Novel Therapies for <em>T315I</em>-Mutant CML

Omar Al Ustwani, MD

Leukemia Section, Department of Medicine, Roswell

Park Cancer Institute, Buffalo, NYCorresponding Author:

Meir Wetzler, MD

Leukemia Section, Department of Medicine, Roswell

Park Cancer Institute, Buffalo, NY;meir.wetzler@roswellpark.org

Abstract

The use of tyrosine kinase inhibitors (TKIs) to inhibit BCR-ABL protein in chronic myeloid leukemia (CML) is one of the major milestones in modern oncology. After the FDA approval of imatinib (a first-generation TKI), dasatinib, nilotinib, and later bosutinib, recurrence of disease due to multiple mechanisms of resistance became the new challenge in CML treatment. TheT315Imutation is of special interest as it continues to be an obstacle to the use of TKIs. In this review, we cover the clinical efficacy data of the approved agents for this indication, ponatinib and omacetaxine, in addition to discussing the role of stem cell transplantation and other novel agents in the treatment of CML.

Introduction

Abelson tyrosine kinase (ABL1) is a nonreceptor tyrosine kinase involved in cell growth and proliferation. Chronic myeloid leukemia (CML) arises from the fusion of theABL1gene (chromosome 9q34) with the breakpoint cluster region (BCR) gene (chromosome 22q11.2), generating the Philadelphia chromosome expressingBCR-ABL1. BCR-ABL1 is a constitutively activated tyrosine kinase that activates many signaling pathways, thus providing a proliferative advantage.¹Imatinib, the first tyrosine kinase inhibitor (TKI), competitively inhibiting the BCR-ABL1 kinase, was approved based on the results of the International Randomized Study of Interferon versus STI571 (IRIS) trial showing that at 18 months, 76.2% of the patients achieved complete cytogenetic response (CCyR) and 96.7% were free from disease progression.²Longer follow-up revealed significant relapses³; of these patients, 40% to 50% were identified as having point mutations at the ATP-binding site of the ABL1 kinase domain.⁴

Ponatinib (AP24534)

Development of second-generation TKIs (dasatinib, nilotinib) helped overcome most mutations exceptT315I.⁵Dasatinib was able to overcome 14 of the initially identified 15 imatinib-resistant mutations.⁶Subsequently, dasatinib was found to be less effective against additional mutations such asF317LandT315Adue to the important role of phenylalanine 317 and threonine 315 serving as contact residues to imatinib and dasatinib.⁷Nilotinib is not affected by the phenylalanine 317 position. Thus,F317Lis not considered resistant to nilotinib. However, other mutations, such asE459KandY253H, were found to be resistant to nilotinib.⁸InT315I, a threonine to isoleucine gatekeeper mutation results in alteration of the structure of the ATP-binding pocket by eliminating a hydrogen-bonding interaction involved in binding first- and second-generation TKIs.⁹Several third-generation TKIs (including bosutinib) were designed to targetT315I, but only a few agents have shown clinical activity.Ponatinib was designed to accommodate theT315Iside chain via a carbon-carbon triple bond and was confirmed to bind to the inactive mode of the kinase domain in the murine ABL1^T315I. Preclinical data suggested that it prevents the autophosphorylation of both native andT315I-mutant kinase and inhibits growth and signaling in the cells expressing native or mutant BCR-ABL1. Dose-dependent antitumor activity was shown in a BCR-ABL1^T315Imouse xenograft model, with significant response at daily doses of 10 mg/kg and 30 mg/kg.10 It was also shown to inhibit compound mutations, in addition to multiple other kinase pathways such as the SRC family kinases, platelet-derived growth factor receptor-&alpha;, vascular endothelial growth factor receptor pathways, andc-KIT.^10,11

Based on these results, a phase I trial enrolled 48 patients (31 with refractory chronic-phase [CP] CML, six with accelerated-phase [AP] CML, five with blast-phase [BP] CML, and two with Philadelphia-positive acute lymphoblastic leukemia [ALL]), 18 of whom had theT315Imutation.¹²Interim results showed that pancreatitis was the dose-limiting toxicity at 60 mg orally daily, and 45 mg became the recommended dose for future studies. CCyR was noted in 33%, and major molecular response (MMR) in 48% of all patients. CCyR was achieved in 57% of patients with theT315Imutation. Significant adverse events (AEs) included nausea (20%) and fatigue (15%). Additional data on 11 patients with theT315Imutation from the same trial showed that 82% achieved major cytogenetic response (MCyR) and 40% achieved MMR.¹³The final results of the dose-escalation trial (n = 81) were recently published.¹⁴Among 12 patients who hadT3151-mutant CP CML, 100% had a complete hematologic response (CHR) and 92% had a MCyR. AEs were similar to previously published results.

