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Mutations des Leucémies Aiguës Myéloïdes Intérêts cliniques
Christian Récher
DES hématologie
16 Janvier 2015
De la morphologie au séquençage
Classification
Morphologique
FAB
Cytogénétique Moléculaire
Mutations FLT3-ITD/KIT
NPM1 CEBPA
DNMT3A/IDH1/2 WT1/MLL-
PTDRAS/AML1 PHF6/TET2/ASXL1
1985-2000 1997-2010 1976
Séquençage du génome
Impact des mutations au sein des sous-groupes cytogénétiques
Les trois qualités d’un marqueur moléculaire
* Impact pronostique clair * Impact thérapeutique * Marqueur de maladie résiduelle
CBF
CN et Intermédiaire
CHU de Toulouse 2000-2009: 643 patients CTx intensive
Mutations de FLT3
o ITD: • 20-25% des LAM • LAM CN: 25-40 % • Taille variable: 3-400 bp • Domaine juxta membranaire • 30% intègre le domaine TKD1
• Feuillet β1 TKD1
o TKD: • 5-10% • D835Y le plus souvent • Résistance aux ITK
o Mutation ponctuelle du domaine JM*
• <1%
Membrane plasmique
TK1
TK2
ITD
D835Y
*
*
RTK de classe III FMS c-KIT
PDGFRA/B
FLT3
FLT3-ITD
• De novo
• Hyperleucocytose
• ↑ % de blastes sanguins et médullaires
• Caryotype normal (65-70%)
• Association aux mutations de NPM1
• Rechute:
– perte de la mutation ou émergence d’un autre mutant FLT3-ITD
– 88% des patients présentent la même mutation qu’au diagnostic
– Ratio ITD/wt ↑: perte de l’allèle sauvage, disomie uniparentale (UPD13q)
Pronostic
Kottaridis, Blood 2001
Pas d’impact sur la RC
Risque de rechute précoce ++ Time (years)
Ov
era
ll S
urv
iva
l
0.0 0.5 1.0 1.5 2.0 2.5 3.0
0.0
0.2
0.4
0.6
0.8
1.0
FLT3 wtFLT3-ITD
Log-rank test: p-value = 0.0005
GOELAMS-LAM 2006 IR
FLT3-ITD et traitement de post-rémission Intérêt de l’allogreffe?
Gale, Blood 2005; Bornhauser, Blood 2007; Brunet, Current Op Oncol, 2013
≈30% de rechute post-allo
FLT3-ITD et post-rémission Intérêt de l’allogreffe?
Schlenk F, NEJM 2008
Hétérogénéité des mutations FLT3-ITD
Taille Ratio ITD/WT
Nombre de mutations/patients Localisation de l’insertion
Gale R, Blood 2008; Kayser S, Blood 2009
• 1 mutant (73%) • 2 mutants (21%) • 3 mutants (5%) • 4 mutants (1%)
Ratio ITD/wt
Rechute
Gale R, Blood, 2008
Influence du ratio ITD/wt sur la réponse à l’induction
Introduction rapide d’ITK à l’induction ?
* Taille et nombre d’ITD également associés à la RC
Schlenk, Blood 2014
Influence du ratio ITD/wt sur la survie Expérience du AMLSG
Patients non allogreffés
Schlenk, Blood 2014
Ratio ITD/wt et allogreffe AMLSG
ITD/wt >0,51 ITD/wt <0,51
Allogreffe à réserver pour les patients avec ratio >0.5?
Schlenk, Blood 2014
Ratio ITD/wt et allogreffe Expérience du MRC
Linch, Blood 2014
FLT3-ITD et allogreffe
• Plutôt oui ……mais
– Impact du ratio: seuil 0.5? Autre?
