The document discusses new drugs for the treatment of lymphomas. It outlines several monoclonal antibodies that target antigens on B-cells, including CD20, CD19, CD22 and CD37. Ofatumumab and GA-101 are new anti-CD20 monoclonal antibodies that exhibit enhanced binding and cell-killing properties compared to Rituximab. Inotuzumab Ozogamicin is an antibody-drug conjugate targeting CD22 that is internalized and releases a cytotoxic drug, showing promising activity in early clinical trials.

1. New drugs for the treatment of lymphomas Anastasios Stathis, MD New Drugs Program and Lymphoma Unit (IOSI) Oncology Institute of Southern Switzerland 3 RD EASO Masterclass in Clinical Oncology Amman,27-29 Oct 2011

2. Introduction In 2010 around 75.000 people were diagnosed with NHL in Europe For the most common subtypes the addition of rituximab to chemotherapy has significantly improved outcomes However death rates are significant ( 31000 in 2010 in Europe) New drugs are needed

3. Drug development for lymphomas Slow process with only few drugs approved No new drugs approved for HL over the last 30 years High attrition rate in the development of anticancer agents Only a minimal proportion of approval applications in onco-hematology have resulted in approved drugs for lymphomas

4. Outline Monoclonal antibodies Small molecules Future directions

5. Monoclonal antibodies B-cell lineage antigens Other antigens (CD30,CD40,CD80) CD19, CD22, CD37 CD20 Free MoAb (CDC, ADCC, Apoptosis) Conjugated to chemo (cytotoxic) Target Mechanism of action

6. IgG 1 =immunoglobulin G 1 ; CDC=complement-dependent cytotoxicity; iNHL=indolent non-Hodgkin's lymphoma; ADCC=antibody-dependent cellular cytotoxicity; SMIP=small modular immunopharmaceutical drug; RA=rheumatoid arthritis; ITP=idiopathic thrombocytopenic purpura; mAb=monoclonal antibody Old target, new drugs: CD20-MoAbs Phase III for CLL, phase II for iNHL, DLBCL Human (Ig transgenic mice) IgG 1 with high CDC I Ofatumumab Antibody Antibody Type Format Stage of development RO 045-2294 I Subcutaneous Rituximab Phase III, iNHL Ocrelizumab (PRO-70769) I Humanized IgG 1 (2H7) with increased binding to Fc γ RIIIa and decreased CDC Phase III trials for NHL and autoimmune conditions Veltuzumab (Ah20) I Humanized (similar binding and activity to rituximab) Phase I/II in iNHL and ITP (including subcutaneous route) AME-133v I Humanized IgG 1 selected for increased binding to CD20 and FcRIIIa, leading to augmented ADCC Phase I/II in relapsed NHL PRO-131921 (version 114) I Humanized IgG 1 version of LyB-1 with elbow mutations and modified Fc glycosylation giving augmented ADCC and apoptosis Phase I/II in CLL and NHL GA-101 II Humanized, glyco-engineered, type II mAb: increased ADCC and apoptosis but reduced CDC killing Phase III DLBCL, iNHL

7. New generation of anti-CD20 mAbs Veltuzumab Ocrelizumab Ofatumumab AME-133v GA-101 PRO-31921 Murine Chimeric Humanized Fully human Engineered 1987 1994 1997 2006 2009 1f5 “ serotherapy ” in 4 pts with refractory B-cell carcinoma CD2B: phase I study in pts with recurrent B-cell lymphoma Rituximab: FDA approval for relapsed or refractory, low grade, CD20+, B-cell NHL Rituximab: approved for first-line use in B-cell lymphomas Ofatumumab : approved in US for CLL refractory to fludarabine and alemtuzumab Rituximab: approved in Europe for untreated and relapse/refractory CLL mAb=monoclonal antibody; pts=patients; FDA=Food and Drug Administration (US); NHL=non-Hodgkin ’ s lymphoma

8. Expressed: Exclusively on B cells On most B cells in periphery On most malignant B cells Stable on B-cell surface, allowing sustained mAb binding Some reports indicate that it is infrequently internalized or shed Function not well understood but believed to contribute to B-cell growth, proliferation, differentiation and activation No known ligand May form a membrane ion channel and play a role in calcium flux Involved in B-cell receptor activation and signalling CD20: attractive target for the treatment of B-cell malignancies B cell CD20 Large loop Small loop B-cell membrane

