Clinical development of mechanism-based lymphoma therapies

基于机制的淋巴瘤治疗的临床进展

• 批准号: 9780066
• 负责人: Louis Staudt
• 金额: $ 107.75万
• 依托单位: DIVISION OF BASIC SCIENCES - NCI
• 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/9780066
• 关键词: 1-Phosphatidylinositol 3-Kinase; Acoustics; Adverse effects; Apoptosis; Apoptotic; Autoantigens; BCL2 gene; Biopsy; Brain; Breast Lymphoma; Bypass; Catalytic Domain; Cell Line; Cells; Central Nervous System Lymphoma; Chemotherapy-Oncologic Procedure; Chronic; Clinical; Clinical Trials; DNA Damage; Data; Development; Dimerization; Disease; Disease remission; Dose; Drug Combinations; Drug Screening; Drug Targeting; Enrollment; Extranodal; Family member; Foundations; Gene Expression Profiling; Genetic; Genotype; High-Throughput Nucleotide Sequencing; Immunoglobulin Variable Region; In complete remission; Individual; Investigation; JAK1 gene; Laboratories; Lymphoma; MCL1 gene; MRI Scans; Malignant Neoplasms; Malignant lymphoid neoplasm; Medicine; Microtubules; Molecular; Molecular Diagnosis; Molecular Profiling; Mutation; NF-kappa B; Nodal; Oncogenic; Pathway interactions; Patients; Pharmaceutical Preparations; Phase; Phase III Clinical Trials; Precision medicine trial; Prevalence; Progression-Free Survivals; Protein Tyrosine Kinase; Protocols documentation; Recurrent tumor; Refractory; Refractory Disease; Regimen; Regulatory Pathway; Relapse; Resistance; Robot; STAT3 gene; SYK gene; Scanning; Series; Signal Pathway; Signal Transduction; Testicular Lymphoma; Testing; Therapeutic; Time; Titrations; Toxic effect; Translating; Work; addiction; base; cell killing; chemotherapeutic agent; chemotherapy; clinical development; design; exome sequencing; genetic analysis; genomic profiles; improved; inhibitor/antagonist; large cell Diffuse non-Hodgkin' s lymphoma; molecular subtypes; mutant; nano-string; partial response; randomized trial; response; small molecule; small molecule libraries; synergism; targeted agent; therapy resistant; tool; transcriptome sequencing; treatment response; tumor; whole genome

To identify synergistic drug combinations, we work with Craig Thomas at NCATS on matrix drug screens, which use acoustic dispensing robots to array two drugs in a dose titration series against one another, looking for doses at which the drugs achieve greater cell killing together than individually. We use a chemical library of 2000 drugs that are either approved or in development as cancer therapeutics plus small molecules that serve as tool compounds for important signaling and regulatory pathways, such as NF-kB. In the initial screen using ABC DLBCL lines, we searched for compounds that would synergize or antagonize the toxicity of ibrutinib. Multiple agents targeting the PI(3) kinase pathway strongly synergized with ibrutinib, including drugs targeting the PI(3) kinase catalytic subunit, Akt, or mTORC1. This result is consistent with the notion that ibrutinib primarily targets the pro-survival NF-kB pathway, while having less effect on the PI(3) kinase survival pathway, which is also engaged by BCR signaling. Ibrutinib synergized strongly with PRT-060318, an inhibitor of the SYK tyrosine kinase that is activated proximally in the BCR pathway, and with ABT-199, a BCL2 inhibitor that we have studied extensively in the context of ibrutinib resistance. Another broad class of synergistic compounds included cancer chemotherapeutic agents that elicit a DNA damage response or trigger apoptosis by interfering with microtubules. The reasons behind this synergism is likely due to the ability of NF-kB to antagonize the apoptotic effects of chemotherapy. Indeed, all components of both the CHOP and EPOCH chemotherapy regimens synergized with ibrutinib in killing ABC DLBCL cells, providing impetus to combine ibrutinib with these regimens. Based on our identification of chronic active BCR signaling as a key survival pathway in ABC DLBCL, we conducted a phase I/II clinical trial of ibrutinib using gene expression profiling to assign patients to the ABC and GCB subtypes of DLBCL. As predicted by our laboratory investigations, ibrutinib produced a 37% response rate in ABC DLBCL patients but only a 5% response rate in GCB DLBCL, demonstrating that the molecular diagnosis of DLBCL subtypes can inform precision medicine trials. This translated into improved overall survival in ABC relative to GCB DLBCL, including several patients who have remained in complete remission for more than 3-6 years, taking ibrutinib daily without discernable side effects. Based on these promising results, ibrutinib plus chemotherapy is now being evaluated in untreated non-GCB DLBCL patients in a phase 3 randomized trial