– 30 % de rechute (ITK post-greffe? Sorafenib, Metzelder, Leukemia 2012)
– Impact de NPM1
– Impact de la maladie résiduelle
• Choix du donneur
• Essai BIG-1: pas d’indication en RC1 si ratio <0.10 et mutation NPM1 et MRD2 <1%
Site d’insertion de l’ITD (TKD1)
Kayser S, Blood, 2009
Site d’insertion de l’ITD (TKD1)
Inhibiteurs de FLT3
Zarrinkar P, Blood 2010
Inhibiteurs de FLT3 en monothérapie
Kindler T, Blood 2010
PKC-412 (midostaurin) Phase III internationale CALGB 10603 (RATIFY)
Arm 1: Induction therapy *Midostaurin 50mg oral twice daily on days 8-21 *Cytarabine 200mg/m2 IV on days 1-7 *Daunorubicin 60mg/m2 IV on days 1-3. Consolidation therapy *Midostaurin 50mg oral, twice daily on days 8-21 *Cytarabine 3,000mg/m2 IV over 3 hours every 12 hours on days 1, 3, and 5. Both as part of a 28 day cycle for up to 4 cycles. Continuation therapy *Midostaurin 50mg oral, twice daily on days 1-14 as part of a 28 day cycle. Arm 2: Placebo
Inhibiteurs de FLT3: AC220: le plus prometteur?
Lestaurtinib (CEP-701)
Midostaurin (PKC-412)
Sorafenib
Quizartinib (AC220)
Pratz et al. Blood 2010;115(7):1425-32
ui artini IC50 cellular
assays IC50 nM
(Medium) IC50 nM
(Plasma)
Lestaurtinib 2 700
Midostaurin 12 1,000
Sorafinib 0.9 265
Quizartinib 0.6 18
AC220 (quizartinib)
Développement clinique
Phase Study Subject N (dose range)
Phase 1 CP0001: A first-in-human study in relapsed/refractory AML 76 (12 - 450 mg)
Phase 2 Study AC220-002: A monotherapy study in relapsed/refractory AML
333 (90, 135 & 200 mg)
Phase 2b
Study 2689-CL-2004: A randomized study in relapsed/refractory FLT3-ITD(+) AML
76 (30 & 60 mg)
Phase 1 2689-CL-0011: AC220 maintenance therapy in subjects post-allogeneic hematopoietic stem cell transplant (HSCT)
13 (40 & 60 mg)
Phase 1 Study 2689-CL-005: AC220 in combination with chemotherapy in newly diagnosed AML*
18 (40 & 60 mg)
Phase 2 (AC220-002)
FLT-ITD(+) (n=136)
FLT3-ITD(+)
(n=112)
FLT3-ITD(-)
(n=45)
Cohort 1 (n=157)
≥60 years, 1st relapse within 1 year, or refractory to 1st line treatment
Patients with AML or AML secondary to MDS (n=333)
(Included FLT3-ITD[+] and [-] patients with a 10% allelic ratio cutoff by a central laboratory)
Cohort 2 (n=176)
≥18 years, relapsed after, or refractory to 2nd line treatment or after HSCT
FLT3-ITD(-)
(n=40)
• A total of 333 patients enrolled in the Phase 2 • Initial dose 200 mg daily but reduced after 17 subjects enrolled due to QT prolongation; subsequently females received
90 mg and males 135 mg • Primary endpoint: Composite CR (CRc = CR + CRp + CRi)
Critères de réponse
• Complete Remission (CR) and Complete Remission with Incomplete Platelet Recovery (CRp): per IWG criteria (Cheson et al., Journal of Clinical Oncol. 2003 21: 4642 – 4649)
• Complete Remission with Incomplete Hematological Recovery (CRi): Same as CR except
for incomplete hematological recovery with residual neutropenia <1 × 109/L and/or platelet
recovery (<100 × 109/L). RBC and platelet transfusion independence is not required.
