tumore delle plasmacellule MIELOMA MULTIPLO tumore delle plasmacellule producono immunoglobuline vivono nelle ossa DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

Multiple myeloma uncontrolled proliferation of Ig secreting plasma cells most commonly IgG (57%), IgA (21%) or light chain only (18%) twice as common in men as women and in blacks as whites 1% of all cancers 2% in african americans incurable median survival 3 years few therapeutic advances since the introduction of melphalan (Bergsagel, 1962)

Myeloma bone pathology

Multiple Myeloma (MM) B-cell neoplasia, characterized by the expansion of plasma cells producing an abnormal monoclonal immunoglobulin 21,500 new cases yearly in Europe Median age at diagnosis: 65 years incurable disease

MM – Impact for Patients Consequences of MM include: Painful osteolytic bone lesions Bone marrow infiltration, causing anemia, fatigue, and immunodeficiency, with an increased risk of serious infections The abnormal proteins may cause renal dysfunction or kidney failure

Bruno B, Rotta M, and Boccadoro M, Lancet Oncology 2004

IL-6 CRP IL-1 MIELOMA MULTIPLO hepatocyte OAF OSTEOCLAST DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA S. GIOVANNI BATTISTA TORINO, ITALY

350 pazienti/anno in Piemonte MIELOMA MULTIPLO malattia dell'anziano 5/100.000/pazienti/anno 350 pazienti/anno in Piemonte età media alla diagnosi 70 anni DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

Serum protein electrophoresis (SPEP) Elevated total protein suggests hypergammaglobulinemia Total protein= Albumin + Globulins albumin    

Serum protein electrophoresis (SPEP) Elevated total protein suggests hypergammaglobulinemia Total protein= Albumin + Globulins Quantitative immunoglobulins measures amount of IgM, IgG and IgA in myeloma, typically see “reciprocal depression” of uninvolved Igs albumin    

Serum protein electrophoresis (SPEP) Immunoeletrophoresis   albumin     

Serum protein electrophoresis (SPEP) Immunoeletrophoresis Immunofixation SP     albumin        

Serum protein electrophoresis (SPEP) IgG 57% IgA 21% IgD 1% IgM or IgE almost never Light chain only 18% Immunofixation SP     

Serum protein electrophoresis (SPEP) IgG 57% IgA 21% IgD 1% IgM or IgE almost never Light chain only 18% Immunofixation SP  M-spike stands for Monoclonal, not IgM    

Serum protein electrophoresis (SPEP) IgG 57% IgA 21% IgD 1% IgM or IgE almost never Light chain only 18% Immunofixation SP  M-spike stands for Monoclonal, not IgM   IgM, IgG and IgA are all gamma-globulins  

Serum protein electrophoresis (SPEP) IgG 57% IgA 21% IgD 1% IgM or IgE almost never Light chain only 18% Immunofixation SP  M-spike stands for Monoclonal, not IgM   IgM, IgG and IgA are all gamma-globulins   Light chains (Bence-Jones proteins) are not detected in the serum, because of their low molecular weight, they are secreted in the urine

Table 1 Multiple myeloma* Diagnostic criteria 1 Monoclonal plasma cells in the bone marrow 10% and/or presence of a biopsy-proven plasmacytoma 2 Monoclonal protein present in the serum and/or urinea 3 Myeloma-related organ dysfunction (1 or more) [C] Calcium elevation in the blood (serum calcium >10.5 mg/l or upper limit of normal) [R] Renal insufficiency (serum creatinine >2mg/dl) [A] Anemia (hemoglobin o10 g/dl or 2 gonormal) [B] Lytic bone lesions or osteoporosisc

Myeloma - clinical features bone pain - often with loss of height constitutional - weakness, fatigue and weight loss anemia - responds to erythropoeitin renal disease -renal tubular dysfunction susceptibility to infections - neutropenia, hypogammaglobulinemia) hypercalcemia - myeloma cells secrete osteoclast activating factors hyperviscosity - 2 % with myeloma, 50 % with macroglobulinemia neurologic dysfunction - spinal cord or nerve root compression

