Waldenstrom's Macroglobulinemia:
Advances in the Biology.
Steven P. Treon, MD, MA, PhD
Director, Bing Center for Waldenstrom's
Macroglobulinemia
Dana Farber Cancer Institute
Harvard Medical School
Advances in the Biology of Waldenstrom's Macroglobulinemia
Faculty disclosure information
Consultltant: Celgene, Millenium, Genentech,
Biogen Idec
Grant/Research Support: Celgene, Millenium
Speakers Bureau: Celg
pgene, Millenium,
Genentech
Major Stock Shareholder: No
Advances in the Biology of Waldenstrom's Macroglobulinemia
5th International
International Workshop
Workshop on
Waldenstrom's Macroglobulinemia.
Stockholm, Sweden · Nobel Hall, October 2008
Advances in the Biology of Waldenstrom's Macroglobulinemia
Clinicopathological definition of WM.
Presence of a monoclonal IgM
protein, irrespective of serum level;
level;
Pathological diagnosis of
lymphoplasmacytic lymphoma using
REAL/WHO criteria.
Owen et al, Semin Oncol 2003
IWWM2, ATHENS 2002
Advances in the Biology of Waldenstrom's Macroglobulinemia
Predispositions to WM.
Chronic antigen stimulation (HCV ?,
HIV ?, Rickettsiosis)
Ashkenazi ethnicity (20-25%)
Familial (20%)
Common Variable
Variable Immunodeficiency
Immunodeficiency
Disorder (CVID)
Treon et al, Ann Oncol 2006; Landgren et al, IWWM5 2008; Giodano et al, IWWM5 2008;
Hunter et al, IWWM5 2008.
Advances in the Biology of Waldenstrom's Macroglobulinemia
Familial B-
B cell Disorders
Disorders among First and Second
Second
Degree Relatives of Patients with WM.
25%
20%
N=
N 626
15%
1st
1st &
2nd
10%
5%
0%
Total
WM
NHL
M M
CLL
ALL
HD
M GUS
Updated from Treon et al, Ann Oncol 2006
Advances in the Biology of Waldenstrom's Macroglobulinemia
Familial Disease Patterns in WM.
WM
CLL
WM
ND
WM
ND
WM
WM
ND
NHL
ND
NHL
WM Alone
B-cell Disorders
Hunter et al, IWWM5 2008
Advances in the Biology of Waldenstrom's Macroglobulinemia
WM Familial Predisposition
Predisposition Study
Study
at DFCI.
35%
No History
30%
BCell
25%
WM
20%
15%
10%
5%
6.7% 4.8% 22.7%
7.8% 11.1% 9.1%
14.4% 15.9% 31.8%
0%
Monoclonal Protein
Hypergammaglobulinemia
Either
Ml
Monocl
l
ona
Hunter et al, 5th IWWM 2008
Advances in the Biology of Waldenstrom's Macroglobulinemia
Hl
Hypogammagl b
o
l
u ilinemia in Untreated
Patients With WM.
300
Per Patient IgA Levels in WM
250
(mg/dL) 200
A
IgA Lower Limit of Normal
Ig 150
50
Serum
0
1 4
7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88
1800
Per Patient IgG Levels in WM
L)d 1400
(mg/ 1000
IgG 600
IgG Lower Limit of Normal
200
erumS
0 1 3 5 7 9 1113 15 17 19 21 2325 2729 31 33 35 37 394143 45 47 49 5153 555759 61 63 65 67 6971 73 75 77 79 81 8385 8789
Hunter ZR, et al. ASCO 2007.
Slide 169
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Anthony, 11/26/2007
Advances in the Biology of Waldenstrom's Macroglobulinemia
IA
IgA
d
an IgG hypogammaglbl
lobu ili
i
nem a does
not correct after response to therapy in WM.
