Brian GM Durie. Black Swan Research Initiative (BSRI) Purpose

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1 Black Swan Research Initiative Brian GM Durie Saturday August 22, Black Swan Research Initiative (BSRI) Purpose The Black Swan Research Initiative (BSRI) is a global collaborative approach Which uses the most precise MRD testing To track myeloma at the lowest levels As a basis for treatment decisions To achieve a cure 2

2 Black Swan Research Initiative Where are we? What are the next steps? 3 Key Elements of BSRI 1. Early Diagnosis 2. MRD Assessment of Response 3. Clinical Trials 4

3 Step 1: Early Diagnosis BLACK SWAN RESEARCH INITIATIVE 5 Key New Publication recommends the implementation of these criteria in routine practice 6

4 New Criteria for Active Myeloma CRAB Criteria Calcium Renal Anemia Bone and/or Myeloma Defining Events 7 New Criteria for Active Myeloma Myeloma-Defining Events Creatinine clearance < 40 ml/min Bone marrow plasma cells 60% Serum Freelite ratio 100 Imaging evidence of active disease MDE >1 focal lesion on MRI New CRAB Positive PET/CT Lesions >5mm on WBLD CT 8

5 Step 2: Next Generation MRD Testing BLACK SWAN RESEARCH INITIATIVE 9 Going beyond the CR criteria with MRD monitoring < 5% PCs in bone marrow Negative IFE of serum and urine Disappearance of soft tissue plasmacytomas Cellular clonality Cellular production Cellular spread Immunohistochemistry ASO-PCR Next Generation Sequencing (NGS) Next Generation Flow (NGF) sflc Hevylite Sensitive M-spike measurement PET/CT WB-MRI 10

6 MRD monitoring in multiple myeloma using NGS Commercial Home-made 1. Extraction and quantification of gdna (qpcr) 2. VDJ, DJ,KDEL etc. PCR amplification with Biomed 2 primers 3. Ligation with barcodes 4. Sequencing, Ion Proton Platform Martinez-Lopez J, et al. 11 IMF/ EuroFlow Consortium Develop more sensitive and standardized flow method: Next Generation Flow (NGF) Ideal antibody cocktails: now sensitive at and 10-color cross panel validation Multi-dimensional analysis software: now 12 minutes! 12

7 NGF Antibody Panels Panel Tube BV421 BV510 BV605 FITC PE PerCP Cy5.5 PE Cy7 APC APC A700 APC C color 1 CD117 CD81 CD138 CD27 CD38 CD56 CD45 CD19 2 CyIgk CyIgl 10-color 1 CD138 CD27 CyIgl CD38 CD56 CD45 CD19 CD117 CyIgk CD81 13 Current Use of NGF: 8 Colour Gold Standard U.S. MAYO MDAH UAMS (MIRT) U of Chicago Columbia (NY) Mount Sinai (NY) Carolinas Roswell Park Europe Latin America Japan Singapore China Australia Spain France (IFM) Italy (Palumbo) Netherlands (Hovon) Germany Turkey Brazil Tokyo National University Beijing, Tianjin, Shanghai Melbourne 14

8 MRD monitoring in MM using NGF: ultra-sensitivity Next-generation flow - + Total NGS - 9/14 (64%) 2/14 (14%)* 11/14 (78%) + 0/14 (0%) 3/14 (22%) 3/14 (22%) Total 9/14 (64%) 5/14 (36%) NGS was applicable in 14/16 (88%) of MM cases 15 Current Use of NGF: 8 Color Gold Standard

9 NGF for MRD monitoring in MM: GEM2012MENOS65 (>400 tests) CR and MRD-negative 49% 49% MRD-positive % MRD-positive % MRD-positive % MRD 10-7 <1% + 51% 17 Iceberg Effect 49% % 20% 51% 8% % 10-5

10 NGF for MRD monitoring in MM: ultra-sensitivity 10 Patient % clonal PCs % MRD % MRD % MRD % MRD Diagnosis CR Induction HDT/ASCT Consolidation 19 Steps to Assess and Treat MRD Monitor or Maintain If negative If positive Develop specific Rx MoAb Studies Study Residual MRD Assess Relapse/ Resistant Disease MRD Assessment Car/Rev/Pom/ + Elo or DARA Alternate Rx 20

11 Newly-diagnosed symptomatic MM patients with an MGUS-like profile by Flow and GEP Phenotypic MGUS-like profile Molecular MGUS-like profile Symptomatic MM MGUS-like symptomatic MM (~10%) Paiva B, et al. Leukemia. 2013;27(10): Zhan et al. Blood. 2007;109: Survival for MGUS-like MM patients is independent of CR Less than CR should not be considered a sub-optimal response TTP 100 TTP Median: NR 59%@10y 80 Median: NR Median: NR 20 Median: 44 months 14%@10y 20 0 HR: 3.27 ; P < P = Time from diagnosis (months) Time from diagnosis (months) MGUS-like profile (n=59) MM-like profile (n=639) CR (n=26) < CR (n=33) Paiva B, et al. Leukemia. 2013;27(10):

