guenther koehne, md phd adult bone marrow transplant...
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Allotransplant: Is there a role in myeloma?
Guenther Koehne, MD PhD
Adult Bone Marrow Transplant ServiceDivision of Hematologic Oncology
Department of MedicineMemorial Sloan-Kettering Cancer Center
New York, New York
Autologous SCT
Who?
When?
How?
Maintenance?
Allogeneic SCT
Who?
When?
How?
Maintenance?
“Toward developing novel therapies, we recommend a concerted focus on patients with high-risk myeloma whose
outcome has not been advanced”
Barlogie B. Blood. 2014
High-risk Disease
1. High-risk cytogenetics: 25% of patients
– Deletion 17p: del(17p)
• 10% of newly diagnosed patients
• Associated with aggressive disease and shorter overall survival
– Translocation of the immunoglobulin heavy chain (IgH) locus on chromosome 14
• t(4;14); t(14;16)
– Deletion 13q: del13q
• Related to association with t(4;14) and del17p
– Hypodiploidy
2. Early relapse - 15 – 20 months post auto SCT w or w/o high risk cytogenetics
3. R - ISS
High risk disease affects outcome and should therefore affect treatment
R- ISS
Antonio Palumbo et al. JCO 2015;33:2863-2869
Allogeneic SCT
Who?Risk stratification based on high-risk factors
When?Sooner than later
How?Myeloablative/TCD HSCT
Maintenance?Immunotherapeutic Approaches
Allogeneic Vs. Autologous
US intergroup trial (S9321)
N = 813Induction Therapy
VAD
RANDOMIZE
n=261HD-CTX
collection
N=255HD-CTX
collection
n=213HDT
Mel/TBIautotransplant
n=211SDT
VBMCPautotransplant
n=39<55 years
HLA matched sibling
n= 36Mel/TBI
allotransplant
GVHD prophylaxis
x TRM:53%
HD-CTX, high-dose cyclophosphamide; HDT, high dose therapy; HLA, human leukocyte antigen; MEL, melphalan; SDT, standard dose therapy; TBI, total body irradiation; VAD, continuous infusion of vincristine and doxorubicin plus high-dose dexamethasone;VBMCP, vincristine, carmustine, melphalan, cyclophosphamide, and prednisone. Barlogie B, et al. J Clin Oncol. 2006; 24:929-936.
Summary of Recent Studies With Non-Myeloablative Conditioning for Multiple Myeloma
Study Conditioning Transplant(No. Pts)
PFS / OS TRM Acute GvHD Chronic GVHD
Bruno, et alN Engl J of Med2007
TBI 200 cGy 80 36%
@ 3 y
80%
@ 3 y
10% 43%Grade II ‒IV
63%
Extensive – 32%
Rosiñol, et alBlood2008
Mel 140/FLU 25 Median not reached
Median not reached
16% 32%Grade II‒IV
66%
Vesole, et alBiol Blood Marrow Transplant2009
FC 31 58%
@ 3 y
78%
@ 3 y
8% 17%Grade III‒IV
57%
Extensive – 26%
Krishnan, et alLancet Oncol2011
TBI 200 cGy SR: 189
HR: 37
43%
40%
@ 3 y
77%
59%
@ 3 y
11% 26%Grade II‒IV
54%
Björkstrand, et alJ Clin Oncol2011
TBI 200 cGy /FLU
108 35%
@ 5 y
65%
@ 5 y
12% 20%Grade II‒IV
54%
Extensive –23%
FC, fludarabine plus cyclophosphamide; FLU, fludarabine; HR, high risk; OS, overall survival; PFS, progression-free survival; SR, standard risk. Koehne G, Giralt S. Curr Opin Oncol. 2012;24:720-726.