The PACE (Ponatinib Philadelphia-positive ALL and CML Evaluation) trial,15 a pivotal phase II study, was conducted in 449 heavily pretreated patients (including 85 with AP CML, 62 with BP CML, and 32 with Philadelphia-positive ALL) who were resistant/intolerant to nilotinib or dasatinib or had theT315Imutation at baseline, and were followed for a median of 11 months (range, 0.1-21 months). In patients with CP CML with theT315Imutation, 70% achieved the primary endpoint of MCyR. For AP CML, BP CML, and Philadelphiapositive ALL, the primary endpoint was major hematologic response (MaHR) and was achieved in 50% and 33% (combined for the latter two), respectively. A post-hoc analysis showed that the presence of the mutation was not a predictor of response, which was instead explained by the younger age of the patients, exposure to less treatment, and shorter duration of leukemia in the patients with theT315Imutation. At 45 mg daily, ponatinib most commonly caused thrombocytopenia (36%) and rash (33%). The most common serious AE was pancreatitis (5%). Arterial thrombotic events and hepatotoxicity were also noted and added to the black box warnings for this drug.¹⁵Based on the PACE study, the FDA approved ponatinib as a treatment option for all phases of CML that are resistant or intolerant to TKIs.

Clinical Pearls

• TheT315Imutation alters the structure of the ATP-binding site by eliminating a hydrogen bond that mediates bonding with most TKIs
• Ponatinib is now FDA-approved for all phases of CML resistant or intolerant to TKIs; ponatinib has activity against theT315Imutation
• Omacetaxine is a semisynthetic alkaloid that is FDA-approved for patients with chronic- and accelerated-phase CML who have failed at least two prior TKI therapies or were intolerant to other treatments; omacetaxine has activity against theT315Imutation

Omacetaxine Mepesuccinate

Although ponatinib was originally developed as a pan BCR-ABL inhibitor, recent studies identified new mutations that are resistant to ponatinib in vitro, such asE255V,L248R, and/orT315V, or in the case of having compound (L248R/F359I) mutations.^16,17Further, a follow-up study (based on the PACE data) compared the impact of baseline mutations and end-of-treatment mutations on response to ponatinib. MCyR was achieved in 49% of patients with no mutations at baseline, 64% of patients with one mutation, and 62% in patients with two or more mutations present at baseline.¹⁸These data suggested that patients without mutations harbored other, yet unknown mechanisms of resistance. In addition, MCyR was achieved in 57% of patients with mutations other thanT315I, 74% of patients withT315I, and 57% of patients withT315Iand other mutations. Multivariate analysis still showed thatT315Iis not an independent predictor of response as it was noted in the initial PACE study. Among 56 patients who had an end-oftreatment mutation evaluation, 46 had no change, five lost a mutation and five gained mutations, again suggesting other, not yet discovered mechanisms of resistance.¹⁸In the 1970s, homoharringtonine (HHT; an omacetaxine precursor) and other esters of alkaloid cephalotaxines were isolated from the bark of theCephalotaxus fortuneievergreen tree and found to have activity against murine leukemia by decreasing protein synthesis and inducing apoptosis.^19,20HHT was found to induce apoptosis in vitro in CML cells (includingT315I-mutant cells), and also in the murine model of CML and BCR-ABL1-positive B-ALL.^21,22It is different from TKIs as it induces apoptosis in both CML and non-CML stem cells in vitro and in murine models, which makes it an effective strategy to eradicate resistant disease.^21,22Interestingly, before the imatinib era, HHT was considered an effective agent for CML that had failed interferon-alpha therapy.²³Anecdotal reports illustrated HHT activity in patients withT315I-mutant CML refractory to TKIs.^24,25

Omacetaxine, a subcutaneous, semisynthetic HHT, was evaluated in 2006 in a phase II trial (CML-202) in imatinib-resistant,T315I-mutant CML.²⁶In this study, omacetaxine was given at 1.25 mg/m²twice daily for 14 days every 28 days until CHR, followed by maintenance at the same dosage for 7 days every 28 days, for up to 24 months. The preliminary data included 55 patients (32 CP, 14 AP, and 9 BP CML); 53% had failed at least two TKIs and 27% had failed at least three TKIs. CHR rates were 80%, 45%, and 13%, respectively, per disease phase. Cytogenetic response (CyR) rates were 28%, 9%, and 0%. The 2-year progression-free survival (PFS) was 70% for patients with CP CML. The most common grade 3/4 AEs were thrombocytopenia (53%) and neutropenia (28%). The final results from this study were published in 2012 and illustrated that among 62 patients with CP CML, MCyR was 23% and CCyR was 16%, with a median PFS of 7.7 months.²⁷A median overall survival (OS) was not reached at a median follow-up to 19 months.

