Tumor microenvironment in CLL and MCL: pathogenesis, targets, and therapy

CLL 和 MCL 的肿瘤微环境：发病机制、靶点和治疗

• 批准号: 10008763
• 负责人: adrian u wiestner
• 金额: $ 231.27万
• 依托单位: NATIONAL HEART, LUNG, AND BLOOD INSTITUTE
• 依托单位国家: 美国
• 资助国家: 美国
• 起止时间: 至
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10008763
• 关键词: Address; Anatomy; Antibody Response; Behavior; Benchmarking; Biological; Biopsy; Blood; Bone Marrow; Cause of Death; Cells; Cessation of life; Characteristics; Chickenpox; Chronic Lymphocytic Leukemia; Clinical; Clinical Data; Clinical Research; Clinical Trials; Conduct Clinical Trials; Correlative Study; Data; Data Reporting; Databases; Diagnosis; Disease Progression; Disease Resistance; Drug resistance; Elderly; Enrollment; Event; Evolution; Gene Expression Profiling; Health; Hepatitis B Vaccines; Histologic; Immuno-Chemotherapy; Immunocompetence; In complete remission; Incidence; Infection; Inferior; Innovative Therapy; Intervention; Investigation; Laboratories; Mantle Cell Lymphoma; Mature B-Lymphocyte; Measures; Medical Genetics; Modeling; Molecular; Multivariate Analysis; Mutation; Oral; PLCG2 gene; Pathogenesis; Pathogenicity; Pathway interactions; Patient risk; Patients; Pattern; Pharmacodynamics; Phase; Phase II Clinical Trials; Pilot Projects; Pre-Clinical Model; Preventive; Progressive Disease; Publications; Randomized; Refractory; Relapse; Reporting; Residual Neoplasm; Resolution; Risk; Sampling; Siblings; Signal Transduction; Specimen; Suggestion; System; Systems Biology; TP53 gene; Testing; Therapeutic Intervention; Time; Tissues; Translations; United States National Institutes of Health; Update; Vaccines; Zoster Vaccine; acquired drug resistance; alternative treatment; base; chemotherapy; cohort; disorder risk; exome sequencing; experience; falls; follow-up; high risk; high risk population; immune function; improved; in vivo; influenza virus vaccine; inhibitor/antagonist; kinase inhibitor; lymph nodes; novel strategies; open label; patient stratification; peripheral blood; pre-clinical; predictive modeling; prevent; prognostic; resistance mechanism; response; small molecule inhibitor; subclonal heterogeneity; targeted treatment; therapeutic target; therapy resistant; transcriptome sequencing; treatment response; tumor; tumor microenvironment

Chronic lymphocytic leukemia (CLL) and mantle cell lymphoma (MCL) are tumors of mature B cells and are closely related biologically and in clinical behavior. Both are currently incurable with chemotherapy. Median survival for patients with CLL is 10 years and for MCL patients ranges between 5 and 6 years. BCR signaling has emerged as the pivotal pathway in the pathogenesis of CLL and MCL. A major contribution from my group has been the first demonstration of active BCR signaling in CLL patients in vivo. Furthermore, we showed that BCR signaling and the consequent activation of the NF-B pathway occurs primarily in the lymph node microenvironment rather than in the peripheral blood or bone marrow. Small molecule inhibitors of BCR signaling have transformed clinical approaches. The