Current Study at MSKCC:
TCD HSCT for Multiple Myeloma – IRB #10-051
• Phase II study of TCD Allogeneic Transplantation for Relapsed
High-Risk Multiple Myeloma
– Principle Investigator: Guenther Koehne MD, PhD
• Eligibility Criteria:
Relapsed multiple myeloma following ASCT
High risk cytogenetics or relapse ≤ 15 months postASCT
At least PR to salvage therapy prior to TCD HSCT
• Conditioning: Bu/Mel/Flu (+ ATG)
• TCD: CliniMacs device: CD34+ cells positively selected
G. Koehne. et al MSKCC
Design of Study: TCD (CD34+ selection) ASCT
for Multiple Myeloma
-DLI (5x105 CD3+/Kg) at earliest 5-6 months post SCT-DLI (5x105 CD3+/Kg) at earliest 8-9 months post SCT-DLI (1x106 CD3+/Kg) at earliest 12-13months post SCT
-DLI (1x105 CD3+/Kg) at earliest 5-6 months post SCT-DLI (5x105 CD3+/Kg) at earliest 1-3months post SCT, following the first infusion-DLI (1x106 CD3+/Kg) at earliest 3-4months post SCT, following the second infusion
Prophylactically in recipients of HLA-matched allografts
Preemptively in recipients of HLA-mismatched allografts
DLI, donor lymphocyte infusion.Courtesy of Koehne G, et al. MSKCC.
Busulfan:0.8 mg/kg x 10 dosesMelphalan:70 mg/m2 x 2 dosesFludarabine:25mg/m2 x 5 dATG: 2.5 mg/kg x 2 d
G. Koehne. et al MSKCC
U
P
N
MM Cytogenetics Prior Lines of TX (Detail)
Prior
Lines of
TX
Age at
BMTBMT Match Donor
17 IgA Lambda extra1q, del(13q), t(4:14) COP + MP; Thal; Thal; BDD x3;Mel + auto SCT
#1,Thal maintenance; RDx4; RVD; BDD x2; VDT-Pace x4; Mel+ auto SCT #2
10 59 9/8/2010 9/10 Unrelated
18 IgG Kappa del(13q), der(1)TD Dex x5; Mel + tandem auto SCT, TD; XRT;
Bortez + Doxil; Revlimid; BD; RD; DCEP x7 8 61 11/10/2010 9/10 Unrelated
19 IgG Lambda NormalCyD x2; BD x2; Mel + auto #1 SCT; VD; RD/Mel;
Mel + auto SCT #26 57 12/2/2010 10/10 Related
20 IgG Kappa Normal TD x4; RVD RD x5; Mel + auto SCT #1; RVD 4 54 12/10/2010 10/10 Unrelated
21 IgG Kappa p53, tri 17, 5p, 11, 15, BiRD x5; Mel+ auto SCT #1; RVD; Rev
maintenance; CyBorD x5; VDT-PACE x2; Mel + auto SCT #2
7 37 3/2/2011 10/10 Unrelated
22 IgG Kappa NormalBDDx3; TDx2; Rev; Mel + auto SCT #1, Rev
maintenance; Mel+ auto SCT #2, Revmaintenance; VDT-PACE x2; R-VDC x3
7 49 4/14/2011 10/10 Unrelated
23 Nonsecretory del(20q), del(13q), del(17p), p53 Pulse dose dex; VADx4; BDx4 ; Mel+ auto SCT #1,
BD maintenance; RD; Mel + auto SCT #2; BiRDmaintenance
7 63 4/20/2011 10/10 Related
24 IgG Kappa MLL, del(13q), IgH, p53 Pulse dose dex x2; BBD x2; TD x2; Mel + tandem
auto SCT, XRT, maintenance Thal; RVD x 10 5 45 5/26/2011 10/10 Unrelated
25 IgG Lambdaextra 1q23 and 19p13, IgH, MLL,
del p53, extra of 1q, 1p, del(13) and del(17p), extra 4,11, and 14
TD x 3 ; BD x3; RD, VD-PACEx1; VD-PACE x3; Mel + auto SCT #1; Bortez maintenance
6 60 6/3/2011 10/10 Unrelated
26 IgG Lambdaextra 1q25, mono 13, Der3, I5p, I5q,
trans IgH locus, del(17p)
TD x1; RD x4; Cytoxan Mel + auto SCT #1; XRT/Dex RD x6; Mel + auto SCT #2, Rev
maintenance; CyBorD x3; CyBorD x27 62 8/31/2011 10/10 Unrelated
27 IgG LambdaDup(1q), del(4p), 1q25, tri(9), mono (13), tri 15, mono 16, loss p53 gene,
MLL
RVDRD x 4; Mel + auto SCT #1;RVDRDR; DCEP+RVDRD; BD + Benda; VDT-PACE x1; Mel +
auto SCT #2 7 56 9/21/2011 9/10 Unrelated
28 IgG Kappadel(1)(p13p22), +3,+5+9,+11,del(13),
(q12q14), del(14)(q24), der(16), t(11;16), (p13.1;q24
RVD x9; XRT; Mel + auto SCT #1; VD x3; RVD; VDT-PACE x3;Mel+ auto SCT #2
7 61 10/21/2011 9/10 Unrelated
29 Lambda LC NormalT-BIRD; Mel + auto SCT; maintenance Rev; RD;
RVDx1VDx65 56 12/29/2011 10/10 Unrelated
30 IgG Lambda NormalRVDx6; Cytoxan Mel + auto SCT #1,
maintenance Rev; ClaPD x5; Car x3; VDT-PACE; Mel + auto SCT #2
6 50 2/1/2012 10/10 Related
Acute GvHD + NRM (n=44)
Chronic GvHD has not been observed in any patient.