Myeloma staging system Median Survival (months) 12 2 cells x 10 /m Stage I No anemia >60 <0.6 No hypercalcemia no more than one bony lesion low M protein Stage II in between I and III 41 0.6-1.2 Stage III Anemia 23 >1.2 hypercalcemia advanced lytic bone disease high M protein

Principles of treatment no evidence that early treatment prolongs survival wait for symptoms, or evidence of disease progression to start treatment supportive measures are critically important drink 3l of fluids daily treat infections promptly prophylactic bisphosphonates reduce skeletal cmplications anemia responds to erythropoeitin

Causes of death in multiple myeloma Progressive myeloma 45% Sepsis 25% Renal failure 10% Other (old age) 20%

Treatment course Asymptomatic MGUS Stable MM Years Months Days

Treatment course Asymptomatic Symptomatic MGUS Stable MM M protein Treatments Years Months Days

Treatment course Asymptomatic Symptomatic Acute MGUS Stable MM Pancytopenia Plasma cell leukemia M protein Treatments Years Months Days

trattato con blande chemioterapie MIELOMA MULTIPLO trattato con blande chemioterapie parzialmente chemiosensibile il tumore si riduce ma dopo breve intervallo riprende a crescere DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

Melphalan e Prednisone (MP) MIELOMA MULTIPLO chemioterapia Melphalan e Prednisone (MP) (Alexanian, 1969) DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

MIELOMA MULTIPLO sopravvivenza 100 50 36 mesi DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

Melphalan dose-response curve MULTIPLE MYELOMA Melphalan dose-response curve RESPONSE DOSE DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

relazione dose-risposta MIELOMA MULTIPLO relazione dose-risposta ALTA-DOSE = + risposte complete + lunga sopravvivenza DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

CELLULE STAMINALI PERIFERICHE FATTORI DI CRESCITA CELLULE STAMINALI PERIFERICHE RIDUZIONE DELLA TOSSICITA' DELLE TERAPIE AD ALTE DOSI tossicità comparabile alla terapia convenzionale possibilità di trattare pazienti anziani alte percentuali di risposte complete

A PROSPECTIVE, RANDOMIZED TRIAL OF AUTOLOGOUS BONE MARROW TRANSPLANTATION AND CHEMOTHERAPY IN MULTIPLE MYELOMA Sopravvivenza a 5 anni 52% trapianto 12% convenzionale Attal, et al., NEJM, 1996

EFS TOT % of patients MEL100 p<0.001 MP Months DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

OS TOT MEL100 % of patients MP p<0.005 Months DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

MULTIPLE MYELOMA AGE AT DIAGNOSIS 55 60 65 70 AGE DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

MULTIPLE MYELOMA AGE AT DIAGNOSIS HIGH-DOSE CONVENTIONAL 55 60 65 70 DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

MALATTIA INCURABILE survival % years 100 DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

Multiple myeloma Unmet Medical Need Relapsed Disease Diagnosis Survival 3-5 yrs Relapsed Disease Transient Response to Therapy Survival 1-3 years Relapsed and Refractory Resistant to all therapy Universally fatal Survival 6-9 months Unmet Medical Need DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

Bruno B, Rotta M, and Boccadoro M, Lancet Oncology 2004 DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

Advancing Treatment Options in MM 1962 Prednisone + melphalan 1999 First report thalidomide Thalidomide Pharmion licence Aus/NZ 2003 Melphalan From 1990s Myeloablation + ASCT VELCADE® US licence 2003 VELCADE® EU positive opinion 2004 DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

MULTIPLE MYELOMA scenario NEW DRUGS + DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

Thalidomide Originally developed in 1950s as a treatment for insomnia and morning sickness in pregnancy Thalidomide is an immunomodulatory agent Precise mechanism of action not yet understood Multiple actions, including anti-angiogenic effects Anti-angiogenic effects of thalidomide provide the rationale for its use in MM Angiogenesis in bone marrow supports growth and development of MM cells DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

