I NUOVI ANTICORPI ANTI-LINFOMA

PIER LUIGI ZINZANI Istituto di Ematologia e Oncologia “L. e A. Seràgnoli” Università degli Studi di Bologna

Milano, 28 maggio 2007 CD80 Expression on Lymphoma Properties

® • PRIMATIZED IgG1 monoclonal • Structurally indistinguishable from human • Specifically binds CD80 • Anti-tumor effects in Neoplastic CD80 B cell preclinical studies • Binds FcRI, FcRII & Fc RIIIa • Blocks CD80 binding with CD28 but not with CD152 galiximab (CTLA-4)

Primate variable regions

Human constant regions (IgG1 lambda isotype) Galiximab + Increase Survival Human B-Lymphoma Mouse Model (N = 40) 100 galiximab (200 μg) + rituximab (200 μg) (N = 10)

80

60 galiximab (200 μg; N = 10)

40 Survival (%) Survival

rituximab (200 μg; N = 10) 20

Control (N = 10) 0 10 20 30 40 50 60 70

Days After Implant

Younes et al., Clinical Lymphoma, 2003 Mar;3(4):257-9 Galiximab Trials in Follicular NHL • Study 114-20: Galiximab monotherapy for relapsed or refractory, follicular NHL – Enrollment: Jan 2002 - Mar 2003 – 37 patients treated

• Study 114-21: Galiximab + rituximab for relapsed or refractory, follicular NHL – Enrollment: Nov 2002 - Mar 2004 – 73 patients treated 114-20: Galiximab Monotherapy • Phase I/II, dose-escalation study of galiximab (125, 250, 375, or 500 mg/m2/wk x 4) • Favorable safety profile – Most common related AEs were fatigue, nausea, and headache • Tumor burden reductions in 46% of patients • Overall response rate = 11% (4 of 37 patients) – 375 mg/m2 (N = 21): 2 CRs, 1 PR – 500 mg/m2 (N = 10): 1 PR • PFS for responders: 11.2, 24.3+, 26.5, and 31 mos.

Czuczman et al., J Clin Oncology, 2005 114-21: Galiximab + Rituximab

• Phase I/II, dose-escalation study of galiximab in combination with a standard course of rituximab • 4 treatment groups

Treatment Galiximab Rituximab Group ( 4 infusions) ( 4 infusions) 1 125 mg/m2 375 mg/m2 2 250 mg/m2 375 mg/m2 3 375 mg/m2 375 mg/m2 4 500 mg/m2 375 mg/m2 Visit Schedule

Treatment On-Study Follow-Up Survival

183 15 22 50 3 6 9 12 15 18 21 24 30 36 42 48 Day Day Month Month

Rituximab infusion Evaluations • Efficacy • Safety Galiximab infusion • Pharmacokinetics • Immunogenicity Rituximab + galiximab infusions Key Entrance Criteria

• that has relapsed or has failed primary therapy • Patients who received prior rituximab-containing therapy had to respond with a TTP > 6 months • WHO Performance Status < 2 • Acceptable hematologic status – Hemoglobin > 8.0 g/dL – ANC > 1500 cells/mm3 – Platelet count > 75,000 cells/mm3 Study Status

• 73 patients treated • 64 treated at 500 mg/m2 galiximab + 375 mg/m2 rituximab weekly x 4 • Median follow up = 20.4 months Most Common Related Adverse Events 15% %

Anemia Grade 1 23 21% Pyrexia Grade 2 47 21% Grade 3 25 Thrombocytopenia 27% Grade 4 1 Chills 22% Neutropenia

Leukopenia 36%

Fatigue 36%

Lymphopenia 48%

0 102030405060708090100 Patients (%) Incidence >15%; probably, possibly, or unknown relationship to study treatment Efficacy Results (500 mg/m2 Galiximab Group)

• Responses were evaluated using the International Workshop Response Criteria • Overall response rate = 64% (41 of 64 patients) – 17% CR, 16% CRu, 31% PR • Median PFS = 12.1 months (95% CI, 9.7 to 15.0 mo.) OfatumumabOfatumumab ProgramProgram