Biol Blood Marrow Transplant, 09/2015
Overall + Progression-free survival (n=44)
Median follow up for
survivors:
25 months (11.2 – 82mos)
54%
42%
31%
18%
Biol Blood Marrow Transplant, 09/2015
OS by lines of therapy PFS by lines of therapy
57%
25%
42%
67%
Biol Blood Marrow Transplant, 09/2015
OS by disease status PFS by disease status
62%
19%
62%
47%
22%
14%
Biol Blood Marrow Transplant, 09/2015
OS by extramedullary disease PFS by extramedullary disease
66%
53%
31%
21%
41%
30%
Biol Blood Marrow Transplant, 09/2015
Relapsed patient population w/o extramedullary disease, VGPR prior to transplant and < 6 lines of prior therapy
0.0
0.2
0.4
0.6
0.8
1.0
Months following BMT
Su
rviv
al
0 6 12 18 24 30 36 42 48
Overall Survival, N=13
Progression-free Survival, N=13
Follow-up among survivors42.5 mos (9.8-87.1)
OS –48 months 1.00
PFS 24 months : 0.75 (0.53-1)48 months: 0.53 (0.3-0.95)
Adoptive Immunotherapy post TCD HSCTfor Multiple Myeloma
Single Patient Response
DLI 5x10e5/kg 06/09
72 months in CR79 months post allo BMT
39-year-old male dx stage III IgA lambda, multiple myeloma (MM) high-risk cytogenetics (del 13; t(4;14). Velcade (Vel)/Dexamethasone (Dex) x 6, autoSCT 9/07
with relapse disease 12/07, Lenalidomide/Dex x1, Vel/Dexx2, alloHSCT from matched related donor (10/10) in 06/08,
in complete remission (CR) since 5/09.
WT1-Specific T-Cell Responses in Patientswith Multiple Myeloma
A2-RMG, HLA-A2 restricted peptide; CMB, cytomegalovirus; MHC, major histocompatibility complex; WT1, Wilms tumor gene product 1. Tyler EM, et al. Blood. 2013;121:308-317.
WT1-specific T cells by MHC tetramer
A24-CMV
A2-RMF
4/2/09
04/09 Blood 01/11 Bone Marrow 01/11
3.5% 1.0 % 2.9 %
A2-RMF
CD
8+
CD
8+
Cheever MA et al. The Prioritization of Cancer Antigens: A National Cancer Institute Pilot Project for the Acceleration of Translational ResearchClinical Cancer Res. 2009.
Wilms Tumor Antigen 1 (WT1)—
WT1: zinc finger transcription factor
— Roles in cell proliferation, differentiation, apoptosis and organ development
— Oncogene
Preferentially expressed during embryogenesis, but also at low levels in
kidney, ovary, endometrium, testis and spleen of adults
Frequently overexpressed in a number of solid and hematologic malignancies
— Expression correlates with disease progression in MDS, ALL, & CML
— Molecular marker for risk assessment
Wilms Tumor Antigen 1 (WT1)—A Potential Target for Multiple Myeloma?
