose (RP2D) based on safety, tolerability, PK predictions and PD activity. Maximum average increase in mean QTcF from baseline ranged from 0 to 8 milliseconds (ms) during cycles 1 and 2 across the 4 schedules. At RP2D, the maximum average increase in mean QTcF observed was 6ms. 1 out of 38 pts (2.6%) treated on the MWF schedule experienced a Grade (G) 3 QTcF prolongation, possibly related to ST-T segment changes identified as a class effect of HDACi. QTcF prolongation G1–2 was rarely observed across schedules and mostly occurred as an isolated reversible observation whilst on study drug. Reversible, non-sustained ventricular tachycardia (NSVT) was observed as a dose limiting toxicity (DLT) in 3 out of 39 pts (7.7%) receiving QD or MTWT dosing but was not observed on the MWF or MT schedules. Other reversible, but dose-limiting, cardiac effects were T-wave inversion (2 pts on MT and MTWT), supraventricular tachycardia (1 pt on MT) and hypertension with raised troponin (1 pt on MWF). Non-specific, reversible, asymptomatic ST-T segment changes were frequently observed. LVEF was unaffected during treatment with JNJ26481585.

Conclusion: The RP2D of JNJ26481585 was determined as 12 mg on the MWF schedule and demonstrated an acceptable cardiac safety profile. One pt had QTcF>500 ms but no clinically significant effect on the QTcF interval was observed across schedules. Reversible NSVT was identified as a DLT in some patients on the QD and MTWT dosing schedules but not on the MWF and MT schedules.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2011 Nov 12-16; San Francisco, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2011;10(11 Suppl):Abstract nr A164.

Abstract A37: Development of biologics targeting soluble ligands: Novel biomarker and PK-PD analyzes examining free and total ligand profile following treatment with carlumab (anti-CCL2 mAb)

Background: Despite the large numbers of antibodies targeting soluble ligands in development in oncology and other therapeutic areas, very few reports have described pharmacodynamic (PD)/ mechanism of action (MOA) biomarkers of free ligand or total (antibody-complexed) ligand and their PK-PD relationship. Carlumab is a human IgG1 monoclonal antibody that binds the chemokine CCL2, which is a potent chemoattractant for tumor associated macrophages and promotes tumor growth and metastasis. Therapeutic targeting of CCL2 was based on the hypothesis that carlumab binding would inhibit chemokine activity and block tumor inflammation and macrophage differentiation thereby impairing tumor growth and metastases. Because proof of concept (POC) is a major milestone in early drug development, the objective of this study was to develop key PD/MOA biomarkers to facilitate the clinical evaluation of POC for carlumab. This required the development of robust analytical assays to accurately measure free and total CCL2 concentrations in the serum, and mechanistic PK-PD modeling for data analysis.

Methods: Carlumab was evaluated in three oncology clinical studies (as monotherapy in a Phase 1 first-in-human trial in patients with solid tumors, a Phase 1b chemotherapy combination study, and as a single agent Phase 2a study in patients with advanced prostate cancer). Biomarkers evaluated included free and total CCL2 concentrations in serum, a broad panel of soluble biomarkers, bone turnover markers, and circulating tumor cell (CTC) enumeration. Sequential tumor biopsies in ten patients from Phase 1 study yielded 4 paired specimens for immunohistochemical analysis of tumor associated macrophages (TAMs). A mechanistic PK-PD model that simultaneously characterized free and total CCL2, and carlumab concentrations in serum was used to estimate biologically effective doses that would inhibit CCL2 signaling.

Results: Analysis of CCL2 levels following carlumab administration revealed a rapid fall in free CCL2 as expected; however, post-treatment free CCL2 levels rapidly rebounded and quickly exceeded pretreatment serum concentrations. Two different analytical methods showed that carlumab suppressed CCL2 levels for only ∼24 hrs followed by a sustained increase in CCL2 concentration with subsequent treatment. These surprising results suggest that carlumab was ineffective at neutralizing free CCL2. PK-PD modeling confirmed the transient suppression of free CCL2 consistent with a higher carlumab dissociation constant (Kd) for CCL2 binding in vivo. Finally, carlumab did not affect other biomarkers including bone turnover markers or CTC numbers, consistent with an inability to impact CCL2 signaling. No evidence of clinical efficacy was observed in any of carlumab clinical trials.

