Bortezomib-associated peripheral neuropathy: Relationship between clinical neurophysiologic evidence in previously
untreated multiple myeloma patients and preclinical characterization in a mouse model
Paul G. Richardson,1 Jordi Bruna,2 Anthony A. Amato,1,3 Esther Udina,2 Constantine S. Mitsiades,1 Patrick Y. Wen,1,3 E. Tessa Hedley-Whyte,4 Anne Louise Oaklander,4,5 Johan Monbaliu,6 An Vynckier,6 Lee Silverman,7 Kenneth C. Anderson,1 Xavier Navarro2
1Dana-Farber Cancer Institute, Boston, MA, USA; 2Institute of Neurosciences and CIBERNED, Universitat Autònoma de Barcelona, Bellaterra, Spain; 3Brigham and Women's Hospital, Boston, MA, USA; 4Department of Pathology, Massachusetts General Hospital, Boston, MA, USA;
5Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; 6Johnson & Johnson, GPCD, Beerse, Belgium; 7Millennium Pharmaceuticals, Inc., Cambridge, MA, USA
BACKGROUND
RESULTS
DISCUSSION AND CONCLUSIONS
· Bortezomib(VELCADE®,MillenniumPharmaceuticals,Inc.,andJohnson
­ SignificantincreaseswerereportedinTotalNeuropathyScoreand
· Incommonwiththechangesinsmall-fiberfunctionseeninclinicaltesting,
Table 5. Morphometric analysis of sciatic myelinated fibers at 6 weeks
· Overall,thereappearstobegoodcorrespondencebetweenclinical
Clinical incidence of PN
&JohnsonPharmaceuticalResearch&Development,L.L.C.)therapyfor
sensoryscore.
thermalalgesimetryinthemousemodelshowedasignificantdecreaseinpain
manifestationsofbortezomib-associatedPNandevidencefromthe
· Patientsreceivedamedianof8cyclesofbortezomib;mediancumulative
multiplemyeloma(MM)resultsinhighoverallandcompleteresponserates,1
­ Significantreductionswereseeninsuralandulnarsensorynerveaction
sensibilityat6weeks,withanincreasedwithdrawalthresholdinbortezomib-
mousemodel.
dosewas33.65mg/m2(range7.8­41.6).
butcanalsoleadtoperipheralneuropathy(PN).2,3
potential(SNAP),reflectinglarge-fiberfunction,andinQSARTofthedistal
treatedmicecomparedwithcontrols(Figure3).
Bortezomib-
Difference
­ BothshowapredominantlysensoryPNthataffectsbothlargeandsmal
· Table1summarizestheprevalenceofPNatbaselineandtheincidence
Mean ± SD values
Control
treated
%
p-value
· Bortezomib-associatedPNhasbeenshowntobeacumulative,dose-related,
legandfoot,reflectingsmall-fiberfunction.
fibersand,importantly,isreversible.
oftreatment-emergentbortezomib-associatedPNreportedinthephase2
primarilysensoryneuropathythatisreversibletobaselineinthemajorityof
­ Nochangesfrombaselinewereseeninmedianmotorsignsandsymptoms
Figure 3. Thermal algesimetry ­ time to withdrawal to hot pain stimulation
Fiberperimeter,m
25.2±0.3
22.8±0.2
­9.8
<0.001
­ Inbothstudies,motorinvolvementislimited.
clinicalstudybyNCICTCAEgrading.4
cases.2
andinmedianautonomicscore.
Axonperimeter,m
15.6±0.2
14.8±0.1
­5
<0.001
· Neurophysiologicfindingsweresimilarbetweentheclinicalandpreclinical
­ Inthephase3APEXtrialinpatientswithrelapsedMM,64%ofpatients
Table 1. PN reported by investigators (NCI CTCAE grading)
· Anumberofsimilaritiesareevidentbetweentheneurophysiologicchanges
studies.
whoexperiencedgrade2PNwhilereceivingsingle-agentbortezomibhad
gratio
0.61±0.002
0.65±0.002
+6.2
<0.001
reportedinthe15patientswithnew-onsetPNandinthe20animalsgiven
1.5
Bortezomib
­ Thedatasuggestthatbortezomib-associatedPNisaxonalor
improvementorresolutiontobaselinewithinamedianof3.6months.2
Control
Diameter,m
8.04±0.08
7.24±0.05
­10.0
<0.001
Patients with PN, N=64
bortezomibtwice-weeklyfor6weeksinthemousemodel.
neuronopathic;thedemyelinatingchangesseeninthepreclinicalmodel
­ Similarly,inthephase3VISTAtrialinpatientswithpreviouslyuntreated
*p=0.045
· Inmice,impairmentofsensory-motorfunctionwasseenbyRotarodtesting.