Type 1

Type 2

ofatumumab OfatumumabOfatumumab

- Generated from Ig-Transgenic mice - Human IgG1,  - Excellent binding; slow off-rate - Potent ADCC & CDC Ofatumumab, a Novel Fully Human Anti-CD20 :

Results of a Phase I/II Trial in Relapsed or Refractory Follicular Non- Hodgkin’s Lymphoma Study Hx-CD20-001 Objectives

 To investigate the safety and efficacy of ofatumumab in patients with relapsed or refractory follicular lymphoma grade 1-2

 To determine the pharmacokinetics after a single dose and after 4 doses of ofatumumab at weekly intervals Design

 An open label, dose-escalating, multicenter clinical trial  4 cohorts of 10 patients  4 weekly i.v. infusions of 300, 500, 700 or 1000 mg  Patients were premedicated with oral acetaminophen and i.v. antihistamine  In case of CTC grade 3 adverse events during infusion i.v. glucocorticosteroids were given Inclusion criteria

 Relapsed or refractory follicular lymphoma grade 1-2, defined according to WHO  Lymphoma verified to be CD20+ from excisional lymph node biopsy  CT in screening phase showing:  2 or more clearly demarcated lesions with a largest diameter  1.5 cm, or  1 clearly demarcated lesion with a largest diameter  2.0 cm  Age  18 years 57% of adverse events reported on the infusion days

10 N=10 Grade 3 Grade 2 9 N=10 N=10 N=10 Grade 1 8 7 The use of steroids was limited to 19% of 6 infusions. 5 4

number of patients of number 3 2 1

1234 1234 1234 1234 Infusion no 300mg 500mg 700mg 1000mg Dose group Infections reported in 33% of patients

SAEs 2 unrelated: urinary tract infection, neutropenic sepsis

Non-serious AEs (all grade 1-2) Unrelated: upper respiratory tract infection (11 events), urinary tract infection (2 events), herpes (1 event), candidiasis (2 events), pneumonia (2 events) Related: Influenza

Dose group, mg 300 500 700 1000 No of patients 10 10 10 10 No of patients with infection 5 0 3 5 Hematological toxicity

Laboratory values  Neutropenia  Grade 1: 2 of 39 patients  Grade 2: 4  Grade 3: 1  Grade 4: None  Thrombocytopenia  Grade 1: 6 of 37 patients  Grade 2: 1 (reported as an adverse event)  Grade 3: None Pharmacokinetics of ofatumumab after fourth dose

n Cmax (_g/ml) T_ (hr) Cl (ml/hr/kg) AUC0-inf (hr*_g/mL)

10 129 [112 – 161] 446 [293 –711 ] 9 [1 – 1 7 ] 74616 [41286 -282593 ]

9 185 [84 – 373] 303 [57 – 632 ] 1 6 [4 – 7 8 ] 53261 [6957 -203068 ]

9 3 55 [263 – 560] 322 [189 – 625] 1 0 [6 – 2 3 ] 185251 [51925 -380185]

10 610 [362 – 857] 567 [77 – 720 ] 3 [1 – 2 9 ] 644080 [47188 -1107841 ]

Summaries are shown as median [range]

For comparison, the mean T of Rituximab after fourth dose is 208.5 h; SD 95 h (Berinstein et al., Ann Oncol 9:995-1001, 1998) Clinical response Best objective response

300 mg 500 mg 700 mg 1000 mg Patients 81 92 10 10 CR 4 1 CRu 1 1 PR 2 2 5 SD 3 6 6 3 PD 2 1 Response rate % 63 33 20 60 (95% CI) (11-100) (0-96) (0-84) (15-100) 1 Two patients not evaluable due to lack of indicator lesions 2 One patient withdrawn before assessment Objective responses in patients previously treated with Rituximab

 9 of 14 (64%) evaluable patients treated with ofatumumab after initial response to Rituximab achieved CR (3), CRu (1) or PR (5)

For comparison,  23 of 60 (38%) patients responded (10% CR and 28% PRs) after re-treatment with Rituximab1