9. Haematopoietic stem cell Bone Marrow Blood, Lymph CML Precursor B-cell acute leukaemias Myeloma Lymphoid stem cell Pro- B cell Pre-B cell Immature B cell Mature B cell Activated B cell Memory B cell Plasma cell CD20+ CD20 expression begins at early pre-B cell stage, is largely lost during plasma cell differentiation 1-2 Present on stages that give rise to CLL and B-cell lymphomas Not present on essential cells, including haematopoietic stem cells and antibody-producing plasma cells B-cell lymphomas CLL 1 Cragg MS, et al. Curr Dir Autoimmun 2005; 8 : 140–174; 2 O'Connor OA. Presented at: Optimizing Strategies for Targeting CD20 in B-cell Lymphoproliferative Disorders Satellite Symposium; June 7, 2007; held in conjunction with the 12th Annual Congress of the European Hematology Association; June 7–10 2007; Vienna, Austria CML=chronic myeloid leukaemia; CLL=chronic lymphocytic leukaemia CD20: expressed at key stages of B-cell development

10. CDC 1-3 ADCC 1-3 Apoptosis 1-3 Anti-CD20 mAbs mechanism of action 1 Bello C, Sotomayor EM. Hematology Am Soc Hematol Educ Program ; 2007 : 233–242; 2 Glennie MJ, et al. Mol Immunol 2007; 44 (16): 3823–3837; 3 Jazirehi AR, Bonavida B. Oncogene 2005; 24 (13): 2121–2143 ADCC=antibody-dependent cellular cytotoxicity; CDC=complement-dependent cytotoxicity; MAC=membrane attack complex C1q mAb CD20 B cell MAC Macrophage

11. 1 Cragg MS, et al. Curr Dir Autoimmun 2005; 8 : 140–174; 2 Glennie MJ, et al. Mol Immunol 2007; 44 (16): 3823–3837; 3 Teeling JL, et al. Blood 2004; 104 (6): 1793–1800 Differences between type I and type II anti-CD20 mAbs 1-3 – = no activity; + = some activity; ++ = significant activity Type I Type II mAb=monoclonal antibody; CDC=complement-dependent cytotoxicity; ADCC=antibody-dependent cellular cytotoxicity Anti-CD20 mAbs: two types Type I Type II CD20 clustering in B-cell membrane ++ - Induction of CDC ++ + Induction of ADCC ++ ++ Induction of apoptosis + ++

12. Low CD20 density Rituximab requires high CD20 density for CDC Limited efficacy in CLL may be due to relatively low CD20 density Complement inhibition 3,4 B-cell overexpression of complement inhibitory proteins, for example CD55 and CD59, may reduce rituximab-mediated CDC Potential mechanisms for rituximab limitations Lower rituximab-induced CDC correlates with lower CD20 density 1 *Antibodies bound per cell = number of CD20 molecules per cell 100 80 60 40 20 0 0 1.0x10 5 2.0x10 5 3.0x10 5 4.0x10 5 5.0x10 5 6.0x10 5 7.0x10 5 8.0x10 5 CLL Lymphoma % CDC CD20-ABC*

13. Ofatumumab A novel, human monoclonal antibody developed for the treatment of refractory CLL Targets both the small and large loop epitopes on CD20 Exhibits enhanced binding to, and slow dissociation from, CD20 in vitro Enables CD20-mediated cell lysis in vitro in cells with low CD20 expression or in rituximab-resistant cells

14. Ofatumumab targets a unique CD20 epitope on the small extracellular loop Schematic diagram of the structure of CD20 Ofatumumab binding site Rituximab binding site Large loop Small loop B-cell membrane

15. Ofatumumab in CLL Well tolerated in patients with CLL in doses up to 2000 mg (MTD not reached) Infusion-related AEs: 56% of AEs reported on the day of infusion reduced at each subsequent infusion 2000 mg selected as RP2D as all response with a duration >2 months were achieved with this dose Considerable single-agent activity in the treatment of refractory CLL patients: ORR: 50% , PFS: 15 weeks

16. Ofatumumab-further clinical development Is it better than Rituximab? In P2T of relapsed FL, 42% RR (not different from R) Ongoing phase II and III studies in iNHL and DLBCL