Myelinthickness,m
1.54±0.02
1.27±0.01
­17.5
<0.001
aremostlikelysecondary.
MM,79%ofPNeventsinpatientsreceivingbortezomibplusmelphalan­
Neuropathy, n (%)
Any grade
Grade 3*
1.3
Baseline
­ Therewasasignificantdecreaseintimeofsustainedwalkingattheendof
· Bortezomibdoesnotinduceprimarydemyelination.
prednisone(VMP)improvedorresolvedwithinamedianof1.9months,
including60%thatcompletelyresolvedwithinamedianof5.7months.3
SensoryPN
13(20)
­
6weeksoftreatment(Figure1).
­ Intheclinic,bortezomib-associatedPNisonlyrarelyassociatedwith
basal 1.1
MotorPN
3(5)
­
· Discrepancieswereapparentbetweentheclinicalandpreclinicalstudiesin
demyelinatingfeatures.7
vs
termsofchangesinintraepidermalnervefiber(IENF)density,assessedby
Neuropathicpain
1(2)
­
Figure 1. Time of sustained walking (Rotarod)
· Preclinicalstudieswithbortezomibandotheragentshavesuggestedthatthis
Rationale
immunohistochemicalanalysisofproteingeneproduct(PGP)9.5.
Treatment-emergent
0.9
PNisamechanism-basedeffectofproteasomeinhibitors.8,9
*
· Furtherresearchisneededtodeterminethemechanismsbywhichbortezomib-
Change
SensoryPN
41(64)
2(3)
1.1
· Intheclinicalstudy,themeanIENFdensityatbaselineamongall35patients
­ However,themolecularmechanismsofproteasomeinhibition-inducedPN
associatedPNarisesandtodeterminepotentialneuroprotectivestrategies.
%
studiedwasatthe26.0percentilecomparedtoage-matchednormals.
requirefurtherelucidation.
­ Apreclinicalmodelthatreflectstheneurophysiologicchangesseenin
MotorPN
7(11)
2(3)
0.7
­ ThisreflectsMM-relatedneurologiceffects.
Neuropathicpain
8(13)
3(5)
1.0
· Preclinicalstudiesofneuronalfunctionhavesuggestedthatproteasomeinhibitor
patientsdevelopingPNduringbortezomibtreatmentwouldprovehighly
­ Forthe7patientswithbaselinePN,thepercentileofIENFdensitywas10.4.
neurotoxicitymaybeassociatedwithdisruptionofthebalancebetweenprotein
valuable.
*TherewasnoGrade4PNreportedinthistrial.Overall,5(8%)patientshadanygrade3neuropathy;1patient
0.5
synthesisanddegradationindorsalrootganglia(DRG)neurons.10,11
· Hereweassesstherelationshipbetween:
hadsensoryPNandneuropathicpain,1patienthadsensoryPNandmotorPN,2patientshadneuropathicpain
0.9
· NoreductioninmeanIENFdensitywasseenpost-treatmentintheclinicalstudy.
only,1patienthadmotorPNonly.
0
2
4
6
8
10
­ Thisisafeatureofvariousneurodegenerativecentralnervoussystem
­ ClinicalneurophysiologicfindingsinpreviouslyuntreatedMMpatientswho
basal
· Bycontrast,inthepreclinicalmodel,IENFdensitywassignificantlylowerin
Weeks
disordersassociatedwithubiquitin­proteasomeimpairment.10
receivedsingle-agentbortezomibanddevelopedPNinaphase2study4
0.8
vs
plantarfootpadsofbortezomib-treatedversuscontrolmice(density:573±61
vs789±82,p<0.05)(Figure4).
· Preclinicalstudiesinmicehaveshownthattheprimarytargetforproteasome
­ Preclinicalneurophysiologicandhistologiccharacterizationofbortezomib-
· RatesofPNbymodifiedconsensuscriteriaamong35patientstreatedatDFCI,
inhibitor-associatedPNistheneuronalcellbody,specificallytheDRGneuronal
inducedPNinaSwissOF1mousemodel.5
asassessedusingextensiveneurophysiologictesting,aresummarizedinTable2.
