Nasir K. Khan

Mechanistic Investigation of Bone Marrow Suppression Associated with Palbociclib and its Differentiation from Cytotoxic Chemotherapies.

Purpose: Palbociclib (PD-0332991) is the first selective cyclin-dependent kinase (CDK) 4/6 inhibitor approved for metastatic breast cancer. Hematologic effects, especially neutropenia, are dose-limiting adverse events for palbociclib in humans. Experimental Design: Reversible hematologic effects and bone marrow hypocellularity have been identified in toxicology studies in rats and dogs after palbociclib treatment. To understand the mechanism by which the hematologic toxicity occurs, and to further differentiate it from the myelotoxicity caused by cytotoxic chemotherapeutic agents, an in vitro assay using human bone marrow mononuclear cells (hBMNC) was utilized. Results: This work demonstrated that palbociclib-induced bone marrow suppression occurred through cell-cycle arrest, with no apoptosis at clinically relevant concentrations, was not lineage-specific, and was reversible upon palbociclib withdrawal. In contrast, treatment with chemotherapeutic agents (paclitaxel and doxorubicin) resulted in DNA damage and apoptotic cell death in hBMNCs. In the presence or absence of the antiestrogen, palbociclib-treated hBMNCs did not become senescent and resumed proliferation following palbociclib withdrawal, consistent with pharmacologic quiescence. The breast cancer cells, MCF-7, conversely, became senescent following palbociclib or antiestrogen treatment with additive effects in combination and remained arrested in the presence of antiestrogen. Conclusions: Palbociclib causes reversible bone marrow suppression, clearly differentiating it from apoptotic cell death caused by cytotoxic chemotherapeutic agents. This study also distinguished the cell-cycle arresting action of palbociclib on normal bone marrow cells from the senescent effects observed in breast cancer cells. These results shed light on the mechanism and support risk management of palbociclib-induced bone marrow toxicity in the clinic. Clin Cancer Res; 22(8); 2000–8. ©2015 AACR.

Characterization, Biomarkers, and Reversibility of a Monoclonal Antibody-induced Immune Complex Disease in Cynomolgus Monkeys (Macaca fascicularis)

Two 6-month repeat-dose toxicity studies in cynomolgus monkeys illustrated immune complex–mediated adverse findings in individual monkeys and identified parameters that potentially signal the onset of immune complex–mediated reactions following administration of RN6G, a monoclonal antibody (mAb). In the first study, 3 monkeys exhibited nondose-dependent severe clinical signs accompanied by decreased erythrocytes with increased reticulocytes, neutrophilia, monocytosis, thrombocytopenia, coagulopathy, decreased albumin, azotemia, and increased serum levels of activated complement products, prompting unscheduled euthanasia. Histologically, immunohistochemical localization of RN6G was associated with monkey immunoglobulin and complement components in glomeruli and other tissues, attributable to immune complex disease (ICD). All 3 animals also had anti-RN6G antibodies and decreased plasma levels of RN6G. Subsequently, an investigational study was designed and conducted with regulatory agency input to detect early onset of ICD and assess reversibility to support further clinical development. Dosing of individual animals ceased when biomarkers of ICD indicated adverse findings. Of the 12 monkeys, 1 developed anti-RN6G antibodies and decreased RN6G exposure that preceded elevations in complement products, interleukin-6, and coagulation parameters and decreases in albumin and fibrinogen. All findings in this monkey, except for antidrug antibody (ADA), reversed after cessation of dosing without progressing to adverse sequelae typically associated with ICD.

Liver Microvascular Injury and Thrombocytopenia of Antibody-Calicheamicin Conjugates in Cynomolgus Monkeys - Mechanism and Monitoring