Pre-
Post-
Pre-
Post-
N
IgG
IgG
N
IgG
T-Test
T
IgA
IgA
T-Test
T
CR
8
644
472
0.05
75
37
0.08
PR
70
415
349
0.09
27
28
0.91
MR
14
474
394
00
0. 1
01
38
26
00
0. 2
02
Treon et al, ASH 2004; Hunter et al, Submitted.
Advances in the Biology of Waldenstrom's Macroglobulinemia
Sequence Analysis
Analysis for Familial Cancer
and CVID Predisposition Genes.
Familial Predisposition
CVID Predisposition
BRCA 1
AICDA
BRCA2
BTK
p53
p
CD40
CD154
NEMO
3/19 (15%)
TACI
SH2D1A
Treon et al, ASH 2008
UNG 1/19 (5%)
Advances in the Biology of Waldenstrom's Macroglobulinemia
Central rol
o e of
o NEMO in the NF-B pathway
a .
y
Agou et al. (2004) J. Biol. Chem. 279: 27861.
Hunter et al, Am
Am Soc
Soc Hematology 2008.
Advances in the Biology of Waldenstrom's Macroglobulinemia
Deletions of chromosome 6q21-25
-
are
common in patients with WM.
Pt
Present 30
30-50% of WM
WM pts;
Not disease defining.
May distinguish IgM MGUS
from WM;
Prognostic significance
controversial;
May
denote loss
loss of
of BLIMP
BLIMP-1
Schop et al, Blood 2002; Treon et al, Ann Oncol 2006; Ocio et al, BJH 2007; Chang et al, IWWM5 2008.
Advances in the Biology of Waldenstrom's Macroglobulinemia
Blimp-
Blimp 1a
-1 nd
and XBP
XBP-1
- .
Blimp-1 (B-lymphocyte-induced maturation protein 1) and Xbp-1
(X-
(X box binding protein 1) are key regulators of terminal B-
B cell
differentiation.
Expression pattern
pp
of Blimp-1
p
and Xbp-1
p
during B-cell differentiation
Germinal-center
Resting B cell
B cell
Plasma-blast
Plasma cell
Blimp-1
Xbp-1
ERN-1 (IRE1a)
Xbp-1s
Advances in the Biology of Waldenstrom's Macroglobulinemia
BLIMP1-
BLIMP1 XBP1
-
signaling pathway
pathway in WM.
WM
NBM
Sequence studies showed no mutations in PAX5, PRMD1 (BLIMP1),
XBP1, ERN1
ERN1 (IRE1a).
(IRE1a).
Leleu et al, Br J Haematol 2008
Advances in the Biology of Waldenstrom's Macroglobulinemia
Ht
Hyperme h
th l
y t
a i
tion t
s d
u i
dies in WM
WM:
DLC-1.
Tumor suppressor gene (8p21.3)
Encodes a GTPase activating protein that acts
as a negative reg
ggulator of the Rho family of
small GTPases.
Silencing due to hypermethylation reported in
myeloma.
Advances in the Biology of Waldenstrom's Macroglobulinemia
DLC-1
- is
is hypermethylated
hypermethylated in most
patients with WM.
N1
N2
N3
N4
P1
P2
P3
P4
P5
P6
P7
P8
P9
P10
P11
P12
P13
P14
P15
P16
P17 H2O
Marker U M U M U M U M U M U M U M U M U M U M U M U M U M U M U M U M U M U M U M U M U M U M
N1-4 (Normal Donors); P1-17 (WM Patients)
Xu et al, IWWM5 2008
Advances in the Biology of Waldenstrom's Macroglobulinemia
Combination of
of azacitidine
azacitidine and SAHA
SAHA.
The Combination of azacitidine and SAHA induces significantly more
apoptosis in BCWM.1 WM cells and primary WM patient
lymphoplasmacytic cells.