Antitumor activity of thalidomide in refractory multiple myeloma. Singhal S, Mehta J, Desikan R, Ayers D, Roberson P, Eddlemon P, Munshi N, Anaissie E, Wilson C, Dhodapkar M, Zeddis J, Barlogie B. N Engl J Med 1999 Nov 18;341(21):1565-71 Myeloma and Lymphoma Program, South Carolina Cancer Center, University of South Carolina, Columbia, USA. BACKGROUND: Patients with myeloma who relapse after high-dose chemotherapy have few therapeutic options. Since increased bone marrow vascularity imparts a poor prognosis in myeloma, we evaluated the efficacy of thalidomide, which has antiangiogenic properties, in patients with refractory disease. METHODS: Eighty-four previously treated patients with refractory myeloma (76 with a relapse after high-dose chemotherapy) received oral thalidomide as a single agent for a median of 80 days (range, 2 to 465). The starting dose was 200 mg daily, and the dose was increased by 200 mg every two weeks until it reached 800 mg per day. Response was assessed on the basis of a reduction of the myeloma protein in serum or Bence Jones protein in urine that lasted for at least six weeks. RESULTS: The serum or urine levels of paraprotein were reduced by at least 90 percent in eight patients (two had a complete remission), at least 75 percent in six patients, at least 50 percent in seven patients, and at least 25 percent in six patients, for a total rate of response of 32 percent. Reductions in the paraprotein levels were apparent within two months in 78 percent of the patients with a response and were associated with decreased numbers of plasma cells in bone marrow and increased hemoglobin levels. The microvascular density of bone marrow did not change significantly in patients with a response. At least one third of the patients had mild or moderate constipation, weakness or fatigue, or somnolence. More severe adverse effects were infrequent (occurring in less than 10 percent of patients), and hematologic effects were rare. As of the most recent follow-up, 36 patients had died (30 with no response and 6 with a response). After 12 months of follow-up, Kaplan-Meier estimates of the mean (+/-SE) rates of event-free survival and overall survival for all patients were 22+/-5 percent and 58+/-5 percent, respectively. CONCLUSIONS: Thalidomide is active against advanced myeloma. It can induce marked and durable responses in some patients with multiple myeloma, including those who relapse after high-dose chemotherapy

Bruno B, Rotta M, and Boccadoro M, Lancet Oncology 2004, in Press DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

~ Thalidomide: mechanism of action ?? “Thal metabolism required for its anti-myeloma efficacy” Human myeloma Human myeloma Human liver Thal reduced Thal ~ unchanged Yaccoby et Al, Blood, 2002 DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

INTERIM ANALYSIS PROSPECTIVE RANDOMIZED TRIAL GRUPPO ITALIANO PER LO STUDIO DEL MIELOMA MULTIPLO INTERIM ANALYSIS PROSPECTIVE RANDOMIZED TRIAL NEWLY DIAGNOSED PATIENTS, AGE > 65 YEARS MELPHALAN, PREDNISONE + THALIDOMIDE (MPT) versus MELPHALAN PREDNISONE (MP) DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

ADVERSE EVENTS WHO (grade) 1-2 3-4 1-2 3-4 Hematologic (%) MPT MP WHO (grade) 1-2 3-4 1-2 3-4 Hematologic (%) Constipation (%) Neurologic (%) Cardiac (%) Cutaneous (%) Infection (%) Thromboemb.(%) Early death (%) 29 28 32 17 15 14 18 7 9 3 2 10 35 - 11 3 12 25 - 4 1 19 5 4 5 DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

Dept. Hematology, University of Torino RESPONSE TO THERAPY 77.1% 15.6% 46.7% % of Response 33.8% 28% 27.7% 13.3% 5.4% Dept. Hematology, University of Torino

(median follow up 13.6 months) EVENT-FREE SURVIVAL (median follow up 13.6 months) Proportion MPT p<0.001 MP Months DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

RESPONSE TO THERAPY 27.7% % CR 5% 3-5% MP Thal MP + Thal 30 20 10 DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

Revlimid ™ (lenalidomide) Thalomid® (thalidomide) Actimid™ (CC-4047) Revlimid ™ (lenalidomide) (CC-5013)

The Proteasome: A Target for Novel Therapies Bruno B, Rotta M, and Boccadoro M, Lancet Oncology 2004, in Press DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

IkB IkB IkB IkB IkB TNFa TNFaR p65 p50 p65 p65 p50 p50 Protein kinases IkB p65 p50 P Ub IkB p65 p50 TNFaR Degradation of IkB by 26S proteasome p50 p65 IkB P Ub NFkB-IkB complex IkB P Ub