0.7
Change
cellbodies.8,9
*
Bortezomib
· Together,thesedatabyNCICTCAEgradingandneurophysiologictesting
%
· Aswasseenintheautonomicscoreinpatients,nosignificantdifferencesin
Figure 4. Immunohistochemical images of PGP 9.5 immunoreactivity in footpads
Control
­ Ithasbeendemonstratedbothin vitroandin vivoinmicethatadministration
showbortezomib-associatedPNtobepredominantlyamild-to-moderate,
0.6
heartratevariabilitywereseeninthemousemodel(datanotshown).
representative of a control mouse and a bortezomib-treated mouse
*p=0.026
ofproteasomeinhibitorsisassociatedwithaccumulationofubiquitinated
sensoryPN.
· SympatheticsudomotorfunctionevaluatedbytheQSARTmethodwas
cytoplasmicaggregates,whichmarginatethecellnucleus.8,9,12
METHODS
0.5
significantlydecreasedinpatients.Inbortezomib-treatedmice,therewasa
· HistologicfindingsintheSwissOF1mousemodelofmildaxonallossand
Table 2. PN by modified consensus criteria (neurophysiologic testing)
0
2
4
6
8
10
declineinthenumberofinnervatedsweatglandsinathirdofthemice,as
secondarylossofmyelinatedfibersareinaccordwithNCSfindings.
Clinical study design4
Weeks
judgedbythesiliconeimprintmethod.
Patients with PN, N=35
­ Thesemaybeduetothereversibledisruptionofproteasomaldegradationof
PMP22,aglycoproteinincorporatedintomyelin.9
· 64patientswithpreviouslyuntreatedsymptomaticMMreceiveduptoeight
Pure small-
Large- and small-
3-weekcyclesofbortezomib1.3mg/m2ondays1,4,8,and11.
Neuropathy, n (%)
Any
fiber PN
fiber involvement
Histologic studies
· Giventhesimilaritieswithclinicalfindings,theSwissOF1mousemodelof
­ PNadverseevents(AEs)weregradedbyinvestigatorsaccordingto
· InNCSinthemousemodel(Figure2):
bortezomib-associatedPNmayrepresentapromisingvehicleforfurther
BaselinesensoryPN
7(20)
6(17)
1(3)
· Histologicstudiesinmiceshowedsignificantreductionsinmyelinatedfiber
NCICTCAEv3.0.
­ SignificantdecreaseswereseeninmeanSNAPamplitudeandinproximal
150m
explorationofthistoxicityandthedevelopmentofneuroprotectivestrategies.
Treatment-emergentsensoryPN
anddistalsensoryNCVbetweenbortezomib-treatedandcontrolanimalsafter
countinbortezomib-treatedversuscontrolmiceafter6weeks(Table4).
Furtherconfirmationandvalidationofthismodelisrequired.
­ Patientswithgrade>2PNatbaselinewereexcluded.
Total
22(63)
13(37)
9(26)
6weeksoftreatment
­ Thiswaslikelysecondarytoaxonaldamage.
­ Possiblefuturestudiesincludeassessmentofdoseandscheduleof
· Asubsetof35patientswhoweretreatedattheDana-FarberCancer
New-onset
15(43)
7(20)
8(23)
­ Nodifferenceswereseenbetweenbortezomib-treatedandcontrolanimals
­ Resultscorrelatedwithelectrophysiologicfindingsinthemousemodelof
bortezomibadministration.
Institute(DFCI)hadaneurologicalassessment,includingextensive
Worsening
7(20)
6(17)
1(3)
reductionindigitalnerveSNAP(datanotshown).
neurophysiologictesting.
incompoundmotoractionpotentialandmotorNCV.
Reversibility of bortezomib-associated PN
­ Assessmentstookplaceatbaseline,upondevelopmentofneuropathy,
· Importantly,bortezomib-associatedPNwasshowntobereversibleinboththe
andatendofstudytreatment,andincluded:
Clinical and preclinical neurophysiologic findings
Figure 2. Mean (A) compound motor action potential of plantar muscle, (B) SNAP of digital
Table 4. Mean myelinated fiber counts in bortezomib-treated mice after 6 weeks of
clinicalandpreclinicalstudies(Table6).