17. GA -101 Humanized glyco-engineered MoAb High affinity binding to CD20 Type II binding to the epitope: low complement-dependent cytotoxicity Increased antibody-dependent cellular toxicity (ADCC) and direct cell-death induction (compared to rituximab) Greater efficacy than Rituximab in carriers of the Fc  RIIIa low affinity receptor polymorphism

18. Salles, ASH 2010 # 2868 (Poster) GA-101 in Heavily Pre-treated R/R iNHLs RR: 17% (LD) RR: 55% (HD) n=40, median 4 prior lines, 60% refractory to Rituximab, 25% post auto SCT LD Cohort 400, n=18 & HD Cohort 1600/800, n=22

19. n=40, 3 previous lines, 63% refractory to Rituximab LD Cohort 400, n=21  DLBCL 10, MCL 11 HD Cohort 1600/800, n=19  DLBCL 15, MCL 4 Cartron, ASH 2010 # 2878 (Poster) GA-101 in Heavily Pre-treated R/R DLBCL and MCL ORR for LD ORR for HD CR All cases 24% 32% DLBCL 30% 27% 0/24 MCL 18% 50% 2/15 Median PFS 78 days 83 days

20. Salles, ASH 2010 # 2868 (Poster) GA-101 in Heavily Pre-treated R/R iNHLs RR: 17% (LD) RR: 55% (HD)

21. GA101-current clinical development Is it better than Rituximab? Ongoing 1st line study with chemo (Benda or CHOP) in FL New phase III trial in DLBCL, 1st line G-CHOP vs R-CHOP

22. Subcutaneous rituximab To simplify treatment, especially for maintenance therapy Drug together with hyaluronidase Rash, erythema, mild discomfort, no general reactions

23. Subcutaneous rituximab Results of phase Ib study in iNHL showed comparable concentrations at C trough for SC 625-800mg/sm and IV 375mg/sm Dose for further studies: flat dose 1400mg SC Phase III induction + long term maintenance study in iNHL that have relapsed after R-chemo

24. Monoclonal antibodies against other B-cell lineage antigens 19, 3 19 22 22 CD I/II FL, MCL , ALL bispecific T cell engager Blinatumomab (MT103) Aggressive, Indolent Aggressive, Indolent Indolent, DLBCL Population I/II conjugated to a tubulin inhibitor SAR3419 III humanized, conjugated to calicheamicin Inotuzumab Ozogamicin III IgG1 humanized Epratuzumab Phase Specificity Agent

25. Inotuzumab Ozogamicin (CMC-544) CD22 expressed in more than 90% of B cell NHLs Not expressed on lymphocyte precursor cells and memory cells CD22 internalized after antibody binding Intracellular hydrolysis of the linker and release of calichemaicin: CYTOTOXIC

26. Inotuzumab Ozogamicin (CMC-544) Potent cytotoxic in vitro and in vivo, also in Rituximab resistant tumors Increased activity in xenograft models in combination with other agents (rituximab) First phase I single agent study published in JCO, Advani et al April 2010 Advani et al, JCO April 2010 )

27. Inotuzumab Ozogamicin (CMC-544) phase I study

28. Inotuzumab Ozogamicin (CMC-544) phase I study RP2D 1.8mg/sm q4 weeks Toxicities: Thrombocytopenia (60% gr 3-4 at the MTD), neutropenia (34.7%) asthenia (8.2%), nausea (2%) ORR 39% (median number of previous treatments was 4, prior ASCT 18%). ( 68% in FL and 15% in DLBCL at the MTD) Several ongoing studies in combination with rituximab

29. n=59, n=50 FL, n=5 MZL, n=3 FL 3 previous lines, 54% high FLIPI CMC-544 1.8mg/sm d1 q28 d Goy , ICML 201 1 # 068 ( Oral Presentation ) Phase II study of CMC-544 in pts with R/R iNHL (R to rituximab, R-chemo, RIT) AEs: PLT 67%, ANC:52%, Increased AST: 47% ORR CR All cases 55 % FL 62 % 10 pts 12 m PFS 50%

