New Drugs and Therapeutic Approaches
Kenneth C. Anderson, M.D.
Jerome Lipper Multiple Myeloma Center
Dana-Farber Cancer Institute
Harvard Medical School
Integration of Novel Therapy
Into Myeloma Management
Bortezomib, Lenalidomide, Thalidomide, Doxil
Target MM in the BM microenvironment to
overcome conventional drug resistance in vitro
and in vivo
Effective in relapsed/refractory, relapsed,
induction, consolidation, and
maintenance therapy
Six FDA approvals and median survial prolonged
from 3-4 to 6-7 years, with additional
prolongation from maintenance
1

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Targeting Growth, Survival, and Drug Resistance of MM in the
MM
BM Microenvironment
migration
GSK-3
SC
FKHR
CD40
PKC
Survival
Caspase-9
Anti-apoptosis
Akt
NF-B
Cell surface
Cell cycle
mTOR
targets
PI3-K
Bad
Bcl-xL
Survival
JAK/STAT3
Mcl-1
Anti-apoptosis
BAFF-R
Raf
MEK/ERK
proliferation
VEGFR
Bcl-xL
Survival
Cytokines
NF-B
IAP
Anti-apoptosis
Cyclin-D
Cell cycle
IL-6, VEGF
IGF-1, SDF-1
TNF
BAFF, APRIL
Proliferation
TGF
MEK/ERK
BSF-3
Anti-apoptosis
VEGF
p27Kip1
Smad, ERK
Adhesion
cytokines
NF-B
adhesion
LFA-1
molecules
ICAM-1
NF-B
MUC-1
BMSC
NF-B
VCAM-1
Fibronectin
VLA-4
Hideshima T and Anderson KC. Nat Rev Cancer 2007,
MAb-Based Therapeutic Targeting of Myeloma
Antibody-dependent
Apoptosis/growth
Cellular cytotoxicity
arrest
(ADCC)
Complement-dependent
via targeting
Cytotoxicity (CDC)
signaling pathways
C1q
Effector cells:
C1q
CDC
MM
MM
ADCC
FcR
Daratumumab
huN901-DM1 (CD56)
MM
(CD38)
nBT062-maytansinoid
(CD138)
1339 (IL-6)
Lucatumumab or Dacetuzumab (CD40)
BHQ880 (DKK1)
Elotuzumab (CS1)
RAP-011 (activin A)
Daratumumab (CD38)
Daratumumab (CD38)
XmAb5592 (HM1.24)
Tai & Anderson Bone Marrow Research 2011
2

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Elotuzumab Anti-CS MoAb in MM
· CS1 is highly and uniformly expressed on MM cells
· Elotuzumab (Elo) is a humanized monoclonal IgG1
antibody targeting CS1
· Clinical trial of Elo in MM achieved SD
· Anti-MM activity of Elo enhanced by lenalidomide (len)
in preclinical models
· Phase I/II trials: 80-90% response to len dex elo in
relapsed MM
· Phase III trial of len dex elo versus len dex in relapsed
MM for new drug approval
·
Hsi ED et al. Clin Cancer Res. 2008;14:2775-2784; Tai YT et al.
Blood. 2008;112:1329-1337; Van Rhee F et al. Mol Cancer Ther.
2009;8:2616-2624; Lonial S et al. Blood. 2009;114:432; Richardson
et al Blood 2010:864
5
·
nBT062-SPDB-DM4 (CD 138 Immunotoxin)
Inhibits Human MM Cell Growth In Vivo
A
nBT062-SPDB-DM4
2000
B
)3 1750
(mm 1500
1250
Volume
PBS
1000
750
100ug/ml
Tumor
500
250ug/ml
250
Median
450ug/ml
010 20 30 40 50
Days post inoculation
PBS
BT062-SPDB-DM4
C)
D
3
2000
SCID-Hu mice model
(mm
D
10
lume 1500
(ng/ml)
8
vo
1000
6
receptor
PBS
Tumor
4
­IL-6
nBT062-SPDB-
Mean 500
2
DM4(250ug/ml)
Soluble
0
15
18
20
23
25
28
30
32
34
7142127
354249
Days post inoculation
Days post treatment
Clinical Trials Ongoing
Ikeda et al, Clin Can Res 2009; 15: 4028
3