most promising clinical results have been achieved with ibrutinib. Between 2012 and 2014, our phase 2 clinical trial with ibrutinib enrolled 84 patients. At the end of 2018, 41 (49%) patients remained on study. Twenty-one publications from my group report data from this clinical study or from laboratory investigations into specimens obtained from participating patients. With the median follow-up now exceeding 5 years, we were able to address long-term tolerability, duration of response, mechanisms of resistance, and impact on immune function. At the time of data cut for our updated report (December 31, 2017), median follow-up was 57 months. Four (4.8%) patients died on study due to reasons other than progressive disease; 3 from infections, and one due to sudden unexplained death. Twenty (23.8%) patients discontinued ibrutinib due to disease progression, and 5 (5.9%) due to AEs. The cumulative complete response (CR) rate was 9.9% at 2 years, and 28.4% at 5 years. Seven patients in CR achieved minimal residual disease (MRD) negativity in either blood or BM. The estimated 5-year PFS was 58.2% for the TP53 cohort and 81.2% for the elderly cohort (P=.026); and the median overall survival (OS) was 75.7% and 83.8% respectively. In both cohorts, PFS was superior for previously-untreated patients (Figure 4). In the TP53 cohort, the estimated 5-year PFS was 74.4% for patients with treatment-nave CLL compared to 19.4% for those with relapsed or refractory CLL (p=.0002), and OS was 85.3% versus 53.7%, respectively (p=.023). Results with ibrutinib monotherapy in these high-risk patients were clearly superior to what has been reported for chemoimmunotherapy and our study provides the largest experience of ibrutinib for first-line therapy of CLL with TP53 aberrations and can serve as a benchmark for alternative treatment approaches. To improve tolerability and minimize off-target effects of ibrutinib, ACP-196 (acalabrutinib), a more BTK selective inhibitor was developed. Taking advantage of our PDX model, we contributed pre-clinical data supporting the translation of acalabrutinib into clinical trials. Between 2015 and 2018, we enrolled 46 CLL patients into a phase 2 single-center, open-label, clinical trial of acalabrutinib. Correlative studies focused on detailed profiling of pharmaco-dynamic readouts in relation to the degree of BTK inhibition. Forty-six patients were enrolled and randomized to receive oral acalabrutinib 100 mg twice daily (BID, n=22) or 200 mg daily (QD; n=24). The ORR for patients who completed 6 months was 90% and not different between BID and QD groups. The study incorporated repeat blood (days 0, 3, 4, 5, 28) and tissue (days 0, and days 3, or 4, or 5; aiming for 2 biopsies of either LN or BM for each patient) sampling to investigate 3 pharmacodynamic questions: a) does BTK target occupancy differ for cells in different anatomic compartments; b) how quickly is BTK resynthesized; and c) at what threshold of BTK occupancy is downstream signaling restored? To quantify the risk of disease progression on BTKis, we developed