IHC With WT1 mAb 6F-H2
CD138 (brown)/ WT1 (red) co-staining of BM biopsy
WT1 (red) co-staining of kidney biopsy CD138 (brown) staining of BM biopsy
BM, bone marrow; IHC, immunohistochemistry.Tyler EM, et al. Blood. 2013;121:308-317.
IHC Analyses of WT1 Expression in the BM of MM pts
++++ +++CD138 (MI15; DAB) = brown; WT1 (6F-H2, nFu) = red
++
Focal Negative Grading
Neg 0Focal < 5%+ < 25%++ 25 – 50%+++ 50 – 75%++++ > 75%
90% PC’s by biopsy
50 -60 % PC’s by biopsy
45% PC’s by biopsy
5% PC’s by biopsy No PC’s by biopsy
DAB 3,3-diaminobenzidine; nFU, nFu1 antibody; PC, plasma cell. Tyler EM, et al. Blood. 2013;121:308-317.
TCR-like mAbs allow to target intracellular
tumor Ags by binding to MHC/Peptide
Complex
T-CellReceptor(TCR)
MHC Class I“HLA”
Cytotoxic CD8+
T CellCancer Cell
TCR-like mAb
Peptide
Dao & Scheinberg
Developing TCR-like mAbs specific for the
WT1p/HLA-A2 complex
A high-affinity fully human IgG1 mAb (ESK1”) specific to
the RMFPNAPYL/HLA-A0201 complex
was developed by use of phage display technology.
1) To select patients for Immunotherapy.
2) To study antigen presentation and immunobiology.
3) To mediate immunotherapy via CDC, ADCC and other mechanisms.
Dao & Scheinberg
Binding of ESK1 to PBMCs from healthy donors. Gated cells are listed on y axis.
Left column is A02 + and right column is A02 -.
(1 representative of 16 samples)
Red = ESK1; Blue = isotype control mAb. (Dao and Scheinberg, unpublished)
ESK-1 staining of MM BMMC of patient with plasma cell leukemia
ESK
hIg
G
CD38 CD38
BB7= mouse Abagainst HLA-A2
94.9%
HLA-A2+
CD
38
ESK1 hIgG1 ESK1 hIgG1
HLA-A2-
94.1% 71.9%
27.4%
68.8%
31.1%
ESK-1 staining of MM BMMC of HLA-A*2 pos and neg individuals with plasma cell leukemia
Dates HLA-A2 ESK IgG Fk/FL M-Spike BM WT1
9/11/13 + - 380 .05/.05 None 0% neg
CD38+CD45-CD56+
ESK Isotype WT1 (6F-H2)
ESK-1 and IHC staining of MM BMMC of HLA*0201 positive patient with plasma cell leukemia in remission.
Dates HLA-A2 ESK IgG FK/FL M-Spike BM WT1
10/16/13 - - 2343 3.13/.83 1.3 20% +++
ESK Isotype
CD38+CD45-CD56+
WT1 (6F-H2)
ESK-1 and IHC staining of MM BMMC of HLA*0201 negative patient with multiple myeloma in relapse.
Dates HLA-A2 ESK IgG Fk/FL M-Spike BM WT1
9/18/13 + + 1436 1.76/.12 0.8 10% +
ESK Isotype
CD38+CD45-CD56+
WT1 (6F-H2)
ESK-1 and IHC staining of MM BMMC of HLA*0201 positive patient with multiple myeloma in relapse.
Phase I Trial #IRB 12-175:TCD (CD34+ selection) Allo SCT Followed by WT1-Specific T-Cell
Infusions for Patients With Relapsed/Refractory Multiple Myeloma or Plasma Cell Leukemia
Busulfan:0.8 mg/kg x 10 dosesMelphalan:70 mg/m2 x 2 dosesFludarabine:25mg/m2 x 5 dATG: 2.5 mg/kg x 2 d
WT
WWT1-specific CTLs
WT1 CTLs - Dose levels 1, 3 and 5 x10e6/ kg; -3 doses/recipient of HLA-matched and HLA-mismatched allografts. -First dose at 6-10 weeks post transplant. -The second dose will be given 4-8 weeks following the first infusion and a third dose will be administered 4-8 weeks following the second infusion. -The second and third dose will only be administered in the absence of grade III-IV toxicity and grade II-IV acute GvHD following the preceding T-cell dose.