TABLE. Summary of Clinical Efficacy Data of Ponatinib and Omacetaxine inT315I-Mutated CML

Drug

Ponatinib¹⁴

Omacetaxine²⁷

Phase

Dose escalation I

II

Number of patients (n)

65

62

n (T315I)

19

62

Median age, years

55

56

Most common AEs

Rash (32%)

Thrombocytopenia (27%)

Thrombocytopenia (79%)

Anemia (66%)

Infection (42%)

Most common G3-G4 AEs

Thrombocytopenia (20%)

Neutropenia (10%)

Elevated lipase (7%)

Thrombocytopenia (76%)

Neutropenia (44%)

T315I-evaluable CP CML

(n = 12)

CHR (100%)

CCyR (75%)

MMR (67%)

(n = 62)

CHR (77%)

MCyR (23%)

CCyR (16%)

T315I-evaluable AP,

BP CML and Ph+ ALL

(n = 13)

MaHR (29%)

MCyR (29%)

CCyR (14%)

MMR (29%)

AEs = adverse events; AP = accelerated phase; BP = blast phase; CHR = complete hematologic response; CCyR = complete cytogenetic response; CP = chronic phase; MaHR = major hematologic response; MCyR = major cytogenetic response; MMR = major molecular response; n = number; Ph+ ALL = Philadelphia chromosome-positive acute lymphoblastic leukemia.

Hematopoietic Stem Cell Transplantation (HSCT)

Another phase II study (N = 122) was conducted in patients with CP and AP CML.²⁸In patients with CP CML who had failed two or more TKIs, MCyR was achieved in 27%, with a median survival of 30 months. Pooled safety analysis of 207 patients in the two phase II studies showed that the most common AEs were thrombocytopenia, anemia, diarrhea, neutropenia, and nausea.²⁹Febrile neutropenia occurred in 11% of patients. Based on these data, omacetaxine was approved by the FDA in 2012 for CP and AP CML intolerant to other therapy or following failed therapy with two or more TKIs. TheTablesummarizes the clinical efficacy data of omacetaxine and ponatinib inT315I—mutated CML.HSCT is another treatment option for patients with theT315Imutation, although evidence in this area is scarce. A retrospective study identified eight patients withT315I-mutated CML who underwent nine unrelated allogeneic HSCT; two patients had CP CML, three had AP CML, and three were in second CP CML.³⁰Two of the patients underwent myeloablative conditioning, four had reducedintensity conditioning, and one had a myeloablative preparatory regimen in the first HSCT, followed by a reduced-intensity regimen in the second. CCyR was achieved in four patients, and complete molecular remission (CMR) was achieved in four patients as the best outcome. The best outcomes were noted in two patients who underwent HSCT in CP CML and achieved CMR; they remained alive without recurrence for 14 and 42 months. At a median follow-up of 13 months, five patients were still alive, three of them in CMR, one in CCyR, and one in CHR.³⁰

Promising Agents

A recent larger study of patients withT315I-mutated CML (N = 64) concluded that allogeneic HSCT resulted in a median OS of 10.3 months in CP CML and 7.4 months in BP CML.³¹Unrelated donor stem cells correlated with poor outcome. The available data suggest that HSCT is a viable option for patients with theT315Imutation, but it has not been proven to be superior or inferior to omacetaxine or ponatinib.DCC-2036 (rebastinib) is a switch pocket inhibitor that prevents ABL1 kinase activation when blocking essential conformation change in the switch pocket. A phase I study in 30 patients with CML (includingT315Imutations) suggested the median tolerated dose to be 150 mg orally twice a day, and resulted in two out of 19 CyRs in patients with CP CML.³²

Conclusion

Aurora kinase inhibitors, including MK-0457 (tozasertib), may also block ABL1 kinase at the gatekeeper site. As noted in a phase I/II study conducted in 18 patients withT315I-mutated CML, eight hematologic responses were achieved.³³The combination of MK-0457 and vorinostat (a histone deacetylase inhibitor) suggested synergistic effect in imatinib-resistant CML cells with theT315Imutation, which could be the beginning of an era of targeted therapy combinations in CML clinical trials.³⁴The success story of CML and TKIs continues to mature with more available options that could tackle treatment challenges. Although more advances have been recently made inT315I-mutant CP, AP, and BP CML, this is still an area that could use more effective agents. The current direction of research is focused on novel experimental agents, combinations of known TKIs, and targeting CML stem cells in hopes of finding the cure for this disease.