Purpose: Adverse reactions reported in patients treated with antibody–calicheamicin conjugates such as gemtuzumab ozogamicin (Mylotarg) and inotuzumab ozogamicin include thrombocytopenia and sinusoidal obstruction syndrome (SOS). The objective of this experimental work was to investigate the mechanism for thrombocytopenia, characterize the liver injury, and identify potential safety biomarkers. Experimental Design: Cynomolgus monkeys were dosed intravenously at 6 mg/m2/dose once every 3 weeks with a nonbinding antibody–calicheamicin conjugate (PF-0259) containing the same linker-payload as gemtuzumab ozogamicin and inotuzumab ozogamicin. Monkeys were necropsied 48 hours after the first administration (day 3) or 3 weeks after the third administration (day 63). Results: PF-0259 induced acute thrombocytopenia (up to 86% platelet reduction) with nadirs on days 3 to 4. There was no indication of effects on megakaryocytes in bone marrow or activation of platelets in peripheral blood. Microscopic evaluation of liver from animals necropsied on day 3 demonstrated midzonal degeneration and loss of sinusoidal endothelial cells (SECs) associated with marked platelet accumulation in sinusoids. Liver histopathology on day 63 showed variable endothelial recovery and progression to a combination of sinusoidal capillarization and sinusoidal dilation/hepatocellular atrophy, consistent with early SOS. Among biomarkers evaluated, there were early and sustained increases in serum hyaluronic acid (HA) that correlated well with serum aspartate aminotransferase and liver microscopic changes, suggesting that HA may be a sensitive diagnostic marker of the liver microvascular injury. Conclusions: These data support the conclusion that target-independent damage to liver SECs may be responsible for acute thrombocytopenia (through platelet sequestration in liver sinusoids) and development of SOS. Clin Cancer Res; 23(7); 1760–70. ©2016 AACR.

Lesions and identification of crystalline precipitates of glycoprotein IIb-IIIa antagonists in the rat kidney.

Two glycoprotein IIb-IIIa antagonists (xemilofiban, SC-54684A, and orbofiban, SC-57099B), which are platelet aggregation inhibitors, caused crystalline precipitates in the kidney tubules of rats at high dosages. Dogs were not affected. Depending on the degree of the precipitation, which was dosage dependent, and the location, which differed somewhat between the two compounds, the lesions varied from acute obstruction with tubule cell necrosis, nephron dilation, and sudden death with no inflammation to severe chronic pyogranulomatous inflammation. In order to understand the relevance of the lesions, it was important to identify the precipitates. This was technically challenging because the crystals were water soluble (dissolving in routine fixing and staining techniques) and were present in insufficient quantity to physically isolate. Techniques were devised to evaluate the crystals in situ in unstained frozen sections prepared without directly embedding the tissues in supporting medium, which interfered with the analyses. The crystals were analyzed in situ by infrared and Raman spectroscopy and time-of-flight secondary ion mass spectroscopy (TOF-SIMS). Uroliths found in the renal pelvis of one animal were analyzed by liquid chromatography/mass spectrometry. The resulting spectra showed that the crystals were the de-esterified acids of the parent compounds. This knowledge allowed us to predict that the crystalline precipitates would not be a hazard to humans because of the large multiples of the human dosage at which they occurred and because of differences in renal physiology between rats, dogs, and humans.

Comparative Expression and Distribution of c-fos, Estrogen Receptorα (ERα), and p38α in the Uterus of Rats, Monkeys, and Humans

The uterine cellular expression and distribution of c-fos, ERα and p38α was compared in humans, nonhuman primates, and rats using immunohistochemistry. ERα and c-fos were present in the glandular (GE) and luminal epithelial cells (LE) of humans and nonhuman primates, with differing expression patterns evident between proliferative and secretory cycle phases. In rats, the highest and lowest expression of c-fos was present during proestrus and estrus, respectively, in the LE and GE. The most intense ERα staining in rats was observed during proestrus in the GE, while the least intense staining was seen in the LE during proestrus. Strong LE and GE expression of p38α as present in rats in all stages of the estrous cycle and during the proliferative phase in both humans and nonhuman primates. No p38α expression was observed during the secretory phase in either humans or nonhuman primates. Our work suggests that c-fos, ERα and p38α (a) are primarily expressed during the proliferative phase, but not the secretory phase and exhibit interspecies expression variability, and (b) rats exhibit cyclic changes in the expression of c-fos and ERα.