30. MoAbs targeting other antigens I HL, ALCL, T cell Human 30 MDX-060 80 30 30 30 40 40 CD I HL, ALCL 2nd generation, Fc engineered XmAb2513 Follicular HL, ALCL HL, CD30 NHL FL, Indolent CLL, FL, DLBCL Population II immunomodulatory effects Galiximab I/II Conjugated to MMAE (antitubulin agent) Brentuximab Vedotin (SGN-35) I Chimeric SGN-30 III IgG1, fully human Lucatumumab (HCD122) III IgG1 humanized Dacetuzumab Phase Specificity Agent

31. Brenduximab Vedotin(SGN35) Anti-CD30 conjugated to an antitubulin agent

32. Brentuximab Vedotin (SGN-35) Antitubulin agent monomethyl auristatin E (MMAE) attached to a CD30-MoAb Phase I study in 45 relapsed HL and ALCL patients (73% had a previous transplant) MTD 1.8mg/kg q3w AEs: fatigue, pyrexia, diarrhea, nausea, neutropenia, and peripheral neuropathy 11 CR. Half of the patients at the MTD responded Tumor regression in 86% of patients Younes A et al. N Engl J Med. 2010 Nov 4;363(19):1812-21

33. Phase II trial in RR HL

34. Patient Characteristics

35. Impressive response rate

36. Almost all patients had tumor reductions

37. Toxicities

38. Toxicities (cont)

39. Conclusions

40. n=102 pts with R/R HL, all had failed ASCT SGN35 1.8mg/sm q21d (outpatient, over 30min, no premedication needed) up to 16 cycles 31-ys, median 3,5 previous lines of chemo follow-up 9m, duration of CR not reached Younes A et al , ICML 201 1 # 161 Durable complete remissions in phase II in R/R HL Peripheral neuropathy 47% (gr3 8%), ANC gr3(14%) 34% CR ORR SD All cases 75% 22%

41. MoAbs - Future directions New anti-CD20 MoAbs in developmet to overcome resistance to rituximab Good preclinical rationale (ofatumumab, GA101) but a superiority to Rituximab needs to be proved clinically MoAbs against other antigens might be more effective in combination with rituximab or chemo IV rituximab might be replaced by SC Inotuzumab and Brenduximab are active and need to find a place in standard treatment

42. Small molecules inhibitors of oncogenic pathways

43. Proteosome inhibition The proteosome regulates protein homeostasis Inhibition of preotosome alters the cellular content of a variety of cell cycle and survival proteins (p53, NFkB,cdk) Cell cycle arrest and apoptosis

44. Proteosome inhibition Bortezomib ORR of 25-50% in relapsed/refractory MCL Modest activity in other lymphoma types Activity in ABC DLBCL when combined with chemo

45. Weekly Bortezomib in combination with Rituximab in R/R iNHL and MCL Italy, phase II BRIL06 trial of IIL Number of prior Rx  2 = 77% Rituximab pre-treated = 69% Chiapella, ASH 2010 # 3965 (Poster) Group Number Outcome MCL 25 ORR 64% MZL 8 ORR 50% SLL 16 ORR 37% All cases 49 ORR 53% All cases 49 PFS 2 25% All cases 49 OS 2 80%

46. Bortezomib + RCHOP in DLBCL and MCL Ruan et al, JCO,29 (690-7), 2011 phase I/II study in pts with untreated DLBCL (n=40) and MCL (n=36) RCHOPq21, Bortezomib 0.7, 1 and 1.3mg/sm on d1 and d4 for DLBCL ORR 100%, 86% CR/CRu, 2y-PFS 64%, 2y-OS, for MCL ORR 91%, 72% CR/CRu, 2y-PFS 44%, 2y-OS 86% in DLBCL similar outcomes for GCB and non-GCB (constitutive activation of NFkB in non-GCB may be the key)

47. Proteosome inhibition Future directions Clinical evaluation in other lymphoma subtypes (also in T-cell lymphomas) New combinations, especially with HDACi New generation preteosome inhibitors (oral, less neurotoxic)

48. Hystone deacetylase inhibitors Promising targets because they regulate several pathways Several compounds in clinical development Activity in T cell cutaneous lymphomas May increase the activity of other agents

49. Hystone deacetylase inhibitors pan-HDACi (vorinostat, romidepsin, panobinostat) or class I HDACi (mocetinostat, etinostat) Vorinostat and Romidepsin approved for CTCL (RR 30% in relapsed patients) Limited single agent activity in DLBCL Significant single agent activity in R/R HL (Panobinostat 20% RR, Mocetinostat)