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Phase I Trial of Vaccination with DC/MM
Fusions in Relapsed Refractory MM
Well tolerated, no
autoimmunity
Induced tumor reactive
lymphocytes in a majority
of patients
Induced humoral
responses to novel
antigens (SEREX
DC/MM fusions induce anti-
analysis)
MM immunity in vitro and
inhibit MM cell growth in
Disease stabilization in
vivo in xenograft models
70% of patients
Vasir et al. BritJHematol 2005; 129:
687-700
Rosenblatt et al Blood 2011; 117:393-402.
Targeting TAAs with Cocktails of Specific Peptides
·Using immunogenic HLA-A2-specific XBP1, CD138,
CS1 peptides to induce MM-specific and HLA-restricted
CTL responses against several MM antigens
Polyfunctional responses: IFN-, cytotoxicity,
proliferation, CD107a degranulation to primary MM
cells and cell lines
Peptide-specific responses: Individual differences in
specificity, more broad response to cocktail
Bae et al, Leukemia 2011, in press
4

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Immune Dysfunction in Myeloma
TH Subset Abnormality
TH1
IFN
CTL
Decreased help
TH2
IL4
4+
Naïve
Increased
CD4
8+
suppression
TH17
POK
TH-17 - assoc
cytokines - IL-17,
21, 22, 23, 25
Pro-MM growth
Improving Immune function
T
Immunosuppressive
reg
TGF
·
Disease control
IL10
·
Immune modulation: Lenalidomide, cpg Dysregulated
·
Cytokine modulation: Anti-IL6, anti-IL-17 Immune-
homeostasis
Rao et al, Blood 2010; in press.
CpG ODNs Restore MM Patient-pDCs Immune
Function and Block pDC-Induced MM Cell
Growth
Chauhan et al: Cancer Cell 2009; 16:309-23.
5

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Proteasome: Present and Future Therapies
Potential
UB enzymes E1, E2 and
E3-UB-Ligases
Therapeutic Targets
Deubiquitylating
Ub
ATPases/
Ub
Enzymes (DUBs)
Ub
Cdc48
Immunoproteasome
P5091 target USP-7
ATP
ADP
PR-924
Poly-ubiquitinated proteins
(proteasome substrates)
19S
Six Protease
activities
5, 5i
Bortezomib,
20S

20S
1, 1i
Carfilzomib,
5
2, 2i
CEP-18770
ONYX-0912
MLN 2238
19S
NPI-0052: 5, 1, 2
Free Ub
for re-cycling
Degraded protein
26S PROTEASOME
Lenalidomide in Myeloma
C
MM cells
IL-6
TNF
B
IL-1
A
Bone Marrow
ICAM-1
Stromal Cells
Bone Marrow
Vessels
NFAT
PKC
IL-2
IL-2
IFN
VEGF
NK Cells
PI3K
CD28
NK-T
bFGF
CD8+ T
Cells
Dendritic
Cells
D
E
Cells
Mitsiades et al. Blood 99: 4525, 2002
Hideshima et al. Blood 96: 2943, 2000
Lentzsch et al Cancer Res 62: 2300, 2002
Davies et al. Blood 98: 210, 2001
LeBlanc R et al. Blood 103: 1787, 2004
Gupta et al. Leukemia 15: 1950, 2001
Hayashi T et al. Brit J Hematol 128: 192, 2005
6