1 Davis et al., J Clin Oncol; 18: 3135-3143, 2000 Bcl-2 conversion peripheral blood

Dose groups, mg 300 500 700 1000 Total

Baseline Bcl-2 positive 5 3 6 3 17 Week 19 Bcl-2 negative 4 1 4 2 11

Bcl-2 conversion 80% 33% 67% 67% 65%

No correlation to objective response Time to progression responders

Predicted probability (%) 100 90 80 70 60 50 40 30 20 10 0 0 30 60 90 120 150 180 210 240 270 300 330 360 390 Time to progression in responders (days) Dose group 300 mg 500 mg 700 mg 1000 mg All groups Conclusions

 ofatumumab is well tolerated in patients with follicular non-Hodgkin’s lymphoma’s  All dose levels caused immediate, profound and long lasting B-cell depletion  Objective responses achieved in all dose groups; response rate up to 63%  High objective response in patients previously treated with Rituximab  Bcl-2 conversion in the blood in 65% of evaluable patients  The half-life of ofatumumab is greater than the half- life reported for Rituximab  Data strongly supports further development of ofatumumab in follicular lymphoma Rationale for Targeting CD4 in CTCL

• CD4 is present on 90% of CTCL T cells • CD4 expression is lineage-restricted • CD4 expression is stable • CD4 is involved in signaling

• High affinity, fully human monoclonal IgG1, antibody (Kd = 5 x10-11 M) • Activity – Antibody Dependent Cellular Cytotoxicity in vitro – Depletion CD4+ T-cells in vivo – The approximate half-life is 40 hours • Blocks interaction between CD4 and MHC II Zanolimumab Mechanisms of Action

ADCC

FcR CDC C1q Cytokines; - surface markers - Inhibition of: CD4+ Classical • Signal transduction pathway • Proliferation • Cytokine production • Surface marker expression

CD4 down-modulation Apoptosis Phase II Trials Refractory Early and Advanced Stage CTCL

• Once weekly i.v. administration for 17 weeks conducted between April 2003 – June 2004 in 47 CTCL patients

• Initial Regimen: 280 mg

• High Dose Regimen: - 560 mg in early stage disease (HxCD4-007) - 980 mg in advanced stage disease (HxCD4-008) Hx-CD4-007 & Hx-CD4-008 (early and advanced stage CTCL patients)

H x-CD 4 -00 7 Phase 2 in Early Stage C T C L

In f u s io n s

Final: 11+14 patients

560 m g

17 weekly infusions

280 m g

H x-CD 4 -00 8 Phase 2 in A dvanced Stage C T C L

Final: 13+9 patients

980 m g 17 weekly infusions

280 m g

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A sse ssm e n ts (w e e ks) Clinical Efficacy in MF Type CTCL (007 – 008)

38 MF Patients 80% 3 / 4

70%

60% 7 / 14 50%

40%

30% 2 / 9

20% Response rate ( CA score) rate Response 1 / 11 10%

0% Early Stage MF Advanced Stage MF Early Stage MF Advanced Stage MF 280 mg 280 mg 560 mg 980 mg

High dose (560 / 980 mg) compared to low dose (280 mg), p=0.016, Fisher's Exact Test Clinical Response in Advanced Stage MF

280 mg 980 mg 50% Reduction in 2 of 9 Patients, 2 Partial 50% Reduction in 3 of 4 Patients, 3 Partial Responses Responses

 Zanolimumab Dosing Response in Stage IB Patient 280 mg

Baseline Week 2 Response in Stage IB Patient 560 mg

Baseline Week 4 Response in Stage IVA Tumor Patient 980mg

Baseline Week 8 Most common AE in CTCL

• Grade 1-2 AE – Flu-like symptoms – Pruritus – Infections (no CMV reactivations) – Eczema (dermatitis) – Fatigue – Headache • SAEs (at 2 yrs follow-up) – 4 patients experienced 6 related SAEs in CTCL trials  4 Infections: Suspected wound infection, groin infection, peri-oral infection, CMV infection (11 months after discontinuation of treatment)  2 cytokine release reactions Current clinical development status

• Zanolimumab is currently in phase III clinical development for MF CD4+ CTCL

• Zanolimumab will soon be tested in clinical trials as an add-on to standard front-line combination in NCTCL.