(Modified from IWG criteria)
• Partial Remission (PR): same criteria for CRi but only require a decrease of at least 50% in
bone marrow blasts with the total marrow blasts between 5% and 25% inclusive. (Modified
from IWG criteria)
Réponses FLT3-ITD+
Response Cohort 1 N = 112
%
Cohort 2 N = 136
%
CRc (CR+CRi+CRp) 56 46
CR 3 4
CRp 4 1
CRi 50 40
PR 21 28
CRc + PR 77 74
Median Duration of CRc (weeks) (95% CI)
12.1 (6.3, 15.7) 11.3 ( 8.1, 16.3)
Median Time to CRc (weeks) 4.3 4.3
Median OS (weeks) (95% CI) 25.4 (21.3, 29.7) 24.0 (21.1, 27.1)
Quizartinib et différenciation
Saxauer, Blood 2012
Taux de réponses par sous-groupes
CRc (%) NR (%) Best Response to Prior Therapy
Prior CR (N=172) 50 18
No prior CR (N=74) 50 13
Prior Allo-HSCT
No prior HSCT (N=207) 50 20
Prior HSCT (N=41) 51 7
Cytogenetic Risk Group*
Good (N=1) 100 (1/1) 0
Intermediate (N=108) 56 14
Poor (N=23) 39 26
Unknown (N=116) 47 20
ITD Ratio
>10 – 25% (N=54) 41 19
>25 – 50% (N=116) 47 21
>50% (N=78) 62 13
Réponses et ratio ITD
ITD “Positive” (ITD >10%)
ITD “Negative” (ITD ≤ 10%)
No Detectable ITD (=0)
Detectable ITD ≤10%
Number of Subjects 248 84 58 26
CRc % 50 33 28 46
PR % 25 12 10 15
Overall Survival (weeks) 24.6 22.7 19.6 25.1
Quizartinib et allogreffe
Facteurs affectant la survie
Hazard Ratio 95% CI (Wald) p-value
Age
< 60 years (n=102) 1
≥ 60 years (n=139) 1.180 (0.878, 1.586) 0.2712
Baseline Bone Marrow *
Blast Count (%) (n=241) 1.008* (1.002, 1.014) 0.0122
Prior CRc (Any)
Yes (n=165) 1
No (n=76) 1.175 (0.573, 2.409) 0.6605
Duration of CR1
≥ 26 weeks (n=64) 1
< 26 weeks (n=90) 1.236 (0.874, 1.750) 0.2309
No response (n=87) 0.960 (0.463, 1.991) 0.9122
FLT3-ITD Allele Burden
>10% to <25% (n=53) 1
≥ 25% to ≤ 50% (n=116) 1.333 (0.901, 1.971) 0.1500
> 50% (n=72) 1.934 (1.263, 2.962) 0.0024
Effets indésirables
Adverse Event Cohort 1 (N = 90) %
Cohort 2 (N = 100) %
Any event 100 100
Nausea 56 55
Diarrhea 41 41
Vomiting 41 41
Pyrexia 39 33
Fatigue 37 20
Anemia 34 18
Febrile Neutropenia 33 41
Thrombocytopenia 32 27
QT prolongation 30 25
Asthenia 27 18
Résistance au quizartinib Acquisition de nouvelles mutations dans le domaine TK (parfois polyclonales)
Smith, Nature 2012
Subject New FLT3
Mutation
Weeks on
Study
1 F691L 19
2 D835Y 6
3 D835V 23
4 D835Y 19
5 F691L 20
6 D835Y 12
7 D835Y 8
8 D835V,F691L 11
Nouveaux ITK pour les résistances au quizartinib
Shah, BJH 2013
NPM1
Falini NEJM 2005; Blood 2006
Caractéristiques des LAM NPM1c+
Mutations spécifiques des LAM, de novo le + svt
Mutations stables (rechute)
Mutations associées: FLT3-ITD (40%); IDH1/2; DNMT3A
Signature moléculaire unique (CD34 ↓ /gènes HOX ↑)
Profil microARN distinct
Profil de méthylation
Adultes (25-30% des cas) > enfant (6-8%)
Incidence plus élevée chez la femme
Association avec un caryotype normal (85% des cas)
Anomalies chromosomiques associées dans 15% des cas (+8; del9q; +4)
Tous types FAB mais plus souvent M4/M5 (M5b: 90%)
Hyperleucocytose