50. Mocetinostat (MGCD0103) in R/R HL USA, multicenter Mocetinostat, an oral drug, given 3 times a week 51 Cases, all had prior Rx including transplantation Initial dose 85mg, n=28 Initial dose 110mg, n=23 Younes, ASH 2010 # 1763 (Poster) Outcome 85mg (n=28) 110mg (n=23) Total (n=51) CR - 2 (8.7%) 2 (3.9%) PR 6 (21.4%) 6 (26.1%) 12 (23.5%) Durable SD 1 (3.6%) - 1 (20%)

51. MDA Panobinostat 10  30mg (12 days in a cycle) Everolimus 5  10mg (28 days in a cycle) Younes, ASH 2010 # 3664 (Poster) Phase I/II Study of Panobinostat + Everolimus in RR HL and NHL Histology Number Some kind of response HL 7 Yes T-Cell 3 Yes MCL 2 Yes DLBCL 2 No FL 2 Yes HL / DLBCL 1 No SLL 1 Yes

52. HDACi Future directions Combinations with other active agents demethylating agents rituximab proteosome inhibitors chemotherapy

53. Targeting the PI3K/Akt/mTOR pathway The PI3K/AKT/mTOR pathway receives signals from several receptors regulates cell growth, proliferation, angiogenesis and cell survival It is active in several lymphoma cell lines constitutive receptor activation survival factors

54. Temsirolimus (CCI-779) Specific inhibitor of the mammalian target of rapamycin (mTOR) Prevents progression from the G1 phase to S phase- CYTOSTATIC Phase I study in 2004, Raymond et al: no MTD reached up to 220mg/sm weekly (gr1-2 euphoria followed by deppression in 3 pts)

55. Temsirolimus (CCI-779) experience in NHLs * 175x3w/75qw vs 175x3w/25qw vs investigators choise III II II II phase 162 72 29 35 n pts 2 2 4 3 previous lines * 25qw 25qw 250qw Dose 22 vs 6 vs 2 35% 41% 38% RR 89 vs 80 vs 68 nr Tc 39% Tc 65% AE gr3-4 MCL non MCL NHL MCL MCL Lymphoma type Author Witzig JCO 2005 Ansell Cancer 2008 Smith ab ASCO 2008 Hess JCO 2009

56. Single Agent Everolimus (RAD001) in R/R MCL SAKK 36/06 Relapsed  3 prior lines of therapy or refractory MCL, 36 cases  evaluable 35 Everolimus 10mg/day, 1-28, 6 cycles ORR  20% CR  2 (6%), PR  5 (14%) Median TTP (all cases) = 5.45 months Renner, ASH 2010 # 2803 (Poster)

57. Everolimus RR 50% in FL, 30% in DLBCL,18% SLL, 53% in HL, 63% in PTCL Maintenance therapy Phase III study in DLBCL Everolimus 10mg die vs placebo for 1 year Patients in CR after RCHOP or similar

58. PI3K inhibitos Targeting molecules upstream of mTOR might be more active Three PI3K classes have been identified, but class I has been looked as anticancer target

59. PI3K δ isoform has a major role in B-cell survivall Highly expressed in lymphoma cells Constitutive activation and invoked PI3K activation are p110 δ -dependent in cell lines and primary patient cells Microenvironment survival factors that are important in the development and maintenance of disease are p110 δ -dependent

60. High expression in several NHL lines

61. CAL-101, an oral PI3K δ inhibitor

62. Target inhibition in different lymphoma cell lines

63. Phase I study in R/R NHLs (indolent and aggressive)

64. Dose escalation

65. Adverse events

66. Reversible increase of liver enzymes

67. Clinical activity

68. Clinical activity (cont)

69. Phase I study in R/R NHLs (indolent and aggressive) CAL-101, OD or BID 50mg BID to 350mg BID n=30 iNHL, n=21 MCL, 4 previous lines, 455 refractory RP2D 150mg BID gr3+ AEs; increased AST/ALT (27%), anorexia (10%), pneumonia (10%), diarrea 88%), ANC (8%) Kahl B et al, 11-ICML, # 350 Outcome iNHL MCL CR 63% 48% PFS > 12m 4m