REFERENCES
nerve, and (C) proximal and (D) distal sensory NCV
· Motorandsensorynerveconductionstudies(NCS)
treatment and post-4-week wash-out period, versus control mice
· ChangesinTotalNeuropathyScore,sensoryscore,motorscore,autonomic
· Quantitativesensorytesting(QST)
score,NCS,andQSARTfrombaselinetoendoftreatmentinthe15patients
1.LaubachJP,etal.JNatlComprCanc
7.FilostoM,etal.JNeurolSci2007;263:40­3.
(A)
(B)
Table 6. Reversibility of bortezomib-associated PN
Network2009;7:947­60.
· Autonomictesting,includingquantitativesudomotoraxonreflex
8.SilvermanL,etal.Blood
withnew-onsetbortezomib-associatedPNaresummarizedinTable3.
Mean ± SD myelinated
Bortezomib-
Difference
2.RichardsonPG,etal.BrJHaematol
2008;112:(abstract2646).
testing(QSART).
120
120
fiber count
Control
treated
%
p-value
2009;144:895­903.
Clinical evidence
9.SilvermanL,etal.ToxicolPathol
· Inthese35patients,presenceorabsenceofPNwasdeterminedusing
Table 3. Changes in neurophysiologic findings from baseline to end of treatment among
100
100
After 6 weeks of treatment
3.MateosMV,etal.ClinLymphomaMyeloma
2006;34:989(abstract).
2009;9:S30(abstractA172).
modifiedconsensuscriteria.6
15 patients with new-onset bortezomib-associated PN
PNbyNCICTCAEgrading
·SensoryPNresolvedin35/41(85%)patients
10.GilardiniA,etal.CurrMedChem
basal
80
basal
80
Sciaticnerve(mid-thigh)
inamedianof98days
4.RichardsonPG,etal.JClinOncol2009;27:3518­25.
2008;15:3025­35.
vs
vs
Total
4021±95
3624±72
­9.9
p<0.01
5.BrunaJ,etal.JPeripherNervSyst
11.DingQ,etal.FASEBJ2006;20:1055­63.
Preclinical study design5
Assessment, median value
Baseline
Change
60
60
·Neuropathicpainresolvedin7/8(88%)patients
2009;14(suppl):22­3(abstract).
12.CsizmadiaV,etal.Neurotoxicology
TotalNeuropathyScore
0
9.5*
Tibial
2362±86
2185±55
­7.5
NS
6.EnglandJD,etal.Neurology2005;64:199­207.
2008;29:232­43.
Neurophysiologictesting
·Reversibilitynotassessed;norepeatstudies
· SwissOF1femalemicewereadministeredbortezomib1.0mg/kg
40
40
*
Sensoryscore
0
5.0*
Change
Bortezomib
Change
Bortezomib
Tibialnerve(ankle)
1270±63
1130±57
­11.0
NS
followingend-of-treatmentassessment
%
%
ACKNOWLEDGMENTS
subcutaneously(N=20)orvehiclesolution(N=10)twiceweeklyfor6weeks.
Sensorysigns
0
3.0
20
Control
Control
20
At 10 weeks, post-wash-out
*p=0.0001
· TheauthorsthankthetechnicalassistanceofJessicaJaramillointhehistologicalstudies,andof
­ Thetotalbortezomibdosereceivedwas42.8mg/m2,similartothe
Sensorysymptoms
0
2.0
Sciaticnerve(mid-thigh)
Preclinical evidence post-4-week wash-out
MónicaEspejo(UAB).
maximumplanneddoseintheclinicalstudy(41.6mg/m2).
0
0
Motorscore
0
0
· TheauthorswouldliketoacknowledgethewritingassistanceofSteveHillofFireKiteduringthe
0
2
4
6
8
10
0
2
4
6
8
10
Total
3966±89
­1.4
NS
­ Withinthebortezomibgroup,10micewerefollowedfora4-weekpost-
Sensory-motorfunction
·Returntonormalvaluesfortimeofsustained
developmentofthisposter,whichwasfundedbyMillenniumPharmaceuticals,Inc.
Motorsigns
0
0
Weeks
Weeks
treatmentwash-outperiod.