CTL, cytotoxic T lymphocytes.Courtesy of Koehne G, et al. MSKCC.
10aa overlap
LQLAL
570
HNMHQRNMTK
560
FARSDELVRH
550
SCRWPSCQKK
HTGKTSEKPFSDHLKTHTRTCKTCQRKFSRRRHTGVKPFQSRSDQLKRHQCDFKDCERRF
540530520510500490
RKHTGEKPYQFKLSHLQMHSCAYPGCNKRYSETSEKRPFMGVAPTLVRSARGIQDVRRVP
480470460450440430
QYRIHTHGVFNHTTPILCGASNHSTGYESDSSSVKWTEGQATLKGVAAGSCMTWNQMNLG
420410400390380370
NLYQMTSQLELLLRTPYSSDPTDSCTGSQAVPPPVYGCHTQGSLGEQQYSSFKHEDPMGQ
360350340330320310
SHHAAQFPNHDGTPSYGHTPRNQGYSTVTFPSCLESQPAIARMFPNAPYLPPPSQASSGQ
300290280270260250
GACRYGPFGPHFSGQFTGTAEEQCLSAFTVEPSWGGAEPHPPPPHSFIKQAPPPAPPPPP
240230220210200190
ASAYGSLGGPAPVLDFAPPGALPVSGAAQWVPSLGGGGGCVRDLNALLPAGSEPQQMGSD
180170160150140130
LQGRRSRGASLGAAEASAERVRDPGGIWAKGCLQQPEQQGASQHTLRSGPDPASTCVPEP
120110100908070
AAILDFLLLQAQAPGPRRLLPTHPPRAGTAFPPSLPPTHSRNPTACPLPHSRQRPHPGAL
605040302010
RNPTACPLPHFPP
SL
SRQRPHPGALRNPTA
HPGALRNPTACPLPH
10aa overlap
10aa overlap
#1:
#2:
#3:
Overlapping (10aa)
Pentadecapeptides
A. The sequence of the WT1 protein.
113112111
110109108107106105104103102101
100999897969594939291
90898887868584838281
80797877767574737271
70696867666564636261
60595857565554535251
50494847464544434241
40393837363534333231
30292827262524232221
20191817161514131211
10987654321
22
21
20
19
18
17
16
15
14
13
12
11
10987654321
WT1 peptide pools: 10 and 16
Pentadecapeptide #60
QFPNHSFKHEDPMGQ
B. WT1 peptide sub pools for epitope mapping
Legend:
A. The sequence of the
WT1 protein consisting
of 575 amino acids and
the principle of 10
amino acid overlapping
pentadecapeptides are
illustrated. A total of
113 pentadecapeptides
are required to span the
entire protein.
B. A total of up to 11
pentadecapeptides are
contained within one
pool and 22 of such
pools are required to
over-span the WT1
protein. For example
pentadecapeptide #60
is contained in pools
##10 and 16.
WT1 protein sequence:
OVERLAPPING WT1 PENTADECAPEPTIDE TOTAL POOL
CD
8
CD
8
IFN-g
1.77%
Pentadecapeptide #61
0.82%3.65%
0.5%
Pentadecapeptide #62 Pentadecapeptide #69
Pentadecapeptide #70
IFN-g
Pool 11 Pool 13Pool 12Pool 14
Pool 17 Pool 18
Pool 21 Pool 22
20.2% 0.6% 0.3% 0.75%0.73%
0.26% 14.5%3.53% 0.31%
0.45%
0.51%0.39% 0.34%
Pool 20
Pool 10
Pool 15 Pool 19Pool 16
HLA type of responding T cells:
A0201 B 3501 C0702 DRB10701 DQB10201
A0201 B0702 C0701 DRB10101 DQB10501
0
20
40
60
80
100
A0201 B0702
C0702
DRB1 0701
DQB10201
DRB10101
DQB1 0501
B3501 C 0701 autologous
BLCL
B3501+WT1+B-ALL
targets
% o
f cyto
toxic
ity
C.
