guenther koehne, md phd adult bone marrow transplant...

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


54%

Björkstrand, et alJ Clin Oncol2011

TBI 200 cGy /FLU

108 35%

@ 5 y

65%

@ 5 y


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%


OS by lines of therapy PFS by lines of therapy

57%

25%

42%

67%


OS by disease status PFS by disease status

62%

19%

62%

47%

22%

14%


OS by extramedullary disease PFS by extramedullary disease

66%

53%

31%

21%

41%

30%


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%


0.82%3.65%

0.5%

Pentadecapeptide #62 Pentadecapeptide #69


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

guenther koehne, md phd adult bone marrow transplant...

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