Conclusion: Development of robust analytical assays to measure free and total CCL2 concentration and utilization of mechanistic PK-PD modeling facilitated the clinical evaluation of POC for carlumab. The unexpected increase in free CCL2 concentration and the lack of CCL2 target suppression likely explain the absence of carlumab clinical activity. Supportive biomarker analyzes and mechanistic PK-PD modeling are important components of the early development clinical plan for developing biologics against soluble ligands.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2011 Nov 12-16; San Francisco, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2011;10(11 Suppl):Abstract nr A37.

Bortezomib in a phase 1 trial for patients with relapsed AL amyloidosis: cardiac responses and overall effects

BACKGROUND

Bortezomib is approved for the treatment of multiple myeloma and a role has been suggested in the treatment of systemic AL amyloidosis (AL).

METHODS

In this phase 1 dose-escalation portion of the first prospective study of single-agent bortezomib in AL, 31 patients with relapsed disease, including 14 (45%) with cardiac involvement, received bortezomib in seven dose cohorts on once-weekly (0.7, 1.0, 1.3, 1.6 mg/m(2)) and twice-weekly (0.7, 1.0, 1.3 mg/m(2)) schedules. Electrocardiographic, Holter and echocardiographic studies were evaluated in all patients to determine safety and response.

RESULTS

During therapy (median treatment period 210 days), no patient developed significant ventricular or supraventricular rhythm disturbance on 24-h Holter monitoring; however, no patient satisfied study criteria for cardiac response using echocardiographic assessment or New York Heart Association classification. Seven patients (23%) had a ≥ 10% fall in left ventricular ejection fraction, but only one met criteria for cardiac deterioration. The predominant cardiac adverse events were peripheral edema (23%), orthostatic hypotension (13%) and hypotension (10%). Two patients developed grade 3 congestive heart failure, which resolved following treatment interruption. In this Phase 1 portion, the maximum tolerated dose of bortezomib on either schedule was not reached. Hematologic responses occurred in 14 patients (45%), including seven (23%) complete responses. In non-responders mean left ventricular wall thickness increased during the course of treatment.

CONCLUSION

AL is frequently rapidly progressive; in these patients who had relapsed or progressed following previous conventional therapies, these results suggest that bortezomib may slow the progression of cardiac amyloid with limited toxicity.

Phase I trial of weekly trabectedin (ET-743) and gemcitabine in patients with advanced solid tumors

PURPOSE

To determine the maximum tolerated dose (MTD) of trabectedin plus gemcitabine administered on a weekly schedule in patients with advanced solid tumors.

METHODS

Patients with ECOG performance status 0-1 and adequate organ function were enrolled. On days 1, 8, and 15 of a 28-day cycle, patients received gemcitabine (starting dose, 800 mg/m(2)) followed by trabectedin (starting dose, 0.3 mg/m(2)). Strict liver function test treatment criteria were employed to avoid hepatic toxicity seen in previous trabectedin studies. Plasma samples were collected during cycles 1 and 2 for pharmacokinetic analyses.

RESULTS

Fifteen patients received >or=1 dose, with a median of two treatment cycles (range 1-10). The most common drug-related toxicity was hepatic. Dose reductions were required for trabectedin in four (27%) patients and gemcitabine in six (40%) patients. Cycle delays/dose holds were required in 11 (73%) patients and doses above trabectedin 0.4 mg/m(2) and gemcitabine 1,000 mg/m(2), which is the recommended phase II dose, were not feasible. Seven patients maintained stable disease after two cycles. Gemcitabine and trabectedin pharmacokinetics were not altered substantially with concomitant administration.

CONCLUSIONS

Given the lack of pharmacokinetic interaction and potential efficacy of trabectedin and gemcitabine combination therapy, further study is warranted with alternate schedules.

Randomized phase II study of trabectedin in patients with liposarcoma and leiomyosarcoma (L-sarcomas) after failure of prior anthracylines (A) and ifosfamide (I)