Peptide # 50: ASSGQARMFPNAPYL
Peptide #59: SHHAAQFPNHSFKHE
Peptide#60: QFPNHSFKHEDPMGQ
Peptide #61: SFKHEDPMGQQGSLG
Peptide #62: DPMGQQGSLGEQQYS
Peptide #69: LLLRTPYSSDNLYQM
Peptide #70: PYSSDNLYQMTSQLE
Pool 5 Pool 8
0.27% 0.25% 0.32% 0.08%
Pool 6 Pool 7 Pool 9
3.19%
HLA class I restricted CTL stimulated with WT1 total pool: epitope mapping
B.
0.98% 6.92%
Pentadecapeptide #50 Pentadecapeptide #59 Pentadecapeptide #60
18.1%
Pool 3
0.35% 0.45%0.76% 0.32%
PBMC only Pool 1
0.35%
Pool 2 Pool 4A.
-WT1- EBV BLCLs
-EBV BLCLs loaded
with peptide#60
Plasma Cell Leukemia
Overall Survival (OS) in pPCL and sPCL, showing superior survival of pPCL vs sPCL from the time of leukemia diagnosis.
pPCL, primary plasma cell leukemia; sPCL, secondary plasma cell leukemia.Albarracin F, Fonseca R. Blood Rev. 2011;25:107-112.
Case―61-Year-Old AA Female With Secondary Plasma Cell LeukemiaUndergoing TCD HSCT Followed by WT1 CTLs
Residual Disease Post VDT-PACE, but HLA-Matched Brother
0
10
20
30
40
50
60
70
Donor PHA Blasts
Donor DC Donor DC Pulsed
K562
% C
yto
toxi
city
E:T
25
:1
Immune Reconstitution Post-WT1-CTL Infusions
TCD HSCT02/13/12
WT1 #11x10e6/kg04/18/12
WT1 #2 1x10e6/kg05/16/12
WT1 #3 1x10e6/kg06/13/12
IFN
-γ
CD8
CD4IF
N-γ
TCD HSCT02/13/12
WT1 #11x10e6/kg04/18/12
WT1 #2 1x10e6/kg05/16/12
WT1 #3 1x10e6/kg06/13/12
WT1 all pools6/13/12
Figure 7
Disease Course of patient with secondary PCL after T-cell depleted transplant +
administration of donor-derived WT1 -specific CTLs
IHC With CD138 + WT1 mAb 6F-H2
Relapse11/11
Post allo BMT + WT1 CTL #1
05/16/12
Disease Course of patient with primary PCL after T-cell depleted transplant +
administration of donor-derived WT1-specific CTLs
Approaches to Allogeneic SCT for High-Risk Multiple Myeloma
InductionConsolidation/
ConditioningMaintenance
Relapse
# lines of treatment
VDT-PACE
2nd salvage auto SCT
Upfront
TCD HSCTImmunotherapy
DLI
Antigen-specific CTLs
Elotuzumab ?
1.
2.
Wilms Tumor Antigen 1 (WT1)—a potential target for multiple myeloma?
Do we need GvHD to prevent relapse in multiple myeloma?
Summary
CD34+-selected allografts a platform for adoptive immunotherapy?
Acknowledgement
Research Team
Eleanor Tyler, PhD, Cornell Weill College
Achim Jungbluth, MD, Pathology, MSKCC
Denise Frosina, Senior Research Technician
Sean Devlin, PhD, Biostatistics, MSKCC
Evelyn Orlando, RSA
Eric Smith, MD, PhD
Satya Kosuri, MD
Adoptive Immune Cell Therapy Facility (AICT
lab)
Ekaterina Doubrovina MD PhD
Richard O’Reilly, MD
Myeloma Service
Heather Landau MD
Hani Hassoun MD
Alex Lesokhin MD
Nikoletta Lendvai MD PhD
David Chung MD, PhD
Sergio Giralt MD
Ola Landgren, MD