Dysplasie multilignée fréquente
Négativité du CD34 (90-95% des cas)
Taux de réponse complète élevé
Détection de NPM1c
Sarcomes myéloïdes
15% des sarcomes myéloïdes ont une mutation NPM1c
NPM1 et rechutes tardives (>5 ans)
Meloni, Haematologica 2009
CHU de Toulouse 2000-2013 1446 patients 924 CTx intensive 197 NPM1+ 70 rechutes 7 après 5 ans
Impact pronostique
Dohner Blood 2005 Schnittger Blood 2005 Verhaak Blood 2005 Schlenk NEJM 2008
Méta-analyse
Liu, Mol Clin Oncol 2014
Réponse
DFS
OS
NPM1 mitige le mauvais pronostic de FLT3-ITD …et vice versa
Gale R,Blood 2008
Implications pour la décision de greffe allogénique
L’allogreffe est réservée en RC1 aux patients qui n’ont pas le génotype FLT3wt/NPM1c
Schlenk F, NEJM 2008
Sujets âgés
Buchner, JCO 2009
Anomalies cytogénétiques et NPM1
Micol Blood 2009; Haferlach Blood 2009
Un rôle pour l’ATRA dans les LAM NPM1+/FLT3-ITD-? AMLSG
Schlenk et al, Haematologica, 2009
FLT3-ITD-/NPM1c avec ATRA *
NPM1mut n=129
NPM1mut + ATRA n=125
P<0.0001
NPM1WT + ATRA n=306 NPM1WT n=308
Time (years)
Even
t-fr
ee S
urv
ival
(%
)
0 1 2 3 4
0
20
40
60
80
100
n=868
Ida/AraC/VP16 + ATRA 45mg/m2 from day 6 to 8, and 15mg/m2 from day 9 to 21
Schlenk, ASH 2011
Sujets âgés
Sujets jeunes
Un rôle pour l’ATRA dans les LAM NPM1+/FLT3-ITD-? MRC
Burnett, Blood, 2010
ATRA 45 mg/m² D1-D60
Allogreffe et NPM1 SAL-AML 2003
NPM1+
CN NPM1+/FLT3-ITD-
Rollig, JCO 2014
Allogreffe et NPM1 SAL-AML 2003
Maladie résiduelle AMLSG
Krönke J, JCO 2010
245 LAM-NPM1c 18-60 ans Essais AMLSG 07-04 et AML HD98A Suivi en RT-PCR quantitative (moelle) MRD- (>3 log)
Post induction (2 cycles)
Fin de traitement
Maladie résiduelle MRC
ASH 2014: Abst#0070 Essai UK NCRI AML17: 341 patients avec mutation NPM1 MRD dans le sang après deux cures d’induction
MRD NPM1 indépendante de FLT3-ITD et DNMT3A
Mutations de CEBPA
Pabst ,Nature Genet 2001; Preudhomme, Blood, 2002; Green, JCO 2010
N-term. nonsense mutation C-term. missense mutation
* Monoallélique: 30-40% * Biallélique: 60-70% * 5-10% des LAM à caryotype normal
Impact pronostique
Preudhomme, Blood, 2002; Fröhling, JCO 2004, Schlenk, NEJM 2008. Wouters, Blood 2009
Mutations bi-alléliques: CEBPAdm
une entité clinico-biologique
• Hb +
• Plaquettes –
• FAB M1/M2
Dufour JCO 2009 ;Taskesen E, Blood 2011
Impact pronostique des CEBPAdm
Dufour JCO 2009; Wouters, Blood 2009, Taskesen E, Blood 2011
CEBPAdm: méta-analyse
Hong-Ying Li, Eur Journal of Haematol, Sept 2014
Le pronostic des CEBPAsm est lié aux mutations associées
Dufour JCO 2009; Renneville Blood, 2009 Taskesen E, Blood 2011
Pas d’impact du caryotype dans les CEBPAdm
Schlenk Blood 2013
Impact de l’auto et de l’allogreffe dans les CEBPAdm
(HOVON-AMLSG)
Schlenk Blood 2013
Taux élevé de RC2 et survie prolongée pour les patients en RC2
Voie Sox4: une cible pour les CEBPAdm
Mutations IDH1/IDH2
Isocitrate dehydrogenase (IDH) is a critical enzyme of the citric acid cycle
IDH mutations occur in a spectrum of solid and hematologic tumors1