Author Disclosures

Dr. Al Ustwani has no conflicts of interest to report.

Dr. Wetzler has been a consultant/advisory board member for TEVA Pharmaceutical Industries, Ltd. and Ariad Pharmaceuticals.

References

1. Deininger MW, Goldman JM, Melo JV. The molecular biology of chronic myeloid leukemia.Blood. 2000;96(10):3343-3356.
2. O&rsquo;Brien SG, Guilhot F, Larson RA, et al; IRIS investigators. Imatinib compared with interferon and low-dose cytarabine for newly diagnosed chronic-phase chronic myeloid leukemia.N Engl J Med. 2003;348(11):994-1004.
3. Kantarjian H, O&rsquo;Brien S, Garcia-Manero G, et al. Very long-term follow-up results of imatinib mesylate therapy in chronic phase chronic myeloid leukemia after failure of interferon alpha therapy.Cancer. 2012;118(12):3116-3122.
4. Hughes T, Deininger M, Hochhaus A, et al. Monitoring CML patients responding to treatment with tyrosine kinase inhibitors: review and recommendations for harmonizing current methodology for detecting BCR-ABL transcripts and kinase domain mutations and for expressing results.Blood. 2006;108(1):28-37.
5. Jabbour E, Cortes J, Kantarjian H. Treatment selection after imatinib resistance in chronic myeloid leukemia.Target Oncol. 2009;4(1):3-10.
6. Shah NP, Tran C, Lee FY, et al. Overriding imatinib resistance with a novel ABL kinase inhibitor.Science. 2004;305(5682):399-401.
7. Soverini S, Martinelli G, Colarossi S, et al. Second-line treatment with dasatinib in patients resistant to imatinib can select novel inhibitorspecific BCR-ABL mutants in Ph+ ALL.Lancet Oncol. 2007;8(3):273- 274.
8. Hughes T, Saglio G, Branford S, et al. Impact of baseline BCR-ABL mutations on response to nilotinib in patients with chronic myeloid leukemia in chronic phase.J Clin Oncol. 2009;27(25):4204-4210.
9. Weisberg E, Manley PW, Breitenstein W, et al. Characterization of AMN107, a selective inhibitor of native and mutant Bcr-Abl.Cancer Cell. 2005;7(2):129-141. Erratum in Cancer Cell. 2005;7(4):399.
10. O&rsquo;Hare T, Shakespeare WC, Zhu X, et al. AP24534, a pan-BCR-ABL inhibitor for chronic myeloid leukemia, potently inhibits the T315I mutant and overcomes mutation-based resistance.Cancer Cell. 2009;16(5):401-412.
11. Karaman MW, Herrgard S, Treiber DK, et al. A quantitative analysis of kinase inhibitor selectivity.Nat Biotechnol. 2008;26(1):127-132.
12. Talpaz M, Deininger M W, Shah NP, et al. Phase I trial of AP24534 in patients with refractory chronic myeloid leukemia (CML) and hematologic malignancies.J Clin Oncol. 2010;28(suppl; abstr 6511).
13. Cortes JE, Talpaz M, Bixby D, et al. Phase 1 trial of oral ponatinib (AP24534) in patients with refractory chronic myelogenous leukemia (CML) and other hematologic malignancies: emerging safety and clinical response findings.Blood. 2010;116(21). Abstract 210.
14. Cortes JE, Kantarjian H, Shah NP, et al. Ponatinib in refractory Philadelphia chromosome-positive leukemias.N Engl J Med. 2012;367(22):2075-2088.
15. Cortes JE, Kim D-W, Pinilla-Ibarz J, et al. A pivotal phase 2 trial of ponatinib in patients with chronic myeloid leukemia (CML) and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ALL) resistant or intolerant to dasatinib or nilotinib, or with the T315I BCR-ABL mutation: 12-month follow-up of the PACE trial.Blood. 2012;120. Abstract 163.
16. Redaelli S, Mologni L, Rostagno R, et al. Three novel patientderived BCR/ABL mutants show different sensitivity to second and third generation tyrosine kinase inhibitors.Am J Hematol. 2012;87(11):E125-E128.
17. Redaelli S ML, Rostagno R, Piazza R, et al. A new BCR-ABL1 mutation (L248R) is highly resistant to imatinib, bosutinib, nilotinib and dasatinib, but can be inhibited by AP-24534 and DCC-2036.Blood. 2010;116(21). Abstract 3398.