a clinical scoring system. Our NIH trial of ibrutinib monotherapy served as the discovery cohort and the model was then validated in the Pharmacyclics database of 607 CLL patients treated with ibrutinib on company-sponsored studies. In the discovery cohort, factors significantly associated with inferior PFS on multivariate analysis were; TP53 aberration, prior treatment, and high B2M. Clinical prognostic groups were based on the number of factors present at baseline: none or one factor (low risk), 2 factors (intermediate risk), all 3 factors (high risk). PFS and OS of the risk groups were significantly different for both models (p<.0001). The 3-year PFS was 51% for patients in the high-risk group and 85% for the low-risk group (Figure 6). The cumulative incidence of BTK/PLCG2 mutations in high and low risk groups was 56% and 19%, respectively. This simple prognostic model, based on 3 readily-available baseline factors, outperformed the CLL-IPI and can serve to stratify patients for risk-based treatment approaches. To assess immunocompetence in patients treated with BTK inhibitors, we conducted a pilot study using influenza vaccine and could show that patients on ibrutinib respond at least as well as untreated CLL patients to the vaccine, demonstrating that patients on ibrutinib can still mount a meaningful antibody response. Given that infections are a leading cause of death, this data have important preventive health implications. We more recently opened a new study using Shingrix, a varicella-zoster vaccine, and Heplisav, a Hepatitis B vaccine to further investigate immune function in CLL patients and will compare treatment-nave patients to patients being treated with kinase inhibitors. Disease progression in CLL patients treated with ibrutinib has been attributed to histologic transformation and acquired mutations in BTK and PLCG2. We explored clinical and genetic characteristics of CLL patients who progressed during treatment with single-agent ibrutinib on our phase 2 trial. Fifteen (17.9%) of 84 patients progressed at a median follow-up of 34 months (Figure 9). Histologic transformation occurred in 5 (6.0%) patients, all in the first 15 months on ibrutinib. In contrast, progression due to CLL was diagnosed at a median 38 months on study. At progression, mutations in BTK (Cys481) and/or PLCG2 were found in 9 patients. High sensitivity testing of stored samples identified the mutations up to 15 months before clinical progression (range 2.9-15.4 months). In 5 patients multiple subclones carrying different mutations arose independently, documenting subclonal heterogeneity in resistant disease. To define the evolutionary dynamics induced by ibrutinib at high resolution, we performed serial exome and transcriptome sequencing for 61 ibrutinib-treated CLL patients. The frequent serial sequencing of early on-treatment (prior to relapse) samples enabled us to directly compare the relative diminution of different clonal subsets in response to ibrutinib. Thirty (49%) of 61 CLL patients showed significant pre-relapse changes in CCF over