being conducted by Jannsen. This trial used an immunohistochemical test we developed with our LLMPP colleagues to identify patients with non-GCB DLBCL and is the first phase 3 trial in DLBCL to use molecular profiling for enrollment. This trial has enrolled 800 patients and will read out in 2018. To understand the molecular basis for response to ibrutinib within ABC DLBCL, we resequenced the tumors for recurrent oncogenic mutations. Tumors with CD79B mutations responded more frequently than those with wild type CD79B (55% vs 30%), demonstrating the clinical validity of our observation that these mutations augment BCR signaling. Nonetheless, the majority of responding patients on this trial had wild type CD79B, which is in keeping with our demonstration that chronic active BCR signaling is driven by self-antigen reactivity of the immunoglobulin variable regions. Notably, tumors that had both a CD79B mutation and a MYD88 L265P mutation responded frequently (80%), whereas those with only a MYD88 mutation did not respond. This "double mutant" genotype occurred in more ABC tumors (11%) than expected by chance based on the prevalence of each mutation individually, providing genetic evidence that the MYD88 and BCR pathways cooperate in these tumors. We showed that ABC cell lines with the double mutant genotype responded to ibrutinib, whereas ABC lines with only MYD88 mutations did not, and that a MYD88 dimerization inhibitor decreased proximal BCR signaling. Together, these observations suggested that the double mutant genotype creates strong addiction to BCR signaling that is hyper-responsive to ibrutinib. Given the frequent responses to ibrutinib in ABC DLBCL tumors with both CD79B and MYD88 L265P mutations, we searched for other lymphoma types that have this double mutant genotype. Recent work has demonstrated that MYD88 L265P mutations are enriched in several types of extranodal lymphoma, including primary breast lymphoma, primary testicular lymphoma, and primary central nervous system lymphoma (PCNSL). Interestingly, the co-occurrence of CD79B and MYD88 L265P mutations in PCNSL is 2-3 times greater than in nodal ABC DLBCL, suggesting that they may be hyper-addicted to BCR signaling due to synergy between the BCR and MYD88 pathways. To explore this hypothesis, we worked with the Lymphoid Malignancies Branch clinical team led by Wyndham Wilson to devise an ibrutinib-based regimen for PCNSL. The basic design of this regimen entailed giving ibrutinib as monotherapy for 2 weeks, followed by the combination of ibrutinib with a set of brain-penetrant chemotherapy agents, given in cycles. By comparing pre-treatment MRI scans with scans immediately after ibrutinib monotherapy, we observed objective responses to ibrutinib in 17/18 treated PCNSL patients, the majority of whom had relapsed/refractory disease. The high rate of response to ibrutinib monotherapy in this trial supports our hypothesis that PCNSL is hyperaddicted to BCR signaling. Although we only had biopsy material available on 4 patients, it was notable that responses were seen in one patient with the double mutant genotype, but also in 2 patients with only a CD79B mutation and 1 with only a MYD88 L265P mutation. Hence, the enrichment in PCNSL for the double mutant genotype was a genetic clue that PCNSL as a whole is typically hyper-addicted to BCR-dependent NF-kB activation. The partial responses to ibrutinib monotherapy in PCNSL were converted into complete responses (CRs) with added chemotherapy in 86% of patients. Notably, 8 of these patients have ongoing CRs with a predicted progression-free survival of 15.5 months, including 5 patients with disease that was refractory to the last therapy. We therefore believe that this chemotherapy platform, which we term TEDDI-R, can serve as the foundation for further improvements in subsequent studies. It is clear that monotherapy with targeted agents will not typically yield durable remissions in DLBCL, so we are undertaking clinical trials to explore combinations of targeted agents. For example, we are initiating a multi-center precision medicine trial in relapsed/refractory DLBCL, which will use Nanostring-based gene expression profiling and genetic analysis by Foundation Medicine to create molecularly-defined "baskets" that will receive therapeutic combinations appropriate for the molecular features. This MasterLymph protocol will incorporate comprehensive genomic profiling of all tumors using high-throughput sequencing of the exome transcriptome and whole genome. We will use these data in the light of therapeutic response or resistance to iterate the molecular baskets in subsequent phase of this master protocol.