CDK4/6 Inhibition on Glucose and Pancreatic Beta Cell Homeostasis in Young and Aged Rats

Genetic deletion of cyclin-dependent kinase 4 (Cdk4) is associated with pancreatic beta cell loss and glucose dysregulation in rodents. Palbociclib, one of the first selective CDK4/6 inhibitors approved for the treatment of advanced breast cancer, is currently being investigated as an adjuvant treatment in patients with early-stage breast cancer and in a variety of cancers covering a wide-range of patient populations. Hence, longer chronic toxicity studies were necessary to further examine its safety profile. The effects of different doses and duration of palbociclib administration on glucose and beta cell homeostasis in young (two months) versus aged (12 months) rats was compared. Glucose dysregulation, due to pancreatic beta cell degeneration, was observed in young rats administered the highest dose of palbociclib for 6 months. Abnormal pancreatic islet histology and activation of the endoplasmic reticulum stress response in beta cells were detected after shorter administration with high-dose palbociclib in young rats. To test the hypothesis that palbociclib-associated inhibition of beta cell proliferation will more profoundly affect younger animals that have not achieved replicative quiescence, we administered high-dose palbociclib to aged rats for 6 months. In contrast to the young rats, despite equivalent exposures to palbociclib, no evidence of impaired glucose tolerance, hypoinsulinemia, beta cell vacuolization, or beta cell loss was seen in aged rats. Palbociclib administration induces beta cell failure in young but not aged rats. Implications: Although adult humans receiving palbociclib have not displayed detectable adverse effects on glucose metabolism, the risk of beta cell failure in children remains unexplored. Mol Cancer Res; 15(11); 1531–41. ©2017 AACR.

Abstract 4597: A novel immuno-oncology approach: targeting cell-surface mesothelin with a fusion construct containing human granzyme B

Immunological approaches to target tumors have gained considerable traction recently because of excellent clinical results. In addition, targeted treatment with antibody-drug conjugates (ADCs) can also be effective in achieving regression of solid tumors. The challenge for ADCs continues to be efficacy, stability of the construct and development of resistance. We have developed a unique fusion protein composed of 1) a novel human single-domain antibody (SD1) that uniquely targets Region III of the mesothelin glycoprotein and 2) an engineered version of the human serine protease Granzyme B (GrB). Mesothelin is highly expressed in aggressive cancers such as malignant mesothelioma, pancreatic and ovarian cancers, and NSCLC. Granzyme B generates an intense, irreversible pro-apoptotic effect through direct cleavage of caspases, release of cytochrome C from mitochrondria, and cleavage of nuclear matrix. Previous ADCs targeting mesothelin have faced the drawbacks of toxic payloads, formation of neutralizing antibodies, and competition with the serum protein MUC16/CA125. SD1-GrB represents a new class of completely human immunotoxins containing a payload with a unique mechanism of action. Additionally, because of its unique binding properties, SD1 does not compete with circulating CA125 and is not subject to cleavage. The SD1-GrB construct was designed as a homodimer (~200kDa) containing an IgG Fc domain and was expressed using transient-transfection of HEK293E cells. The soluble SD1-GrB was isolated from conditioned media and purified to homogeneity as assessed by SDS-PAGE and Western. Enzymatic activity of the GrB component was assessed by IEPD and found to be similar to authentic, native GrB. Binding to mesothelin was confirmed by surface plasmon resonance. Additionally, binding to the human lung adenocarcinoma cell lines H460 and HCC1703 was demonstrated by ELISA. Initial cytotoxicity (IC50) of SD1-GrB against H460 and HCC1703 was in the 30 nM range. Assessment against a larger panel of cell lines is ongoing followed by in vivo efficacy in a human tumor xenograft model. Our preliminary evaluation of SD1-GrB ADC suggests this construct has a unique mechanism of action and is highly cytotoxic against target cells. This molecule appears to be an excellent candidate for further pre-clinical development as a therapeutic agent. Research conducted, in part, by the Clayton Foundation for Research. Citation Format: Lawrence H. Cheung, Rasheed Tijani, Nasir Khan, Claire Thuning-Roberson, Michael G. Rosenblum. A novel immuno-oncology approach: targeting cell-surface mesothelin with a fusion construct containing human granzyme B [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4597. doi:10.1158/1538-7445.AM2017-4597

Abstract LB-202: Liver microvascular injury and thrombocytopenia of antibody-calicheamicin conjugates: mechanism and monitoring