BCWM.1 cells treated with AzaC and
WM patient CD19 cells treated with
Saha
AzaC and Saha
80
120
24 hrs
70
Patient 1
48 hrs
Patient 2
60
100
)% 50
(
)
80
is 40
sis(%
optos
60
to
p 30
p
A
op
20
A
40
20
10
20
0
0
.5
0+0
2+0
0+1
1+2
2+1
1+0
0+0
2+0
4+0
0+2
2+2
4+2
1
AzaC + Saha (uM)
AzaC + Saha (uM)
Xu et al, IWWM5 2008
Advances in the Biology of Waldenstrom's Macroglobulinemia
DLC-1 is re-expressed following
pg Azacitidine in
BCWM.1 WM cells, and shows synergistic re-
expression with SAHA.
0.45
ls 0.4
leve 0.35
0.3
RNAm 02
0. 5
25
0.2
DLC-1 0.15
tive 0.1
0.05
Rela
0
0
8
24
8
24
8
24 (hr)
Untreat d
e
AzaC
SAHA
A C
za + SAHA
Xu et al, IWWM5 2008
Advances in the Biology of Waldenstrom's Macroglobulinemia
Gene expression profilin
pp
g of the Bone Marrow
Microenvironment in Waldenstrom's.
WM
Microenviroment
median intensity
Hatjiharissi et al, IWWM5 2008; DFCI collaborative study with
Univ. of Arkansas (John Shaughnessy, Bart Barlogie).
Advances in the Biology of Waldenstrom's Macroglobulinemia
Increased CD40L expressing
pg mast cells in
bone marrow biopsies of WM patients.
H
WM-1
I
J
WM-2
Tryptase
CD40 Ligand
Tournilhac et al, Ann Oncol
2006
Advances in the Biology of Waldenstrom's Macroglobulinemia
Mast Cell
WM Cells
6000
5000
HMC Mast
Cells
WM LPC
4000
*
3000
WM + HMC
*
Mast Cell
Cells
2000
1000
WM + HMC +
CD40 Fc (1
0
ug/ml)
* p<0 006
.
WM + HMC +
CD40 Fc (10
ug/ml)
Tournilhac et al, Ann Oncol 2006
Advances in the Biology of Waldenstrom's Macroglobulinemia
S l
o bl
u e CD27 levels are elevated in WM
WM.
700
*p = 0.0007
600
p = 0.01
500
400
7(U/mL)
300
sCD2 200
100
0
WM*
IM
IgM MGUS
MGUS
MM
ND
(N = 66)
(N = 4)
(N = 25)
(N = 16)
Ho et al, Blood 2008; Ciccarelli et al, IWMW 2008
Advances in the Biology of Waldenstrom's Macroglobulinemia
CD27
s
is a marker f
o disease in WM
WM.
A. Serum sCD27 levels
C. Correlative changes in sCD27 and IgM levels
R=0.976; p<0.0001
B. Serum IgM levels
Ho et al, Blood 2008
Advances in the Biology of Waldenstrom's Macroglobulinemia
Heterogeneous cell surface
surface
expression of CD27 in WM.
R1
File: 1c012109.101
Sample ID:
File: 1c012109.102
Sample ID:
Gate: G1
Gated Events: 10303
Gate: G1
Gated Events: 10356
File: 1c012109.105
Sample ID:
Total Events: 15648
Quad Location: 18, 17
Total Events: 16098
Quad Location: 18, 17
Gate: G1
Gated Events: 10144
Total Events: 13879
Quad Location: 18, 17
Quad
Events
% Gated
X Geo Mean
Y Geo Mean
Quad
Events
% Gated
X Geo Mean
Y Geo Mean
UL
5
0.05
13.80
18.37
UL
7253
70.04
4.57
40.87
Quad
Events
% Gated
X Geo Mean
Y Geo Mean
UR
16
0.16
26.18
21.64
UR
54
0.52
22.86
39.23
UL
1534
15.12
7.16
34.04
LL
10239
99.38
4.30
4.00
LL
3035
29.31
3.88
10.02
UR
285
2.81
26.12
37.16
LR
43
0.42
21.45
10.62
LR
14
0.14
20.87
12.95
LL
7741
76.31
5.94
5.09
LR
584
5.76
25.44
5.99
Flow Cytometry
RT-PCR
LPC
LPC
CD27
5/12 (42%)
7/7 (100%)
CD70
6/6 (100%)
7/7 (100%)
Ho et al, Blood 2008
Advances in the Biology of Waldenstrom's Macroglobulinemia
S l
o bl
u e CD27
l
re ease by BCWM.1
ll
ce s
is modulated by MMP-8.