Tibial
2385±79
+1.0
NS
walkinginRotarodtesting(Figure1)
Motorsymptoms
0
0
(C)
(D)
Tibialnerve(ankle)
1286±30
+1.2
NS
DISCLOSURES
· Functionalevaluationduringtreatmentandthewash-outperiodincluded:
Autonomicscore
0
0
140
140
SensoryNCS
·SNAPamplitudeandsensoryNCVsrecovered
· Employment:Johnson&JohnsonPharmaceuticalResearch&Development(JM,AV);
­ Nerveconductiontestsformotorandsensoryfunction
NCS
NS,notsignificant.
tonear-normalvalues(Figure2)
MillenniumPharmaceuticals(LS).
120
120
SuralSNAPamplitude,V(normal>5)
11.8
­3.6*
· Consultancy:MillenniumPharmaceuticals(PGR,CSM,ETHW,KCA);Celgene(PGR,KCA);
­ Sensory-motorfunctiontestingbyRotarod
Algesimetry
·Fullrecoveryofpainthresholdinbortezomib-treated
NovartisPharmaceuticals(CSM,KCA);Bristol-MyersSquibb(CSM);Merck&Co.(CSM);
­ Autonomicfunctionbysudomotorandheartratevariabilitytests
Suralnerveconductionvelocity(NCV)
46.7
­2.4
basal 100
basal 100
mice(Figure3),withvalueslowerthanatbaseline
KosanPharmaceuticals(CSM);Pharmion(CSM).
­ Painsensibilitybytheplantaralgesimetrytest.
UlnarSNAPamplitude,V(normal>11)
22.4
­1.8*
vs
*
vs
· Morphometricalanalysisshowedasignificantreductioninmeandiameterof
· Ownershipinterest:Johnson&JohnsonPharmaceuticalResearch&Development(JM,AV).
80
80
UlnarNCV
52.4
­1.8
*
Histologicstudies
·Morphologicappearanceofmostnervessimilar
· Researchfunding:MillenniumPharmaceuticals(PGR,JB,EU,KCA,XN);Johnson&Johnson
myelinatedfibersinthebortezomib-treatedmice.
· Histologicevaluationwasconductedattheendofthe6-weektreatment
60
60
tocontrols
PharmaceuticalResearch&Development(JB,EU,XN);AmgenPharmaceuticals(CSM);AVEOPharma
QSART
Change
Bortezomib
Change
Bortezomib
­ Thiswasmainlyduetoreductioninmyelinthicknessbutalso,althoughtoa
(CSM);EMDSerono(CSM);SunesisPharmaceuticals(CSM);Celgene(KCA);Novartis(KCA).
periodin10bortezomib-treatedanimals,andattheendofthe4-week
Distalleg,L(normal>0.73)
0.95
­0.36*
%
·Normaldensitiesofmyelinatedfibersinsciatic
Control
%
Control
40
40
lesserextent,toaxonalatrophyandsomeaxonalloss(Table5).
· Honoraria:MillenniumPharmaceuticals(CSM,KCA);NovartisPharmaceuticals(CSM,KCA);Bristol-Myers
wash-outperiodintheother10animals.
andtibialnerves
Foot,L(normal>0.55)
0.45
­0.36*
*p=0.035
*p=0.014
Squibb(CSM);Merck&Co.(CSM);KosanPharmaceuticals(CSM);Pharmion(CSM);Celgene(KCA).
­ Morphometricalexaminationfromsystematicallyselectedfields,including
· Thus,thesepreclinicalfindingsarenotconsistentwithaprimary
Forearm,L(normal>0.66)
0.58
­0.28
20
20
·Nosignificantdifferencesinmyelinatedfiber
· Membership:MillenniumPharmaceuticals(PGR,KCA);Celgene(PGR,KCA);Bristol-MyersSquibb(PGR);
0
2
4
6
8
10
0
2
4
6
8
10
demyelinatingneuropathy.
countsbetweencontrolandbortezomib-treated
Johnson&JohnsonPharmaceuticalResearch&Development(PGR);KeryxPharmaceuticals(PGR);
cross-sectionalarea,axonalcounts,myelinatedaxonandfiberperimeters
Thigh,L(normal>0.60)
0.97
­0.30
groups(Table4)
Novartis(PGR).
anddiameters,andcalculatedmyelinthickness,wasconductedusing
Weeks
Weeks
­ Thisisconsistentwithclinicalexperience;PNwithdemyelinatingfeaturesis
semi-thinsectionsofsciaticnerveatmid-thighandtibialnerveattheankle.
*p<0.05
uncommonclinically.
Posterpresentedatthe51stASHAnnualMeeting,NewOrleans,LA,USA,December5­8,2009

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