Gemtuzumab ozogamicin (Mylotarg, GO) and inotuzumab ozogamicin (IO) are antibody-drug conjugates (ADCs) comprised of different humanized monoclonal antibodies (against CD33 and CD22 antigen, respectively) and of the same acid-labile linker and calicheamicin payload. GO and IO are developed for the treatment of acute myeloid leukemia and acute lymphoblastic leukemia, respectively. Adverse events reported with these 2 drugs in patients include thrombocytopenia and liver toxicity, which is characterized by increases in serum aminotransferases and bilirubin along with occasional cases of sinusoidal obstruction syndrome (SOS). The platelet and liver effects were seen in patients with conjugates targeting unrelated antigens and are likely target-independent. Since the specific mechanisms of these toxicities remain elusive, an investigative study was performed in cynomolgus monkeys with a non-binding ADC containing the same linker and payload as GO and IO, PF-0259, with the objectives to investigate the mechanism for thrombocytopenia, characterize the liver injury and identify potential safety biomarkers. Cynomolgus monkeys were dosed intravenously with PF-0259 at 6 mg/m 2 /dose once every 3 weeks for up to 3 doses and were necropsied 48 hours after the 1 st administration (Day 3) or 3 weeks after the 3 rd administration (Day 63). PF-0259 induced acute thrombocytopenia (up to 86% reduction in platelet count) in monkeys with nadirs on Days 3-4. There was no indication of effects on megakaryocytes in bone marrow or activation of platelets in peripheral blood. Microscopic evaluation of liver samples from animals necropsied on Day 3 demonstrated midzonal degeneration and loss of sinusoidal endothelial cells (SECs) associated with marked platelet accumulation in sinusoids. Liver histopathology on Day 63 showed variable endothelial cell recovery and progression to a combination of sinusoidal capillarization and sinusoidal dilation/hepatocellular atrophy, consistent with early SOS. Among biomarkers evaluated, there were early and sustained increases in serum hyaluronic acid (HA) that correlated well with AST levels and liver microscopic changes, suggesting that HA could be a sensitive diagnostic marker of the liver microvascular injury. In conclusion, this work has demonstrated that target-independent damage to liver SECs was responsible for acute thrombocytopenia (through platelet sequestration in the liver) and development of early SOS in monkeys. The translation of these observations to humans has not been evaluated. We further hypothesize that this toxicity mechanism may operate for other types of non-calicheamicin based ADCs in patients where adverse events of thrombocytopenia, increased liver enzymes and liver microvascular disorders (including nodular regenerative hyperplasia) have been observed. Citation Format: Magali Guffroy, Hadi Falahatpisheh, Kathleen Biddle, John Kreeger, Leslie Obert, Karen Walters, Richard Goldstein, Germaine Boucher, Timothy Coskran, William Reagan, Danielle Sullivan, Sharon Sokolowski, Richard Giovanelli, Hans-Peter Gerber, Martin Finkelstein, Nasir Khan. Liver microvascular injury and thrombocytopenia of antibody-calicheamicin conjugates: mechanism and monitoring. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr LB-202.

Evaluation of the effects of subchronic oral administration of n-butyl maleate in Sprague-Dawley rats.

n-Butyl maleate, also referred to as monobutyl maleate, is an ester of maleic acid, which is used as a counterion in the pharmaceutical industry. While substantial published data exist on short-term treatment, maleic acid-induced renal toxicity in the rat, no toxicity data are available on the monobutyl ester. This study evaluated the oral subchronic nephrotoxicity potential of n-butyl maleate administered to Sprague-Dawley rats (10/males and females/group) at doses of 0 (vehicle control), 10, 30, or 60 mg/kg/d for 2 wk. Statistically significant elevations in organ weights were noted in males at 60 mg/kg/d and included: (a) increases in absolute heart, kidney, and liver weights; (b) increased liver to body weight ratios; and (c) increased heart, kidney, liver, spleen, and epididymides to brain weight ratios. In females, statistically significant increases in organ weights were limited to increases in adrenal to brain weights at ≥10 mg/kg/d, kidney to brain weights at ≥30 mg/kg/d, and kidney to body weight and liver to brain weight ratios at 60 mg/kg/d. There were no macroscopic or microscopic pathology changes observed in any of the tissues examined. Importantly, light microscopic examination of the kidney was unremarkable at the end of the 2-wk dosing period with n-butyl maleate. Although lacking a histopathological correlate, resultant increases in organ weights at 60 mg/kg/d might be considered indicative of an adverse effect. However, renal perturbation induced by n-butyl maleate was mild in comparison to maleic acid-induced renal toxicity, which manifested as impaired tubular resorption and necrosis of the proximal tubules at doses ≥60 mg/kg/d. The no-observed-adverse-effect level (NOAEL) for the study was 30 mg/kg/d.