IDH1 mutations: 6–10% of AML and 3% of MDS
IDH2 mutations: 9–13% of AML and 3–6% of MDS
IDH1/2 mutations confer a gain-of-function:
production of 2-hydroxyglutarate (2-HG)2
2-HG drives multiple oncogenic processes: increased histone and DNA methylation
impaired cellular differentiation
Clinical proof of concept established in hematologic cancers:
AG-221, IDH2m inhibitor (AACR 2014)
AG-120, IDH1m inhibitor (EORTC-NCI-AACR 2014)
Tumor cell
Mitochondrion
KG
IDH2
Isocitrate
Citrate
Citrate
Isocitrate
KG
IDH1
Epigenetic changes
Impaired cellular
differentiation
IDH2
mutant 2-HG
IDH1
mutant
NADPH
NADPH
Valeur pronostique dans les NPM1+/FLT3-ITD- ?
AMLSG Paschka, JCO 2010
CALGB Marcucci, JCO 2009
HOVON Abbas, Blood 2010
ECOG Patel, NEJM 2012
L’oncométabolite 2-HG prédit la présence d’une mutation IDH1/2 et la MRD
Ward, Cancer Cell 2010
Di Nardo, Blood 2013
L’oncométabolite 2-HG corrèle avec la réponse à la CTx
Janin, JCO 2013
67 67
Ongoing, first-in-human, dose escalation study [NCT01915498]:
AG-221: First-in-class, oral, potent, reversible, selective inhibitor of mutated IDH2
IDH2 mutation-positive relapsed or refractory AML, MDS, or untreated AML
AG-221 in continuous oral dosing QD or BID daily, 28-day cycles
Key outcome measures:
Assess safety and tolerability, including DLT
Determine MTD and recommended phase 2 dose
Explore PK and PD (2-HG)
Characterize differentiation effect and preliminary clinical activity
Response assessed by investigator using IWG AML and MDS criteria
Update since EHA presentation (data cut May 23, 2014):
Treated 38 additional patients, 73 total
Explored 4 additional dose cohorts (highest cumulative daily dose of 300 mg)
Initiated expansion cohorts at 100 mg PO QD in October 2014
In-parallel dose escalation continues in QD regimen
AG-221 phase 1 study design and status
MTD = maximum tolerated dose; DLT = dose limiting toxicities; PK = pharmacokinetics; PD = pharmacodynamics
68 68
Study Status: Dose Escalation
Activated in September 2013
As of 1 October 2014, 73 patients treated in 10 dose cohorts
Dose Escalation
Cohorts Treated
On Therapy
Discontinued
30 mg BID 7 1 6
50 mg BID 7 3 4
75 mg BID 7 3 4
100 mg BID 8 3 5
150 mg BID 5 4 1
50 mg QD 7 5 2
75 mg QD 5 3 2
100 mg QD 15 7 8
150 mg QD 6 4 2
200 mg QD 6 5 1
Total 73 38 35
69 69
Demographic characteristics
ITT population (n=73)
Age in years, median (range) 67 (33–90)
Diagnosis, n*
RR AML 55
MDS 6
Untreated AML 5
Other (5 CMML, 1 Myeloid sarcoma) 6
Men/women, n 39/34
ECOG performance status, n**
0 18 (25%)
1 39 (53%)
2 14 (19%)
Number of prior regimens, median (range)
RR AML 2 (1‒11)
Prior BMT, n 13 (18%)
IDH2 mutations, n***
R140 54 (74%)
R172 13 (18%)
Abnormal cytogenetics, n 21 (29%)
*Missing for 1 subject; **Missing for 2 subjects; ***Missing for 6 subjects
70
Excellent exposure to AG-221
High accumulation after multiple doses
Mean plasma half-life >40 hours
