Selective MCL-1 inhibitor ABBV-467 is efficacious in tumor models but is associated with cardiac troponin increases in patients.

BACKGROUND: MCL-1 is a prosurvival B-cell lymphoma 2 family protein that plays a critical role in tumor maintenance and survival and can act as a resistance factor to multiple anticancer therapies. Herein, we describe the generation and characterization of the highly potent and selective MCL-1 inhibitor ABBV-467 and present findings from a first-in-human trial that included patients with relapsed/refractory multiple myeloma (NCT04178902). METHODS: Binding of ABBV-467 to human MCL-1 was assessed in multiple cell lines. The ability of ABBV-467 to induce tumor growth inhibition was investigated in xenograft models of human multiple myeloma and acute myelogenous leukemia. The first-in-human study was a multicenter, open-label, dose-escalation study assessing safety, pharmacokinetics, and efficacy of ABBV-467 monotherapy. RESULTS: Here we show that administration of ABBV-467 to MCL-1-dependent tumor cell lines triggers rapid and mechanism-based apoptosis. In vivo, intermittent dosing of ABBV-467 as monotherapy or in combination with venetoclax inhibits the growth of xenografts from human hematologic cancers. Results from a clinical trial evaluating ABBV-467 in patients with multiple myeloma based on these preclinical data indicate that treatment with ABBV-467 can result in disease control (seen in 1 patient), but may also cause increases in cardiac troponin levels in the plasma in some patients (seen in 4 of 8 patients), without other corresponding cardiac findings. CONCLUSIONS: The selectivity of ABBV-467 suggests that treatment-induced troponin release is a consequence of MCL-1 inhibition and therefore may represent a class effect of MCL-1 inhibitors in human patients.

Apoptosis is a type of cell death that removes abnormal cells from the body. Cancer cells can have increased levels of MCL-1, a protein that helps cells survive and prevents apoptosis. ABBV-467 is a new drug that blocks the action of MCL-1 (an MCL-1 inhibitor) and could promote apoptosis. In animal models, ABBV-467 led to cancer cell death and delayed tumor growth. ABBV-467 was also studied in a clinical trial in 8 patients with multiple myeloma, a blood cancer. In 1 patient, ABBV-467 treatment prevented the cancer from getting any worse for 8 months. However, in 4 out of 8 patients ABBV-467 increased the levels of troponin, a protein associated with damage to the heart. This concerning side effect may impact the future development of MCL-1 inhibitors as anticancer drugs.

Venetoclax or placebo in combination with bortezomib and dexamethasone in patients with relapsed or refractory multiple myeloma (BELLINI): a randomised, double-blind, multicentre, phase 3 trial.