12 MRD clonal PCs show de-regulated GEP compared to baseline clonal PCs B A S E L I N E M R D Paiva B, et al. Blood 2013;122(21): abstract 402 (oral presentation) 23 Proteasome inhibitor resistance-related genes PAAF1: proteasomal ATPase-associated factor 1 PSMA6: proteasome subunit, alpha type, 6 PSMB10: proteasome subunit, beta type, 10 POMP: proteasome maturation protein PSME1: proteasome activator subunit 1 PSMD10: proteasome 26S subunit, non-atpase, 10 PSMB6: proteasome subunit, beta type, 6 PSME3: proteasome activator subunit 3 PSMA2: proteasome subunit, alpha type, 2 Low Paiva B, et al. Blood 2013;122(21): abstract 402 (oral presentation) 24

13 PDL1 - PD1 axis is up-regulated after therapy at the MRD stage Amount of PD-L1 MFI-expression / PC P =.05 Percentage of cells with PD1 surface expression CD4 T-cells CD8 T-cells P < Normal PCs Clonal PCs 20 0 Paiva B, et al. Leukemia. 2015; doi: /leu Antigen/Receptor Targets T Cell NK KIR Cell CD 16 SLAM F7 CAR T cell PD-1 checkpoint inhibitor PD-L1 CD 28 CD 117 CD 45 CD 33 CD 20 CD 19 CD 19 4% LDL-R CD 46 CD 56 Lorvo/Dace CD 138 Inda CD 319 Elo (SLAM F7) CD 38 DARA/SAR/MOR % Measles VSV Monoclonal Antibodies Multiple Targets 26

14 Specific Targets Antigens Molecular 18% 36% PD-L1 CD 28 CD 117 CD 45 CD 33 CD 20 CD 19 4% CD 56 CD 138 CD 319 (SLAM F7) CD % BRAF 4% KRAS NRAS CCND1 DIS3 HOX A9 NFKB Hundreds of mutations, SNPs, and pathways 27 Transitioning from conventional CR Complete Response (CR) Negative serum and urine immunofixation <5% PCs in marrow MRD negative Flow negative MRD Sequencing negative MRD Imaging negative MRD Stringent Complete Response (scr) Normal FLC ratio No clonal plasma cells in marrow 28

15 New Criteria for MRD MRD-negative by Next-generation flow MRD-negative by Next-generation sequencing Imaging plus cellular MRD-negative Conventional CR PLUS Absence of phenotypically aberrant clonal plasma cells by nextgeneration flow cytometry on bone marrow aspirates using the EuroFlow standard operation procedure for MRD detection in MM (minimum sensitivity of 1 in 10 5 nucleated cells) Conventional CR +PLUS A clonotype was defined AND Less than 2 identical sequencing reads obtained after DNA sequencing of bone marrow aspirates using the Lymphosight platform (minimum sensitivity of 1 in 10 5 nucleated cells) MRD negative as defined above (MFC or sequencing) PLUS Disappearance of every area of increased tracer uptake found at baseline by PET/CT 29 Upcoming Trials NGF in Blood MGUS SMM MM Low MRD Status New Trial Options MRD NEG MGUS Signature CURE Trials Resistant MRD 30

16 CESAR Trial C urative E strategy S moldering A lto R isk HR SMM KRd x 6 cycles ASCT KRd x 2 cycles Rd x 2 years 31 ASCENT Trial Aggressive Smoldering Cure Evaluating Novel Rx Transplant HR SMM KRd + DARA x 4 cycles ASCT KRd + DARA x 4 cycles KRd + DARA x 4 cycles K DARA x 2 years 32

17 Patients with long-term survival have a unique immune signature Poor Maturation TAMs Myeloid-Dcs Plasmacytoid-Dcs T- Reg MO Numbers NK CD8 CD8 CD8 Inhibition NK N-Pcs B NK N-Pcs B B Bone Marrow Stromal Cells Bone Marrow Stromal Cells Bone Marrow Stromal Cells Pessoa de Magalhães RJ, et al. Haematologica. 2013;98(1): Forward Expectations and Plans Expanding cure fraction 2017 Documenting cure Validation of clinical correlates 2016 Expanding achievement of MRD-negative Studying MRD-positive; introducing Rx to eradicate Understanding MRD-negative Introducing new MRD blood test 2015 Cross correlate with NGS and imaging Now Standardized NGF test for bone marrow 34

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