Increase in adhesion molecules TNFa IkB p65 p50 P Protein kinases IkB p65 p50 P Ub IkB p65 p50 TNFaR Degradation of IkB by 26S proteasome p50 p65 IkB P Ub NFkB-IkB complex IkB P Ub NFkB Nuclear translocation p65 p50 PS 341 NFkB binding site NFkB Induced proteins Block of programmed cell death Increase in Cytokine production Increase in adhesion molecules

Increase in adhesion molecules TNFa IkB p65 p50 P Protein kinases IkB p65 p50 P Ub IkB p65 p50 TNFaR Degradation of IkB by 26S proteasome p50 p65 IkB P Ub NFkB-IkB complex NFkB Nuclear translocation p65 p50 PS 341 NFkB binding site NFkB Induced proteins Block of programmed cell death Increase in Cytokine production Increase in adhesion molecules

Increase in adhesion molecules TNFa IkB p65 p50 P Protein kinases IkB p65 p50 P Ub IkB p65 p50 TNFaR Degradation of IkB by 26S proteasome p50 p65 IkB P Ub NFkB-IkB complex p50 p65 IkB P Ub p50 p65 IkB P Ub NFkB Nuclear translocation PS 341 NFkB binding site NFkB Induced proteins Block of programmed cell death Increase in Cytokine production Increase in adhesion molecules

Increase in adhesion molecules TNFa IkB p65 p50 P Protein kinases IkB p65 p50 P Ub IkB p65 p50 TNFaR Degradation of IkB by 26S proteasome p50 p65 IkB P Ub NFkB-IkB complex p50 p65 IkB P Ub p50 p65 IkB P Ub NFkB Nuclear translocation PS 341 NFkB Induced proteins Block of programmed cell death Increase in Cytokine production Increase in adhesion molecules

Increase in adhesion molecules TNFa IkB p65 p50 P Protein kinases IkB p65 p50 P Ub IkB p65 p50 TNFaR Degradation of IkB by 26S proteasome p50 p65 IkB P Ub NFkB-IkB complex p50 p65 IkB P Ub p50 p65 IkB P Ub NFkB Nuclear translocation PS 341 NFkB Induced proteins Block of programmed cell death Increase in Cytokine production Increase in adhesion molecules Antimyeloma effect

SUMMIT (025): A Phase II Study of VELCADE™ (bortezomib) for Injection in Patients With Relapsed and Refractory Multiple Myeloma Paul G. Richardson,1 Bart Barlogie,2 James Berenson,3 Seema Singhal,4 Ann Traynor,4 Sundar Jagannath,5 David Irwin,6 Vincent Rajkumar,7 Gordan Srkalovic,8 Melissa Alsina,9 Raymond Alexanian,10 David Siegel,11 Robert Orlowski,12 David Kuter,13 Steven Limentani,14 Dixie Esseltine,15 Gretchen Richards,15 Michael Kauffman,15 Julian Adams,15 David P. Schenkein,15 and Kenneth C. Anderson1 1Dana-Farber Cancer Institute, 2University of Arkansas, 3Cedars-Sinai Medical Center, 4Northwestern University Medical Center, 5St Vincent’s Comprehensive Cancer Center, 6Alta Bates Cancer Center, 7Mayo Clinic, 8Cleveland Clinic Foundation, 9H. Lee Moffitt Cancer Center, 10M.D. Anderson Cancer Center, 11Carol G. Simon Cancer Center, 12University of North Carolina at Chapel Hill, 3Massachusetts General Hospital, 14Charlotte Medical Clinic, 15Millennium Pharmaceuticals, Inc

SUMMIT – Prior Therapy 99.5% 92% Median number of lines of prior therapy = 6 (range 2-15) 92% of patients received at least 3 of the drug therapies listed here (excluding stem cell transplant) 91% of patients were refractory to the last prior therapy 83% 81% 64%

SUMMIT – Response Rates with VELCADE® Alone 35% 35% response rate 10% CR (IF+ and IF-) 28% CR+PR 59% of patients SD or better Mean duration of response 12 months CR IF- CR IF+ PR MR SD - + Prior treatment had no significant effect on response rate DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