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Background: Trabectedin, a marine-derived antineoplastic agent, binds to the minor groove of DNA and has previously shown activity in L-sarcomas in single-arm trials. This multicenter, randomized study aimed to characterize the anticancer efficacy with two dosing regimens of trabectedin in pts with treatment-refractory L-sarcomas. Methods: Eligible pts had measurable advanced L-sarcoma, progression despite at least prior A and I, PS 0–1 and adequate organ function. Pts were randomized to IV trabectedin, 1.5 mg/m2, 24h every 3 weeks (q3wk-24h) or 0.58 mg/m2, 3h weekly × 3 on a 28-day cycle (qwk-3h). Primary endpoint is time-to-progression (TTP) and secondary endpoints PFS, overall survival, response, and safety. With 217 events, study provided 90% power to detect a 37% risk reduction in TTP (2-sided 5% significance). Results: 270 pts were randomized as of 5/31/06. Baseline characteristics were comparable: median (range) 2 (1–7) metastatic sites and 2 (1–6) prior regimens; 62% had additional prior agents; 67% had bulky (≥5cm) disease. In the q3wk-24h vs qwk-3h arms median n. cycles were 5 (1–37) vs 2 (1–21); 38% vs 19% received ≥7 cycles. In protocol-specified primary analysis, median (95% CI) TTP was 3.7 (2.1–5.4) vs 2.3 (2.0–3.5) mo [HR: 0.734; p=0.0302] favoring the q3wk-24h arm. Median PFS was 3.3 (2.1–4.6) vs 2.3 (2.0–3.4) mo [HR: 0.755; p=0.0418] and median survival (n=175 events) was 13.8 (12.5–17.9) vs. 11.8 (9.9–13.9) mo [HR: 0.823; p=0.1984]. Benefit from the q3wk-24h arm was more pronounced in pts with central pathology confirmed diagnosis of L-sarcomas. More neutropenia, ↑AST/ALT, emesis and fatigue occurred in the q3wk 24-h. Febrile neutropenia was rare (0.8–1.6%). No cumulative toxicities were noted. Conclusions: Trabectedin can provide clinical benefit to pts with L-sarcoma following failure of all conventional treatment options. Significantly better TTP was noted with the q3wk-24h regimen, although this resulted in somewhat more neutropenia and transaminitis without clinical consequences. No cumulative toxicities were apparent in either arm. Although both dosing regimens are efficacious, there appears to superior disease control with the q3wk-24h arm in this population.

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Phase I and Pharmacokinetic Study of MS-275, a Histone Deacetylase Inhibitor, in Patients With Advanced and Refractory Solid Tumors or Lymphoma

Purpose

The objective of this study was to define the maximum-tolerated dose (MTD), the recommended phase II dose, the dose-limiting toxicity, and determine the pharmacokinetic (PK) and pharmacodynamic profiles of MS-275.

Patients and Methods

Patients with advanced solid tumors or lymphoma were treated with MS-275 orally initially on a once daily × 28 every 6 weeks (daily) and later on once every-14-days (q14-day) schedules. The starting dose was 2 mg/m2and the dose was escalated in three- to six-patient cohorts based on toxicity assessments.

Results

With the daily schedule, the MTD was exceeded at the first dose level. Preliminary PK analysis suggested the half-life of MS-275 in humans was 39 to 80 hours, substantially longer than predicted by preclinical studies. With the q14-day schedule, 28 patients were treated. The MTD was 10 mg/m2and dose-limiting toxicities were nausea, vomiting, anorexia, and fatigue. Exposure to MS-275 was dose dependent, suggesting linear PK. Increased histone H3 acetylation in peripheral-blood mononuclear-cells was apparent at all dose levels by immunofluorescence analysis. Ten of 29 patients remained on treatment for ≥ 3 months.

Conclusion

The MS-275 oral formulation on the daily schedule was intolerable at a dose and schedule explored. The q14-day schedule is reasonably well tolerated. Histone deacetylase inhibition was observed in peripheral-blood mononuclear-cells. Based on PK data from the q14-day schedule, a more frequent dosing schedule, weekly × 4, repeated every 6 weeks is presently being evaluated.

Signal transduction--directed cancer treatments

The pathogenic mechanisms giving rise to cancer frequently involve altered signal transduction pathways. Therefore therapeutic agents that directly address signal transduction molecules are being explored as cancer treatments. Inhibitors of protein tyrosine and threonine kinases including STI-571, ZD-1839, OSI-774, and flavopiridol are ATP-site antagonists that have completed initial phase I and phase II evaluations. Herceptin and C225 are monoclonal antibodies also directed against signaling targets. Numerous other kinase antagonists are in clinical evaluation, including UCN-01 and PD184352. Alternative strategies to downmodulate kinase-driven signaling include 17-allyl-amino-17-demethoxygeldanamycin and rapamycin derivatives, and phospholipase-directed signaling may be modulated by alkylphospholipids. Farnesyltransferase inhibitors were originally developed as inhibitors of ras-driven signals but may have activity by affecting other or additional targets. Signal transduction will remain a fertile basis for suggesting cancer treatments of the future, the evaluation of which should include monitoring effects of the drugs on their intended target signaling molecules in preclinical and early clinical studies.