为了确定协同药物组合，我们与 NCATS 的 Craig Thomas 合作进行矩阵药物筛选，该筛选使用声学分配机器人将两种药物按剂量滴定系列排列，相互比较，寻找药物一起比单独发挥更大细胞杀伤作用的剂量。我们使用包含 2000 种已批准或正在开发的癌症治疗药物的化学库，以及充当重要信号传导和调节途径（例如 NF-kB）工具化合物的小分子。在使用 ABC DLBCL 系的初始筛选中，我们寻找能够协同或拮抗依鲁替尼毒性的化合物。多种针对 PI(3) 激酶通路的药物与依鲁替尼具有强烈协同作用，包括针对 PI(3) 激酶催化亚基、Akt 或 mTORC1 的药物。这一结果与依鲁替尼主要针对促生存 NF-kB 通路的观点一致，而对 PI(3) 激酶生存通路的影响较小，该通路也与 BCR 信号传导有关。依鲁替尼与 PRT-060318（一种在 BCR 通路近端激活的 SYK 酪氨酸激酶抑制剂）以及 ABT-199（一种我们在依鲁替尼耐药性的背景下广泛研究的 BCL2 抑制剂）具有强烈的协同作用。另一类协同化合物包括癌症化疗药物，它们通过干扰微管引发 DNA 损伤反应或引发细胞凋亡。这种协同作用背后的原因可能是由于 NF-kB 具有拮抗化疗细胞凋亡作用的能力。事实上，CHOP 和 EPOCH 化疗方案的所有成分均与依鲁替尼协同杀死 ABC DLBCL 细胞，从而推动了依鲁替尼与这些方案的结合。基于我们确定慢性活跃 BCR 信号传导是 ABC DLBCL 的关键生存途径，我们使用基因表达谱进行了依鲁替尼 I/II 期临床试验，将患者分配为 DLBCL 的 ABC 和 GCB 亚型。正如我们实验室研究预测的那样，依鲁替尼对 ABC DLBCL 患者的缓解率为 37%，但对 GCB DLBCL 患者的缓解率仅为 5%，这表明 DLBCL 亚型的分子诊断可以为精准医学试验提供信息。与 GCB DLBCL 相比，这意味着 ABC 的总体生存率有所提高，包括几名每天服用依鲁替尼的患者保持完全缓解超过 3-6 年，没有明显的副作用。基于这些有希望的结果，Jannsen 正在进行一项 3 期随机试验，在未经治疗的非 GCB DLBCL 患者中评估依鲁替尼联合化疗。该试验使用我们与 LMPP 同事开发的免疫组织化学测试来识别非 GCB DLBCL 患者，并且是第一个使用分子分析进行入组的 DLBCL 3 期试验。该试验已入组 800 名患者，将于 2018 年宣读。为了了解 ABC DLBCL 中依鲁替尼反应的分子基础，我们对肿瘤进行了复发性致癌突变的重新测序。具有 CD79B 突变的肿瘤比具有野生型 CD79B 的肿瘤反应更频繁（55% vs 30%），这证明了我们观察到的这些突变增强 BCR 信号传导的临床有效性。尽管如此，该试验中大多数有反应的患者都具有野生型 CD79B，这与我们的证明一致，即慢性活性 BCR 信号传导是由免疫球蛋白可变区的自身抗原反应性驱动的。值得注意的是，同时具有 CD79B 突变和 MYD88 L265P 突变的肿瘤经常有反应 (80%)，而仅具有 MYD88 突变的肿瘤则没有反应。