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Myeloma cells
VELCADE
SANT-7
MLN3897
ANTI-BAFF
IL6
BAFF
DKK1 inhibitors
MIP-1
RANKL
PASOPANIB
m-CSF
VEGF
DENOSUMAB
fms
DKK1, other
RANK
WNT antagonist
MAPK
RANKL
ERK
TRAF6
JNK
p38
OPG
p50/p52
WNT
AP-1
INTEGRIN
receptor
B-catenin
RUNX-2
Osteoblasts
Osteoclast
Mesenchymal cell
RAP011
VELCADE
BISPHOSPHONATES
Anti-DKK-1 MAb BHQ880 Abrogates the Inhibitory Effect
of MM Cells on Osteoblastogenesis
Isotype Control
BHQ880 (1 µg/ml)
150
- BHQ880
p=0.08
+ BHQ880
nio
- MM cells
l)
sit
100
p=0.0001
o
ro
ep
ont
d
c
miu of 50
p=0.0001
alc
(%
C
+ MM cells
0
-MM
+MM
4x
8
p=0.002
- BHQ880
Clinical Trial Ongoing in MM
l) 6
+ BHQ880
g/m
(n 4
p=0.0003
huIL-6 2
p=0.0002
0
Fulciniti et al Blood 2009; 114;371-9
- MM
+ MM
7

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BHQ880 Inhibits Myeloma Cell Growth in SCID-hu Mice
12500
Control
Early treatment
l)
Treated
10000
mg/
Control
Treated
p 7500
(
6R
OB
5000 Start Treatment
L-
OB
shuI 2500
Bone
p= 0.0001
MM
Bone
0
1
8
15
22
29
Days from tumor detection
60
d
fiells/
Treatment= 200ug/mouse ip 3x/wk
40
cel
p=0.001
tivesi 20
60000
po
Control
LPA
0
Control
Treated
50000
l)
Late treatment
Treated
mg/ 40000
p
Control
Treated
Start Treatment
( 30000
6RL- 20000
B
o
shuI 10000
n
p= 0.03
e
0
MM
1
8
15
22
29
36
43
Days from tumor detection
Fulciniti et al Blood 2009; 114;37-91
Anti-BAFF MAb Inhibits Osteoclasts and
Prolongs Survival in SCID-Hu Model of MM
Control
Anti-BAFF Ab-Treated
Survival in Days
70
CNT Isot.
BAFF
60
50
40
30
p=0.048
Ab(+)
20
10
Ab(-)
0
P<0.05
0
5
10
15
20
25
30
Days from treatment
Clinical Trial Ongoing
Neri et al: Clin Can Res 2007; 13: 5903.
8

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Targeting BTK with PCI-32765 Blocks
Osteoclast Formation & MM Cell Growth In BM
A
C
D
MM1R
MM cell lines
Patient MM cells
BMSCs
PCI-32765
BMSCs+INA6
P
SDF-1
+
INA6
min
02 5 5
ker
1 2
3 4
5
A6
A6GF
IP: Btk
IB: pBtk
ANBL6 IN
IN
MM1S MM1R H929 12BM U266 RPMI8226 mar
MM MM
MM MM
MM
pPLC2
Btk
Btk
pERK
pAKT
-tubulin
IL-6-dependent
B Cytokine Inhibition in OC culture
E 50
* P = 0.03
PCI-32765
40
/ml
ng 30
P = 0.26
6R 20
control
shuIL- 10
0
Specific for
02
4
Mature OC
Weeks from treatment
control
ED50: 0.2 - 0.48 nM
PCI-32765
IMW 2011; P-268
EVALUATION OF CDKIs IN MM
CDKI ID/
Reported CDK
Other
Phase of
References
code number
activity
kinase
development
activity
I. Selective CDKs activity
Phase I/II in
PD 0332991
CDK4,6/cyclin D
__
combination with
Baughn L et al.
bortezomib and
Cancer. Res.
dexamethason in
2006
R/R MM
II. Multi-CDKs activity
CDK2/cyclin A ,E
Preclinical testing
Raje N et al.
Seliciclib
CDK7/cyclin H
__
Blood. 2005.
CDK9/cyclinT1
CDK1/cyclin B
Phase I multicenter
Raje N et al.
P276-00
CDK4/cyclin D
__
study in R/R MM
Leukemia.
CDK9/cyclinT1
(India)
2009.
III. Multi-CDKs and additional targeted kinase activity
CDK1/cyclin B
Phase I/II alone
Santo L et al.
AT-7519
CDK2/cyclin A, E
GSK-3
and in combination
Oncogene .
CDK4,6/cyclin D
with bortezomib
2010
CDK7,9/cyclin H,
T
9

