T-DM1-induced thrombocytopenia in breast cancer patients: New perspectives.

PURPOSE: Human epidermal growth factor receptor 2 (HER2) is overexpressed in 15-20% of patients with breast cancer. HER2 overexpression is the result of a genetic alteration and this marker is associated with poor clinical outcomes. HER2-targeted therapy can significantly improve the prognosis of patients with either early or advanced HER2-positive breast cancer. One such therapy is the antibody drug conjugate (ADC) trastuzumab emtansine (T-DM1), a combination of trastuzumab and the cytotoxic antimicrotubule agent DM1. After T-DM1 binds HER2, DM1 is subsequently released into the cell. T-DM1 is generally well tolerated and has a relatively low incidence of adverse events. However, there are clinical concerns regarding T-DM1-induced high-grade thrombocytopenia. METHODS: Here, we summarize the incidence of thrombocytopenia from several clinical trials and review experimental studies to explore the causes for T-DM1-induced thrombocytopenia. Progress in several other ADCs targeting HER2-positive breast cancer was also reviewed. CONCLUSIONS: We conclude that T-DM1 uptake by megakaryocytes occurs through either Fcγ receptor binding or through pinocytosis, and we suggest several methods through which these processes could be interrupted to potentially improve the clinical safety of T-DM1. More generally, we recommend that toxicity should be carefully addressed during the development of ADCs.

Reductive Desulfuration as an Important Tool in Detection of Small Molecule Modifications to Payload of Antibody Drug Conjugates.

A high resolution accurate mass LC-MS method was developed to facilitate the characterization of a subset of antibody drug conjugate (ADC) biotherapeutics, where the payload is linked to the antibody by a thioether bond. Desulfuration of the thioether linker was optimized for release of the payload to take advantage of the high resolution and high mass accuracy of the Orbitrap to characterize metabolism of the payload. Two model ADCs, trastuzumab emtansine (T-DM1) and SigmaMAb dansyl-cadavarine-SMCC (SigmaMAb ADC mimic) were selected for optimization of the desulfuration reaction as a function of reaction time, pH, organic solvent, and chaotropic reagents (urea, guanidine HCl) by monitoring the yield of released desulfurated DM1 from T-DM1 and desulfurated dansyl-cadaverine-SMCC from SigmaMAb ADC mimic, respectively. The optimized desulfuration technique was successfully applied to enable characterization of the ADC following its incubation in hepatocytes, liver microsomes, and buffers, as illustrated by the identification of a hydrolyzed thiosuccinimide ring of SigmaMAb ADC mimic following incubation in buffer for 48 h. The results from this study demonstrate that the chemical cleavage of thioether bond by desulfuration is simple, efficient, and specific. This technique is useful in characterization of metabolism on the payload of ADC to provide guidance for improvement of its biopharmaceutical profile. This is the first report on characterization of modification to payload of ADC following desulfuration.