18. Deininger M, Cortes JE, Kim DW, et al. Impact of baseline mutations on response to ponatinib and end of treatment mutation analysis in patients with chronic myeloid leukemia.J Clin Oncol. 2013;31(suppl; abstr 7001).
19. Powell RG, Weisleder D, Smith CR, Jr. Antitumor alkaloids for Cephalataxus harringtonia: structure and activity.J Pharm Sci. 1972;61(8):1227-1230.
20. O&rsquo;Dwyer PJ, King SA, Hoth DF, et al. Homoharringtonine-- perspectives on an active new natural product.J Clin Oncol. 1986;4(10):1563-1568.
21. Allan EK, Holyoake TL, Craig AR, Jorgensen HG. Omacetaxine may have a role in chronic myeloid leukaemia eradication through downregulation of Mcl-1 and induction of apoptosis in stem/ progenitor cells.Leukemia. 2011;25(6):985-994.
22. Chen Y, Hu Y, Michaels S, et al. Inhibitory effects of omacetaxine on leukemic stem cells and BCR-ABL-induced chronic myeloid leukemia and acute lymphoblastic leukemia in mice.Leukemia. 2009;23(8):1446-1454.
23. O&rsquo;Brien S, Kantarjian H, Koller C, et al. Sequential homoharringtonine and interferon-alpha in the treatment of early chronic phase chronic myelogenous leukemia.Blood. 1999;93(12):4149-4153.
24. Legros L, Hayette S, Nicolini FE, et al. BCR-ABL(T315I) transcript disappearance in an imatinib-resistant CML patient treated with homoharringtonine: a new therapeutic challenge?Leukemia. 2007;21(10):2204-2206.
25. de Lavallade H, Khorashad JS, Davis HP, et al. Interferon-alpha or homoharringtonine as salvage treatment for chronic myeloid leukemia patients who acquire the T315I BCR-ABL mutation.Blood. 2007;110(7):2779-2780.
26. Cortes J, Khoury HJ, Corm S, et al. Safety and efficacy of subcutaneous (SC) omacetaxine mepesuccinate in imatinib (IM)- resistant chronic myeloid leukemia (CML) patients (pts) with the T315I mutation — results of an ongoing multicenter phase II study.Blood. 2008;112(11). Abstract 3239.
27. Cortes J, Lipton JH, Rea D, et al. Phase 2 study of subcutaneous omacetaxine mepesuccinate after TKI failure in patients with chronicphase CML with T315I mutation.Blood. 2012;120(13):2573-2580.
28. Nicolini FE, Lipton JH, Kantarjian H, et al. Subcutaneous omacetaxine mepesuccinate in patients with chronic phase (CP) and accelerated phase (AP) chronic myeloid leukemia (CML) resistent/intolerant to two or three approved tyrosine-kinase inhibitors (TKIs).J Clin Oncol. 2012;30(suppl; abstr 6513).
29. Wetzler M, Kantarjian H, Nicolini FE, et al. Pooled safety analysis of omacetaxine mepesuccinate in patients with chronic myeloid leukemia (CML) resistant to tyrosine-kinase inhibitors (TKIs).J Clin Oncol. 2012;30(suppl; abstr 6604).
30. Velev N, Cortes J, Champlin R, et al. Stem cell transplantation for patients with chronic myeloid leukemia resistant to tyrosine kinase inhibitors with BCR-ABL kinase domain mutation T315I.Cancer. 2010;116(15):3631-3637.
31. Nicolini FE, Basak GW, Soverini S, et al. Allogeneic stem cell transplantation for patients harboring T315I BCR-ABL mutated leukemias. Blood. 2011;118(20):5697-5700.
32. Chan WW, Wise SC, Kaufman MD, et al. Conformational control inhibition of the BCR-ABL1 tyrosine kinase, including the gatekeeper T315I mutant, by the switch-control inhibitor DCC-2036.Cancer Cell. 2011;19(4):556-568.
33. Giles FJ, Swords RT, Nagler A, et al. MK-0457, an Aurora kinase and BCR-ABL inhibitor, is active in patients with BCR-ABL T315I leukemia.Leukemia. 2013;27(1):113-117.
34. Dai Y, Chen S, Venditti CA, et al. Vorinostat synergistically potentiates MK-0457 lethality in chronic myelogenous leukemia cells sensitive and resistant to imatinib mesylate.Blood. 2008;112(3):793-804