---

PI3K/AKT/mTOR Inhibitors in MM
MR
Bort + Dex
Target
+/- Dex
Len +/- Dex
(n=73)*
Perifosine
AKT
38%
38% 2**
70%3
Everolimus
mTORC1
7%4
63%5
Temsirolimus mTORC1
37%6***
73% 7
24%8
1. Richardson P et al. ASH 2007. Abstract 1164; 2. Richardson PG et al. IMW 2009. Abstract A349;
3. Jakubowiak AJ et al. IMW 2009. Abstract A347; 4. Guenther A et al. ASCO 2010. Abstract 8137;
5. Mahindra AK et al. ASCO 2010. Abstract 8032; 6. Farag SS et al. Leuk Res. 2009;33:1475;
7. Ghobrial IM et al. ASH 2009. Abstract 748; 8. Hofmeister CC et al. ASH 2009. Abstract 2884.
Blockade of Ubiquinated Protein Catabolism
Protein
Ub
Ub
protein aggregates
(toxic)
Ub
Ub
Ub
Ub
26S proteasome
HDAC6
Bortezomib
Ub
Ub
Panabinostat
vorinostat
HDAC6
dynein
Ub
Ub
Lysosome
Aggresome
HDAC6
Ub Ub
dynein
Ub Ub
Ub
Ub
Microtubule
Autophagy
Hideshima et al, Clin Cancer Res;2005; 11: 8530
Catley et al, Blood 2006; 108: 3441-9.
10

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Targeting Proteasome and Aggresome
Triggers Synergistic MM Cytotoxicity
04
MM.1S
RPMI
CT
B
T+B
CT
B
T+B
-Dox
S
R
-LR5
1
1
6
I8226
MI
6
-6
M
MI
P
RP
MM.
MM.
U2
INA
R
RP
HDAC6
-tubulin
MM.1S
C: control T: tubacin (5M)
CT
B T+B
B: bortezomib (5 nM)
p-JNK
120
JNK
100
Caspase-9
Bortezomib
CF
80
Caspase-8
0 nM
60
control
5 nM
CF
% 40
10 nM
Caspase-3
20
CF
0
PARP
05
10
CF
Tubacin (µM)
Hideshima et al. PNAS 2005; 102: 8567.
Panobinostat + Bortezomib to Inhibit Aggresome
and Proteasome In Relapsed Refracory MM
San Miguel et al, ASCO 2010
100
90
80
70%
(%)
70
60%
60
MR
Rate
50
40
PR
Response
30
VGPR
20
10
CR
0
All (N = 47)
BTZ refractory (n = 15)
11

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WT161 is More Potent Selective
HDAC6 Inhibitor Than Tubacin
MM.1S
Tubacin
WT161
1 0.3
30.1 C 0.1 0.3 1
3 µM
Ac-a-tubulin
IB: Ac-K
HDAC 6 Selective Inhibitor WT161
Enhances Bortezomib-Induced Cytotoxicity
in Patient MM Cells
MM1S
Pat #1
Pat #2
C
T 161
C
T 161
C
T 161
HDAC6
Ac-a-tub
a-tub
Pat MM cells + WT161/Tubacin (24h MTT)
120
100
WT161 0 uM
80
WT161 0.5 uM
60
WT161 1 uM
control
40
WT161 2 uM
%
Tubacin 0 uM
20
Tubacin 0.5 uM
0
Tubacin 1 uM
0 nM
2.5 nM
5 nM
10 nM
Tubacin 2 uM
Bort.
Hideshima et al, 2011
12