BACKGROUND: Venetoclax is a highly selective, potent, oral BCL-2 inhibitor, which induces apoptosis in multiple myeloma cells. Venetoclax plus bortezomib and dexamethasone has shown encouraging clinical efficacy with acceptable safety and tolerability in a phase 1 trial. The aim of this study was to evaluate venetoclax plus bortezomib and dexamethasone in patients with relapsed or refractory multiple myeloma. METHODS: In this randomised, double-blind, multicentre, phase 3 trial, patients aged 18 years or older with relapsed or refractory multiple myeloma, an Eastern Cooperative Oncology Group performance status of 2 or less, who had received one to three previous therapies were enrolled from 90 hospitals in 16 countries. Eligible patients were randomly assigned (2:1) centrally using an interactive response technology system and a block size of three to receive venetoclax (800 mg per day orally) or placebo with bortezomib (1·3 mg/m2 subcutaneously or intravenously and dexamethasone (20 mg orally). Treatment was given in 21-day cycles for the first eight cycles and 35-day cycles from the ninth cycle until disease progression, unacceptable toxicity, or patient withdrawal. Randomisation was stratified by previous exposure to a proteasome inhibitor and the number of previous therapies. Sponsors, investigators, study site personnel, and patients were masked to the treatment allocation throughout the study. The primary endpoint was independent review committee-assessed progression-free survival in the intention-to-treat population. Safety analyses were done in patients who received at least one dose of study drug. This study is registered with ClinicalTrials.gov, NCT02755597. FINDINGS: Between July 19, 2016, and Oct 31, 2017, 291 patients were randomly assigned to receive venetoclax (n=194) or placebo (n=97). With a median follow-up of 18·7 months (IQR 16·6-21·0), median progression-free survival according to independent review committee was 22·4 months (95% CI 15·3-not estimable) with venetoclax versus 11·5 months (9·6-15·0) with placebo (hazard ratio [HR] 0·63 [95% CI 0·44-0·90]; p=0·010). The most common grade 3 or worse treatment-emergent adverse events were neutropenia (35 [18%] of 193 patients in the venetoclax group vs seven [7%] of 96 patients in the placebo group), pneumonia (30 [16%] vs nine [9%]), thrombocytopenia (28 [15%] vs 29 [30%]), anaemia (28 [15%] vs 14 [15%]), and diarrhoea (28 [15%] vs 11 [11%]). Serious treatment-emergent adverse events occurred in 93 (48%) patients in the venetoclax group and 48 (50%) patients in the placebo group, with eight (4%) treatment-emergent fatal infections reported in the venetoclax group and none reported in the placebo group. Three deaths in the venetoclax group (two from pneumonia and one from septic shock) were considered treatment-related; no deaths in the placebo group were treatment-related. INTERPRETATION: The primary endpoint was met with a significant improvement in independent review committee-assessed progression-free survival with venetoclax versus placebo plus bortezomib and dexamethasone. However, increased mortality was seen in the venetoclax group, mostly because of an increased rate of infections, highlighting the importance of appropriate selection of patients for this treatment option. FUNDING: AbbVie and Genentech.

Clinical Response of a Patient to Anti-PD-1 Immunotherapy and the Immune Landscape of Testicular Germ Cell Tumors.

Anti-Programed Death 1 (PD-1) is standard immunotherapy for multiple cancers, and the expression of one of its ligands, PD-L1, has been described in germ cell tumors (GCT). Neither the clinical activity of anti-PD-1 nor the incidence of an immunoresponsive tumor microenvironment has been described for GCTs. A patient initially diagnosed with melanoma via fine needle aspiration was treated with one dose of antibody to PD-1. A core needle biopsy was subsequently performed to acquire sufficient tissue for molecular analysis, which led to a change in diagnosis to metastatic embryonal carcinoma. The testicular GCT cohort of The Cancer Genome Atlas was analyzed using a T-cell gene signature associated with benefit from immunotherapy. Primary tumors (N = 134) were categorized as high (T-cell-inflamed), medium, or low (non-T-cell-inflamed) by their T-cell signature derived from RNAseq data. Anti-PD-1 induced decreases in serum markers and a 33% reduction in tumor volume. Gene expression revealed a T-cell-inflamed tumor microenvironment in 47% of testicular GCTs, including seminoma (83%) and nonseminoma (17%) tumor subtypes. Expression of alpha-fetoprotein (AFP) RNA correlated with lack of the T-cell signature, with increasing AFP RNA inversely correlating with the inflamed signature and expression of IFNγ-associated genes. These data suggest that GCTs can respond to anti-PD-1 and that gene expression profiling supports investigation of immunotherapy for treatment of GCTs. Cancer Immunol Res; 4(11); 903-9. ©2016 AACR.

Pazopanib in renal cell carcinoma.

Pazopanib is an oral, multitargeted tyrosine kinase inhibitor that has been approved by the U.S. Food and Drug Administration for treatment of patients with advanced renal cell cancer on the basis of a randomized, double-blind, placebo-controlled, phase III trial, which showed that once a day dosing of 800 mg of pazopanib resulted in progression free survival of 9.2 months versus 4.2 months (P < 0.0001). Pazopanib thus joins sorafenib and sunitinib as one of the clinically available VEGF receptor (VEGFR)-targeted drugs for the treatment of patients with advanced clear cell renal cell cancer. The mechanism of action, preclinical and clinical data, and a comparison with the other drugs in its class are outlined below.