time. Of the 30 CLL patients with significant early clonal shifts, a likely branched pattern was observed in 20, in which distinct clones appeared to reciprocally rise and fall, suggestive of shifts in dominance between the two sibling clones, while the remainder of evolving CLL patients demonstrated a linear evolution pattern. In conclusion, early clonal dynamics may reflect a greater evolutionary capacity, irrespective of specific driver alterations, setting the stage for the emergence of drug-resistant clones.

慢性淋巴细胞性白血病（CLL）和地幔细胞淋巴瘤（MCL）是成熟B细胞的肿瘤，在生物学上和临床行为上密切相关。目前两者都无法治疗化疗。 CLL患者的中位生存期为10年，MCL患者的范围​​为5至6年。 BCR信号已成为CLL和MCL发病机理中的关键途径。我组的主要贡献是在体内CLL患者中首次证明了主动BCR信号传导。此外，我们证明了BCR信号传导和随之而来的NF-B途径的激活主要发生在淋巴结微环境中，而不是在外周血或骨髓中。 BCR信号传导的小分子抑制剂已转化了临床方法。依鲁替尼已经取得了最有希望的临床结果。 在2012年至2014年之间，我们与伊布鲁替尼进行的2期临床试验招募了84例患者。在2018年底，有41名（49％）患者仍在研究中。我的小组的21个出版物报告了这项临床研究的数据或实验室研究中的数据，以从参与患者获得的标本中。随着中位随访现在超过5年，我们能够解决长期耐受性，反应持续时间，抗药性机制以及对免疫功能的影响。在我们更新报告（2017年12月31日）削减数据时，中位随访时间为57个月。由于进行性疾病以外的原因，有四个（4.8％）患者在研究中死亡； 3感染，其中1是由于突然无法解释的死亡。由于疾病的进展，二十（23.8％）患者停止了伊布鲁替尼，由于AES导致了5（5.9％）。 2年的累积完全响应（CR）率为9.9％，在5年时为28.4％。 CR中有7例患者在血液或BM中的残留疾病最少（MRD）阴性。 TP53队列的估计5年PFS为58.2％，老年队列为81.2％（p = .026）；中位总生存期（OS）分别为75.7％和83.8％。在这两个队列中，PFS对于先前未经治疗的患者都是优越的（图4）。在TP53队列中，治疗NAVE CLL患者的估计5年PFS为74.4％，而复发或难治性CLL的患者为19.4％（P = .0002），而OS分别为85.3％，对53.7％（p = .023）。这些高危患者的ibrutinib单药治疗的结果显然优于化学免疫性疗法的报道，我们的研究为ibrutinib提供了与TP53畸变的CLL一线治疗的最大经验，可以作为替代治疗方法的基准。 为了提高易夸替尼（ACP-196（Acalabrutinib））的耐受性并最大程度地减少靶向效果，开发了更多BTK选择性抑制剂。利用我们的PDX模型，我们贡献了临床前数据，该数据支持将acalabrutinib转化为临床试验。在2015年至2018年之间，我们将46名CLL患者纳入了Acalabrutinib的2期单中心临床试验。相关研究的重点是与BTK抑制程度有关的药物动态读数的详细分析。每天两次（bid，n = 22）或200 mg（QD; n = 24），对四十六名患者进行了注册并随机接受口服阿卡劳替尼100毫克。完成6个月的患者的ORR为90％，在投标组和QD组之间没有差异。该研究纳入了重复的血液（第0、3、4、5、28天）和组织（第0天，第3天，第4天，4或5；针对每位患者的2个LN或BM的活检）来研究3个药效学问题：a）BTK靶标在不同解剖区中的细胞差异是否有差异； b）BTK重新合成的速度有多快； c）在BTK占用的阈值下方，下游信号恢复了？ 为了量化BTKIS疾病进展的风险，我们开发了一个临床评分系统。我们对Ibrutinib单一疗法的NIH试验是发现队列的，然后在607名用Ibrutinib治疗的公司赞助研究的607名CLL患者的药物数据库中验证了该模型。在发现队列中，多变量分析中与下PFS显着相关的因素是； TP53像差，先前的治疗和高B2M。临床预后组基于基线上存在的因素数量：无或一个因素（低风险），2个因素（中间风险），所有3个因素（高风险）。两种模型的风险组的PF和OS均显着差异（p <.0001）。高危组的患者为3年的PFS为51％，低风险组为85％（图6）。在高风险组中，BTK/PLCG2突变的累积发生率分别为56％和19％。这个简单的预后模型基于3种易于获取的基线因素，表现优于CLL-IPI，可以用来对患者进行基于风险的治疗方法进行分层。 为了评估接受BTK抑制剂治疗的患者的免疫能力，我们使用流感疫苗进行了一项试点研究，可以表明，伊布鲁替尼的患者至少对疫苗的反应以及未经治疗的CLL患者对疫苗的反应，表明ibrutinib上的患者仍然可以接受有意义的抗体反应。鉴于感染是死亡的主要原因，因此该数据具有重要的预防性健康影响。我们最近使用Shingrix，Varicella-Zoster疫苗和Heplisav（乙型肝炎B疫苗）开设了一项新研究，以进一步研究CLL患者的免疫功能，并将将治疗nave患者与接受激酶抑制剂治疗的患者进行比较。 用依鲁替尼治疗的CLL患者的疾病进展归因于组织学转化，并在BTK和PLCG2中获得了突变。我们探索了在2期试验中用单药ibrutinib治疗期间在治疗期间进展的CLL患者的临床和遗传特征。 84例患者中有15例（17.9％）的中位随访时间为34个月（图9）。在5（6.0％）患者中，在伊布鲁替尼的前15个月中，组织学转化发生。相比之下，在研究38个月的中位数中诊断出CLL导致的进展。在进展时，在9例患者中发现了BTK（CYS481）和/或PLCG2的突变。对储存样品的高灵敏度测试确定了临床进展前15个月的突变（范围2.9-15.4个月）。在5例患者中，多个携带不同突变的亚克隆独立出现，记录了抗性疾病中的亚克隆异质性。为了定义Ibrutinib在高分辨率下引起的进化动力学，我们对61例IBRUTINIB处理的CLL患者进行了串行外显子组和转录组测序。早期对处理（复发之前）样品的频繁序列测序使我们能够直接比较不同克隆亚群的相对减小，响应于伊布鲁替尼。随着时间的推移，61名CLL患者中有30例（49％）在CCF中表现出明显的细胞前变化。在30例具有明显早期克隆移位的CLL患者中，观察到了可能的分支模式，其中有20例在其中似乎相互崛起和下降，这表明两个兄弟姐妹克隆之间的优势转移偏移，而其余的演变Cll患者则表现出线性进化模式。总之，早期克隆动力学可能反映出更大的进化能力，而不论特定的驱动因素改变，这为抗药性克隆的出现奠定了基础。