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Bench to Bedside Translation
of HDAC 6 Selective Inhibitor ACY 1215
Orally bioavailable, highly potent, selective
inhibitor of HDAC 6 synthesized in fall 2009
Synergistic MM cytotoxicity with Bortezomib
in vitro and in vivo
Favorable PK/PD, toxicity profile
Highly favorable FDA regulatory process from
pre-IND through IND allowance
Phase Ia/Ib/II clinical trial of ACY1215, alone and
with Bortezomib, beginning spring 2011
Bortezomib, Lenalidomide and Dex Therapy
Lenalidomide induces caspase 8 mediated apoptosis of MM cells
in BM in vitro and in vivo; Dex (caspase 9) enhances response
Synergistic MM cell toxicity of lenalidomide (caspase 8) with
Bortezomib (caspase 9>8) in vitro and in vivo (dual apoptotic
signaling)
Phase I-II trials show that majority (58%) of patients refractory to
either agent alone respond to the combination
Phase I-II trials show 100% response with 74% CR/VGPR and 52%
CR/nCR when used as initial therapy, including molecular
responses.
Richardson et al JCO 2009; 27:5713-19.
Richardson et al Blood 2010; 116:679-86.
13

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IFM/DFCI Study in Newly Diagnosed MM
Stem Cell Candidates
Randomize
RVDx3
Induction
RVDx3
CY (3g/m2)
MOBILIZATION
CY (3g/m2)
Goal: 5 x106 cells/kg
Collection
MOBILIZATION
Goal: 5 x106 cells/kg
Melphalan
200mg/m2* +
RVD x 5
ASCT
Consolidation
RVD x 2
Maintenance
Revlimid 12 mos
Revlimid 12 mos
SCT at relapse
High-Throughput Screening of MM with
BMSCs to Define Optimal Single Agents/Combinations
100
al 75
iv
Dex
rv 50
Su
No BMSCs
25
%
+HS-5 stroma
0
0.0
0.5
1.0
1.5
2.0
Dex (uM)
100
No BMSCs
75
+HS-5 stroma
Doxo
Luc+
Luc-
Myeloma +
rvival 50
Myeloma cells
Stromal cells
Stromal cells
uS 25
%
0 0
10
20
30
40
50
60
Doxo (ng/mL)
Biolum signal
No signal
Biolum signal
100
75
Bortezomib
No BMSCs
rvival 50
u
+HS-5 stroma
S 25
%
0
McMillin et al. Nat Med 2010; 16: 483.
0
10
20
30
40
PS-341 (nM)
14

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New Drug Screening in Presence of BMSCs
200
McMillin et al. Nat Med 2010; 16: 483
No stroma
Plus stroma
150
rvivalu 100
S% 50
0 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AAABACADAEAFAGAHAI AJAK
CHART CODE
COMPOUND NAME
TARGET
CONC. (uM)
MM1S AVG no stroma
MM1S AVG with stroma
A, B & G
Staurosporine
Pan-specific
10, 1 & 0.1
1.43
3.32
E
Sphingosine
p38 MAPK
10
4.05
103.34
I
Lavendustin A
EGFRK
10
9.05
99.34
N
Piceatannol
Syk
10
21.11
56.82
P
Ro 31-8220
MEK
1
25.77
68.39
R
HDBA
HER1-2
10
30.71
153.95
W
BAY 11-7082
PKC
1
48.22
185.72
AB
Tyrphostin 51
EGFRK
10
63.83
152.16
AF
Kenpaullone
CaMK II
1
79.46
154.02
AH
U-0127
MEK
1
90.36
181.91
AK
Tyrphostin AG 1295
Tyrosine kinases
1
123.05
82.40
Oncogenomics to Identify Targeted Therapies
Integrated platform aCGH, SKY and expression profiling
55 MM Cell Lines; 73 Patient Samples
60
40
20
0
20
recurrence 40
46 amplicons - 658 NCBI genes
% 60Chr. 12 3 4 5 6 7 8 9 10 11 12 13 15 17 19 21 X
Expressed Genes : 258
Functional validation of MM candidate genes.
Small molecule
Carrasco et al Cancer
Monoclonal Abs
HDAC6
Cell 2006; 9: 313
Vaccines
15