Sustained plasma 2-HG inhibition after
multiple doses
– Up to 98% in IDH2-R140Q subjects
PK/PD analysis
Excluded 1 patient from analysis:
very low pretreatment 2-HG level, no 2-HG inhibition
Plasma 2-HG inhibition in
IDH2-R140Q subjects
Plasma AG-221 exposure
THIS SLIDE NEEDS TO BE Q/C’ed
71 71
Best overall response by cumulative daily dose*
≤75 mg (n=9)
100 mg (n=14)
≥150 mg (n=22)
Total
(N=45 efficacy evaluable*)
CR Complete response
3 3 0 6
CRp CR, incomplete platelet recovery
1 1 2 4
mCR Marrow CR
0 0 1 1
CRi CR, incomplete hematologic recovery
0 2 2 4
PR Partial response
0 3 7 10
SD Stable disease
5 3 9 17
PD Progressive disease
0 1 1 2
NE Not evaluable
0 1 0 1
Overall Response Rate*** 4/9 (44%) 9/14
(64%)
12/22 (54%) 25/45 (56%) 95% CI (XX, XX)
* Includes patients with a Day 28 response assessment as of October 1, 2014. Excludes 12 on-going
patients with day 28 not yet available and 16 patients off study without evaluable day 28 assessment.
** ORR = CR + CRp + mCR + CRi + PRi
72 72
Duration of treatment & best overall response
All efficacy evaluable patients on study treatment as of 1 October 2014
18 Patients on study ≥ 4 months, 13 on-going
6 Patients on study ≥ 6.5 months, 4 on-going (1 CR, 3 PR, 2 SD)
5 Responders went on to transplant
N = 45 efficacy evaluable patients
73 73
Duration of treatment and best overall response
All responding patients on study treatment as of 1 October 2014 *censored at last response assessment
Duration of Response: 3-month 90%
N = 25 responders
74 74
AG-221, a potent, selective, oral inhibitor of mutated IDH2, is well tolerated in
patients with advanced hematologic malignancies
2-HG inhibition of >90% in patients with an IDH2-R140 or -R172 mutation
Consistent with preclinical models, AG-221 treatment leads to 2-HG lowering and
differentiation of leukemic blast cells, ultimately leading to objective responses
Overall response rate of 25/45 (56%) including 6 complete remissions
– Responses are durable, with a duration on study as long as 8+ months
Dose expansion at 100 mg PO QD in 4 cohorts of 25 patients in AML and advanced
hematologic malignancies each initiated in October 2014
These data provide continued validation of mutant IDH2 as a therapeutic cancer
target
Conclusions
DNMT3A
Impact pronostique mal défini
DNMT3A R882 vs autres (Marcucci, JCO 2012;
Gaidzik, Blood 2013)
Faux-sens vs autres (Gale, ASH 2014)
Impact des fortes doses d’anthracyclines
Patel, NEJM 2012
LaRochelle, Oncotarget 2011
Classification cytogénétique et moléculaire
Patel et al, NEJM 2012; Meyer, Lancet Oncol 2014
Classification moléculaire
393 pts avec caryotype normal et mutations NPM1
FLT3-ITD- DNMT3A non-R882- IDH1R132- 41%
FLT3-ITD+ 41%
FLT3-ITD- DNMT3A non-R882+ 8%
FLT3-ITD- IDH1R132+ 10%
Peterlin, Haematologica 2014
De la morphologie au séquençage en vie réelle
Classification
Morphologique
FAB 2 heures
Cytogénétique
3-5 jours ou >
Moléculaire
2j et >
1985-2000 1997-2010 1976