Treatment plan – APEX Bortezomib Dexamethasone Randomization Induction 8 cycles 4 cycles 1.3 mg/m2 IV push Days 1, 4, 8, 11 Q3W cycle 40 mg po Days 1–4, 9–12, 17–20 Q5W cycle Maintenance 3 cycles 5 cycles 1.3 mg/m2 IV push Days 1, 8, 15, 22 Q5W cycle 40 mg po Days 1–4 Q4W cycle 273 treatment days 280 treatment days Richardson et al. NEJM 2005

APEX: Time to Progression (n=669) 78% improvement in median TTP with bortezomib Median TTP: Bortezomib 6.2 months vs dexamethasone 3.5 months Richardson et al. NEJM 2005

APEX: Response rates (CR, PR) 100 Median time to response (TTR) 43 days in both arms Duration of response Bortezomib 8.0 months Dexamethasone 5.6 months Median follow-up ~8.3 months 90 80 P<.0001 70 60 Response (%) 50 38% 40 30 25% PR 18% <1% nCR 20 10 7% nCR 16% PR <1% CR 6% CR Bortezomib Dexamethasone Richardson et al. NEJM 2005

APEX: 1-year survival (n=669) 80% 66% The Kaplan-Meier plot for survival censored at one year in both arms for the entire intent-to-treat population. Data for survival analysis were censored on or before January 13, 2004, with P values from stratified log-rank tests. 41% decreased risk of death with bortezomib Richardson et al. NEJM 2005

APEX: Overall survival (n=669) This is a Kaplan-Meier plot of overall survival in the entire intent-to-treat population The survival curves cross at ~500 days, because of the death of one patient on the bortezomib arm at 504 days. At that time, the curve had accounted for 330 of the 333 patients (with 50 deaths and 280 patients censored), with only the one patient death and 2 censored data points after the cross. Median duration of follow-up 8.3 months Richardson et al. NEJM 2005

Conclusion Phase III APEX: Bortezomib demonstrated superior efficacy to high-dose dexamethasone in relapsed MM Significant TTP benefit (P<.0001) Response rate advantage (P<.0001) Superior 1-year survival (P=.0005, HR=.53) Superior overall survival (P=.0013, HR=.57) Richardson et al. NEJM 2005

Most common adverse events from Phase I, SUMMIT, CREST and APEX trials Toxicities were predictable and manageable Adverse event Phase I1 SUMMIT2 CREST3 APEX4 (%) (%) (%) (%) Thrombocytopenia 74 40 30 35 Fatigue 59 41 70 42 Nausea 52 55 54 57 Diarrhea 37 44 44 57 Constipation 30 16 37 42 Vomiting 30 27 NR 35 Peripheral neuropathy 19 31 41 36 NR = not recorded 1Orlowski et al. J Clin Oncol 2002;20:4420; 2Richardson et al. N Engl J Med 2003;348:2609; 3Jagannath et al. Br J Hematol 2004;127:165; 4Richardson et al. ASH 2004 (abstract 336.5)

Combinations therapies in Multiple Myeloma Bortezomib + Thalidomide +/- cytotoxic drugs induction relapse M-COMPONENT High dose remission

Multiple Myeloma Studies in Development: Front Line Dana Farber Richardson Phase II VELCADE alone in 1st line tx CHU de Nantes Harousseau Phase II VELCADE + high-dose dexamthasone 1st line, pre-transplant Location PI Study ECOG/CTEP Dispenzieri Phase II VELCADE in high risk myeloma, 1st line U. Maryland Badros Phase I/II VELCADE + DT-PACE, 1st line CALGB Orlowski Phase II VELCADE + Doxil U. Arkansas Barlogie Phase II VELCADE + Total Therapy III in high risk myeloma 1st line Salick Group Jagannath Phase II VELCADE monotx Dex after 2 cycles for less than optimal response

MULTIPLE MYELOMA cure AUTOLOGOUS FIRST STEP Proteasome inhibitors Thalidomide Mini allo AUTOLOGOUS FIRST STEP DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY

MULTIPLE MYELOMA chronic Chemo Thalidomide Proteasome inhibitors Lanilomide DIVISIONE UNIVERSITARIA DI EMATOLOGIA AZIENDA OSPEDALIERA SAN GIOVANNI TORINO, ITALY