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SNP Array Based MM Prognostic Model
1q+
5q+
12p-
Copy number analyses

reveal novel prognostic
classification
Identifies regions of
clinical importance
especially del12p and
amp 5q
SNParrays highlight few
regions with bi-allelic
0 risk factor (n=54)
deletions
SNP analysis may lead to
an individual therapeutic
1 risk factor
approach.
(n=80)
Avet-Loiseau et al JClin
p<0.0001
2-3 risk factors
Oncol 2009; 27: 4585-90.
(n=58)
MM Genome Sequencing (MMRF)
19/38 (50%) newly diagnosed
19/38 (50%) received prior treatment
t(14;20) None
t(6;14)
t(14;16)
19/38 (50%) del 13q14
t(4;14)
Hyperdiploid
2/38 (5%) del 17p13
t(11;14)
3/38 (8%) del 1p32
Chapman et al Nature 2011; 471: 467-72
16

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Mutations in Myeloma
· Protein homeostasis: 42% including FAM46C,
RPL10, RPS6KA1, EIF3B, XBP1, LRRK2
· NF-B signaling: 10 point mutations, 4 additional
structural re-arrangements affecting coding
· IRF-4, Blimp-1: 2 mutations each
· Histone methylating enzymes: WHSC1, UTX,
MLL
· BRAF: 4% activating
Chapman et al Nature 2011; 471: 467-72
Whole Genome Paired End Sequencing Identifies
Genomic Evolution in Myeloma
Early Tumor Circos Plots Late Tumor
PD3823a
PD3823c
PD3825a
PD3825c
Munshi at al
ASH 2009
17

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Current and Future Directions
1. Development of immune (vaccine and adoptive
immunotherapy) therapies
2. Development of novel agents targeting the MM cell in
the BM microenvironment
3. Development of rationally-based combination therapies
4. Utilization of genomics for improved classification and
personalized therapy
Myeloma will be a chronic illness, with sustained
CR in a significant fraction of patients.
United Nations Against Myeloma:
Jerome Lipper and Lebow Bench to Bedside Research Team
Kenneth Anderson
Teru Hideshima
Paul Richardson
Constantine Mitsiades
Nikhil Munshi
Dharminder Chauhan
Robert Schlossman
Noopur Raje
Irene Ghobrial
Yu-Tzu Tai
Steven Treon
Ruben Carrasco
Jacob Laubach
James Bradner
Greece
Deborah Doss
Gullu Gorgun
USA
Japan
Kathleen Colson
Jooeun Bae
Mary McKenney
Francesca Cottini
Kim Noonan
Michele Cea
Tina Flaherty
Antonia Cagnetta
Kathleen Finn
Teresa Calimeri
Muriel Gannon
Edie Weller
Stacey Chuma
Ajita Singh
Taiwan
Janet Kunsman
Ze Tian
UK
Canada
Diane Warren
Diana Cirstea
Carolyn Revta
Yiguo Hu
Andrea Freeman
Naoya Mimura
Alexis Fields
Jiro Minami
Andrea Kolligian
Sun-Yung Kong
John Feather
Weihua Song
Farzana Masood
Douglas McMillin
Turkey
Nora Loughney
Catriona Hayes
India
Germany
Heather Goddard
Steffen Klippel
Tiffany Poon
Jana Jakubikova
Nicole Stavitzski
Panisinee Lawasut
Ranjit Banwait
Niels van de Donk
Shawna Corman
Eugen Dhimolea
Heather Goddard
Jake Delmore
Meghan Marie Leahy
Hannah Jacobs
Australia
Italy
Caitlin O'Gallagher
Masood Shammas
Austria
Christina Tripsas
Mariateresa Fulciniti
Karin Anderson
Jianhong Lin
Shannon Viera
Jagannath Pal
Katherine Redman
Samantha Pozzi
Amber Walsh
Loredana Santo
Samir Amin
Claire Fabre
Anuj Mahindra
Ireland
Wanling Xie
Israel
China
Rao Prabhala
Parantu Shah
Jake Delmore
Holly Bartel
Puru Nanjappa
Lisa Popitz
Michael Sellito
Jeffrey Sorrell
Avani Vaishnav
18

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