70. Immunomodulators Anticancer drugs derived from Thalidomide (less toxic) Exact mechanism of action remains unknown (direct antiproliferative effect, tumor microenvironment, angiogenesis, immune cell function) Phase II trials of Lenalidomide showed promising activity in different lymphoma types (FL, DLBCL, MCL, T cell lymphomas)

71. Reduces Tumor burden Lenalidomide mechanism of action Activates T, NK and NKT cells NK and Tcell- mediated tumor killing Increases antigen presenting properties of tumor cells Arrests cell cycle Induces tumor suppressor genes Tumor cell apoptosis Activates caspases Disrupts stromal cell support Enhances Immunological synapse formation

72. Lenalidomide in R/R HL Germany, GHSG 45 Cases  evaluable 31 Lenalidomide 25mg/day, days 1-21, every 28 days, median 4 cycles Böll, ASH 2010 # 2828 (Poster) Outcome Figures CR 3% PR 25% SD 39% MR 10% PD 23%

73. Lenalidomide + R front-line therapy in iNHL 76 pts , FL n=41, CLL/SLL n=15, MZL n=19 R d1, Lenalidomide 2 0 mg d 1-21, q28 ORR: 90%, CR 66% (87% in FL) At study entry: 80% of FL had FLIPI ≥2 and 54% had high tumor burden At a median fu of 14 months, only 4 pts had PD After cycle 6, bcl-2 was no detectable in FL pts Fowler , ICML 201 1 # 137 ( Oral Presentation )

74. Other small molecules in clinical development Marginal activity in DLBCL Bifunctional inhibitor of apoptosis Survivin YM155 Agent Target Comments Results / Ongoing trials ABT-263 Bcl2 Targeting apoptosis RR 11% in SLL/CLL SB-1518 JAK2 JAK inhibitors Some responses in MCL, FL and HL Enzastaurin PKC Protein kinase C inhibitor In phase II, some activity in DLBCL and MCL Fostamatinib SYK SYK (TK) inhibitor 25%RR in DLBCL 50% in CLL PCI32765 Btk BTK inhibitor Phase I study Flavopiridol CDK CDK inhibitor 10% RR in DLBCL in phase I/II study

75. New agents for T cell lymphomas combinations with HDACi or demethylating agents RR 67% in RR PTCL and CTCL RR 61% first line with CHOP in PTCL and NK Proteosome Bortezomib Agent Target Results Ongoing trials Everolimus mTOR RR 63% in RR PTCL and CTCL combination with CHOP in first line Fosfamatinib disodium SYK na RR PTCL Vorinostat HDAC FDA approved for RR CTCL combination with CHOP in first line in PTCL Denileukin Diftitox IL2-R FDA approved for CD25+ RR PTCL in vivo purging with HD chemo and ASCT Zanolimumab CD4 na RR CTCL Brenduximab Vedotin CD30 R/R CD30+ ALCL combination with CHOP in first line

76. Considerations for future drug development Clinical drug development proceeds through well established phases (I,II,III) but this may not be the case in NHL Most of the recently approved drugs based on small phase II trials (no OS benefit) What is considered active in phase II trials? usually RR of 40-50% in R/R patients

77. How do we move forward Preclinical problem How do we choose the correct target Clinical problem Methods of early clinical development and priorities in phase I studies Efficacy evaluation in phase II/III studies

78. Target identification Better understanding of the molecular biology with identification of driver molecular defects of oncogenic pathways Discover predictive biomarkers of response (CD20 + lymphomas do not necessarily respond to CD 20 MoAbs, ecc..) Better preclinical models for the in vivo evaluation of new agents

79. Modern phase I studies Establish the recommended phase II dose Implemet pharmacodynamic endpoints (the highest dose is not always the most active) Patient selection based on predictive factors of response

80. Efficacy evaluation Most of the new agents have been approved based on results of small phase II studies Problem of conflicting phase III trials of first line treatment New trials design might be necessary (eg randomized phase II trials) Increase enrollment of patients in clinical trials and major collaborative efforts

81. Conclusions Hundreds of new agents in development Among both MoAbs and small molecules, there are several agents with clear activity in phase I and II studies in HL and NHL The incorporation of these agents into standard care depends on the results of efficacy evaluation (in phase II and III trials) We should make it a priority including patients in clinical trials that respond to relevant questions