这种“双突变”基因型在 ABC 肿瘤中的出现率 (11%) 比根据每种突变的单独发生率所预期的偶然概率要多，这提供了 MYD88 和 BCR 通路在这些肿瘤中协同作用的遗传证据。我们发现，具有双突变基因型的 ABC 细胞系对依鲁替尼有反应，而仅具有 MYD88 突变的 ABC 细胞系则没有，并且 MYD88 二聚化抑制剂降低了近端 BCR 信号传导。总之，这些观察结果表明，双突变基因型对 BCR 信号产生了强烈的成瘾性，而 BCR 信号对依鲁替尼具有高反应性。鉴于同时具有 CD79B 和 MYD88 L265P 突变的 ABC DLBCL 肿瘤对依鲁替尼的频繁反应，我们寻找具有这种双突变基因型的其他淋巴瘤类型。最近的工作表明，MYD88 L265P 突变在多种类型的结外淋巴瘤中富集，包括原发性乳腺淋巴瘤、原发性睾丸淋巴瘤和原发性中枢神经系统淋巴瘤 (PCNSL)。有趣的是，PCNSL 中 CD79B 和 MYD88 L265P 突变的共现率是淋巴结 ABC DLBCL 的 2-3 倍，这表明由于 BCR 和 MYD88 通路之间的协同作用，它们可能对 BCR 信号过度依赖。为了探索这一假设，我们与 Wyndham Wilson 领导的淋巴恶性肿瘤科临床团队合作，设计了一种基于依鲁替尼的 PCNSL 治疗方案。该方案的基本设计是给予依鲁替尼作为单一疗法 2 周，然后将依鲁替尼与一组脑渗透化疗药物联合使用，按周期给予。通过将治疗前 MRI 扫描与依鲁替尼单药治疗后立即进行的扫描进行比较，我们观察到 17/18 接受治疗的 PCNSL 患者对依鲁替尼的客观反应，其中大多数患有复发/难治性疾病。本试验中对依鲁替尼单一疗法的高反应率支持了我们的假设，即 PCNSL 对 BCR 信号传导过度依赖。尽管我们只有 4 名患者的活检材料，但值得注意的是，在 1 名具有双突变基因型的患者、2 名仅具有 CD79B 突变的患者和 1 名仅具有 MYD88 L265P 突变的患者中都观察到了缓解。因此，PCNSL 中双突变基因型的富集是一个遗传线索，表明 PCNSL 作为一个整体通常对 BCR 依赖性 NF-kB 激活过度上瘾。 86% 的 PCNSL 患者对依鲁替尼单药治疗的部分缓解在添加化疗后转化为完全缓解 (CR)。值得注意的是，其中 8 名患者已达到 CR，预计无进展生存期为 15.5 个月，其中 5 名患者的疾病对上次治疗无效。因此，我们相信这个化疗平台（我们称之为 TEDDI-R）可以作为后续研究进一步改进的基础。很明显，靶向药物单一疗法通常不会对 DLBCL 产生持久缓解，因此我们正在进行临床试验来探索靶向药物的组合。例如，我们正在启动针对复发/难治性 DLBCL 的多中心精准医学试验，该试验将使用 Foundation Medicine 基于纳米线的基因表达谱和遗传分析来创建分子定义的“篮子”，以接受适合该疾病的治疗组合。分子特征。该 MasterLymph 方案将使用外显子组转录组和全基因组的高通量测序来整合所有肿瘤的全面基因组分析。我们将根据治疗反应或耐药性使用这些数据，以便在此主方案的后续阶段中迭代分子篮。