35
30
25
20
15
10
5
0
Zhou et al, Submitted.
Advances in the Biology of Waldenstrom's Macroglobulinemia
Soluble CD27 induces
induces APRIL and
and CD40L on BM
Mast Cells from WM patients which is blocked by
the SGN
SGN--70
70 monoclonal antibody.
Ho et al, Blood 2008
Advances in the Biology of Waldenstrom's Macroglobulinemia
Human sIgM and sCD27 after engraftment
gg
and
treatment of BCWM.1 bearing SCID-hu mice with
SGN-70.
SCID, severe
bi
com
d
ne i
d
mmuno
f
e i
fi i
c ency
Ho AW, Blood 2008.
Advances in the Biology of Waldenstrom's Macroglobulinemia
Therapeutic Targets in
in
Waldenstrom's Macroglobulinemia.
Bl
B ce lll
Lh
Lymph
l
op
t
asmacy i
tic
l
ce lll Alkylators
Nucleoside analogues
Alemtuzumab
Rituximab
Bortezomib
Alemtuzumab
MMP-I
Imatinib mesylate
SGN70
SGN-70
sCD27
SGN40/CHIR 12 12
.
CHIR 12.12
Bortezomib
NPI0052
Thalidomide
RAD001 (MTOR-I)
Mast cells
Bortezomib
Perifosine(AKT-I)
5-Azacytidine (HM)
NK/T-
NK/T cells
BMSC
Thalidomide, Lenalidomide, Pomalidomide, IFN
Advances in the Biology of Waldenstrom's Macroglobulinemia
Overall and
and Complete Responses Rates
Rates to
therapy in WM.
ORR
CR
alkylator therapy (chlorambucil)
30-50%
0-5%
nucleoside analogues
30-70%
0-10%
monoclonal antibodies
40-50%
0-5%
bortezomib
40-60%
0-5%
combination therapies
nucleoside analogues/rituximab
70 90%
-
5 10%
-
cytoxan based therapy/rituximab
70-90%
5-15%
thalidomide/rituximab
78%
5%
bortezomib/dex/rituximab
90%
22%
Advances in the Biology of Waldenstrom's Macroglobulinemia
Rt
Response st t
a us
l
corre t
a es i
w th
ith
progression free survival in WM.
P<0.0001
Advances in the Biology of Waldenstrom's Macroglobulinemia
Summary
Familial predisposition is seen in @ 20% of WM patients with
two patterns of predisposition: Families with WM only, and
Families with Various B-cell malignancies including MM.
Immunoglobulin abnormalities appear increased in family
members of patients with WM, particularly those coming from
families with "WM only" with 22% of first degree family members
demonstrating a monoclonal protein.
6 21
q -25 is dltd
deleted in 30 50
- % f
o WM patients, bt
but isusu ll
a y
heterozygous and its significance remains to be clarified.
Epig
pgenetic changes
g
may be very important
p
to WM pathog
pgenesis
and constitutes an area for exploration of novel therapies.
Mast cell interactions appear supportive of WM cell growth, and
targeting of these interactions also appears important for
exploration of treatment advances in WM.
Advances in the Biology of Waldenstrom's Macroglobulinemia
6th
6 It
Int
t
erna i
ti
l
ona Work h
s op on
Waldenström's Macroglobulinemia
Venice
V
, Italy · October 6-10, 2010
www.wmworkshop.org