GVAX: an allogeneic, whole-cell, GM-CSF-secreting cellular immunotherapy for the treatment of prostate cancer.

Antitumor vaccines, also known as active immunotherapies, have become an intense focus of research over the last decade as a means to ideally provide new targeted, and less toxic, therapies to patients with a variety of malignancies. Prostate cancer is among the diseases where a large amount of promising data has been accumulating regarding several distinct active immunotherapies. Here the authors review one of the therapies, known as GVAX, which is among the furthest along in clinical evaluation. The authors review the preclinical studies leading to the development of this immunotherapy, describe the results from clinical trials conducted in patients with prostate cancer, and discuss the benefits, limitations and potential future applications of this technology.

Advance directive use among patients undergoing high-risk operations.

BACKGROUND: The Patient Self-Determination Act requires that patients entering hospitals be asked if they have an advance directive. This has led to increased awareness of advance directives, yet surgeons have paid little attention to their use among patients undergoing even major surgery. We sought to evaluate the use of advance directives in patients undergoing pancreaticoduodenectomy and esophagectomy. METHODS: Patients undergoing these operations between 1996 and 2001 at a university teaching hospital were identified and reviewed for statement of advance directive, its presence in the chart, and impact on patient care. RESULTS: A total of 252 patients met inclusion criteria. The number of patients with an advance directive increased, but had little impact on patient care. CONCLUSIONS: More patients having major surgery have advance directives, but the number present in the medical record remains low. Further attention to advance directives would foster increased communication between surgeons and patients and extend patient autonomy.

Resveratrol acts as an estrogen receptor (ER) agonist in breast cancer cells stably transfected with ER alpha.

Resveratrol (Res) is a phytoestrogen found in grapes and present in red wine. Res has been shown to function as an estrogen receptor (ER) agonist, but it remains unclear whether it may also exert antagonist activity. Our aim was to study the effects of Res at both the molecular (TGFalpha gene activation) and the cellular (cell growth) levels in breast cancer cells stably transfected with wild-type (wt) ER(D351) and mutant (mut) ER (D351Y). TGFalpha mRNA induction was used as a specific marker of estradiol (E(2)) responsiveness. Res caused a concentration-dependent (10(-8)-10(-4) M) stimulation of TGFalpha mRNA, indicating that it acts as an estrogen agonist in these cell lines. The pure antiestrogen ICI 182,780 (ICI) blocked Res-induced activation of TGFalpha, consistent with action through an ER-mediated pathway. Further studies that combined treatments with E(2) and Res showed that Res does not act as an antagonist in the presence of various (10(-11)-10(-8) M) concentrations of E(2). To determine whether Res can be classified as a type I or type II estrogen (Jordan et al., Cancer Res 2001;61:6619-23,), we examined Res with the D351G ER in the TGFalpha assay and found that Res belongs to the type I estrogens. Both Res and E(2) had concentration-dependent growth inhibitory effects in cells expressing wtER and D351Y ER. Although the pure antiestrogen ICI blocked the growth inhibitory effects of E(2), it did not block the inhibitory effects of Res, suggesting that the antiproliferative effects of Res also involve ER-independent pathways. Interestingly, Res differentially affected the levels of ER protein in these 2 cell lines: Res down-regulated wtER levels while significantly up-regulating the amount of mutD351Y ER. Co-treatment with ICI resulted in strongly reduced ER levels in both cell lines. Gene array studies revealed Res-induced up-regulation of more than 80 genes, among them a profound activation of p21(CIP1)/WAF1, a gene associated with growth arrest. The p21(CIP1)/WAF1 protein levels measured by Western blotting confirmed Res-induced significant up-regulation of this protein in both cell lines. In summary, Res acts as an ER agonist at low doses but also activates ER-independent pathways, some of which inhibit cell growth.