Mastocytosis

Olivier Hermine MD, PhD

Hematology Department, Necker Hospital

Centre National de référence des mastocytoses, Necker Hospital

CNRS UMR 81 47

Institut Imagine, Necker Hospital

Paris, France

Mast cells in hypersensitivity type 1

•Mast cells are tissue cells

•They are prevalent in areas

• which interface directly with

• the external environment

•close to blood vessels and

•nerve endings

•They can respond very

•rapidy to a stimulus

•with the production of a

•whole array of mediators

•Mast cells are sentinentals with strategic location

•from JS. Marshall, Nature Rev Immunol 420: 787- (2004)

Cancer Allergy

Autoimmunité

Alloreactivity

Acute

chronic

Mastocytosis

Inflammation

fibrosis Neurological

And

Psychiatric

Diseases

•Mastocytosis

•Mast cells and Diseases

Definition - Mast cell accumulation in various organs (Skin, GI tract, Liver, Bone and Bone Marrow, etc) -Myeloproliferative disorder; Aggressive vs indolent disease

- Association with hematological disorders - Clinical heterogeneity (Infiltration vs Mediators release)

Photos Pr Bodemer et Dr Barete

MASTOCYTOSIS

Children

•MCAS

Updated WHO Classification of Mastocytosis 2016

Cutaneous mastocytosis (CM)

- Maculopapular CM (MPCM) = urticaria pigmentosa (UP)

- Diffuse CM (DCM)

- Mastocytoma of skin

Systemic mastocytosis (SM)

- Indolent SM (ISM)

- Smoldering SM (SSM)

- SM with associated hematologic neoplasm (AHN)*

- Aggressive SM (ASM)

- Mast cell leukemia (MCL)

Mast cell sarcoma

-------------------------------------------------------------------------------------

*The previous term SM-AHNMD (SM with clonal hematologic

non-mast cell-lineage disease) and the new term AHN can be

used synonymously.

Physiopathology

MC TC MC T

Stem Cell CD34+ Bone Marrow

Circulation SCF

IL-10

IL-6

SCF

CD34+

c-kit high

FceRI neg

CD13+

MC C

IL-4 SCF

?

Simplified pathways of human MC differentiation

Tissues

IL-4 Survival : SCF

NGF

IL-4

IFN-g

…...

0

100

200

Day0 SCF- SCF+

0

500

1000

Day0 SCF- SCF+

0

200

400

Day0 SCF- SCF+

•Day 30

•Day 30

•Day 30

•CD34-Kit+ •CD34+Kit+

•Healthy

•Donor

•(SCF+)

•Mastocytosis

•c-Kit D816V

•Mastocytosis

•c-Kit WT

•Histamine level

•ng/

ml

•ng/

ml

•ng/

ml

•CD34-Kit+

•CD34+Kit+

Sophie Georgin et al, Blood 2010

C-kit+CD34-Mast cell precursors in peripheral blood

•C-kit activation pathway

•Lyn

•Ig1 •Ig2 •Ig3 •Ig4 •Ig5 •TM •JM •TK1 •TK2

•1 •2 •3 •4 •5 •6 •7 •8 •9 •10 •11 •12 •13 •14 •15 •16 •17 •18 •19 •20 •21

•Dog mast cell tumor D826-828- InsDT •Q430R

•ins421 aa45

•S479I4

•N508I

•Del/Ins555-559(5)

•ITD571-590(15) •n=88

•Patrice Dubreuil, Katia Hanssen, Sébastien Leutard, Kevun Hahn, Christine Bodemer, Olivier Hermine CEREMAST

•D479N

•V560G D418

D564-576

•E860G D419 (12) •InsFF419

•C443Y •S476I

•ITD501-502(2)

•ITD505-508

•D572A •D816Y(4)

•K509I(6)

•D816I

•ITD502-503(4)

•D816V(353)

•Ig1 •Ig2 •Ig3 •Ig4 •Ig5 •TM •JM •TK1 •TK2

•1 •2 •3 •4 •5 •6 •7 •8 •9 •10 •11 •12 •13 •14 •15 •16 •17 •18 •19 •20 •21

D417-418 D419Y

•n=603 •Human mastocytosis

•MCL leukemia

•And Sarcoma

•No PTD

•Exons 8 to 11 •Exon 17 •WT

•30% of the dogs are mutated

•No PTD

Adult (Indolent and agressive)

•PTD

Pediatric

•No PTD

Single Gene (C-kit) several diseases

•Differential colony-forming ability of ECD and D816X mutants expressing Rat2 cells

•Without

•SCF

•With

•SCF

•Outcome and mutations of c-kit

Patients mastocytosis

Statut of c-Kit

WT Mutation autre que

D816V D816V

Children (N= 59) 15% 46% 39%

Adults (N= 485) 28% 3% 69%

•age

•Mutation %

•persistent

•Mutations

•ex8 & ex9

•puberty

•Mutations

•D816V

•regressive

•50

•75

•25

Children Mastocytosis

Adult Mastocytosis

Kit Mutations

No senescence Chronic disease

AGRESSIVES Fatal Outcome

Non PTD PTD

Senescence Régression

Conclusions and Perspectives

P-p38 P-p38

p53 ATRX ?

APBs

Telomeres

protection

By TRF2

No protection

of Telomere

By TRF2 Germline mutations

(p53; p16) ?

•Role of Telomere Maintenance

•Mutation

•D816V

•(Exon 17)

•C-Kit

• Mastocyte Survival

•=> immortalisation

•Indolent Mastocytosis •Télomere maintenance

•Mutation

•Exons 8 à 11

•C-Kit et WT •Proliferation

•Senescence

•Short telomeres

•SCF

•Spontaneous Regression

•Tumor progression - Genetic instability - ALT

•Role of Telomere Maintenance

•Mutation

•D816V

•(Exon 17)

•C-Kit

• Mastocyte Survival

•=> immortalisation

•Indolent Mastocytosis •Télomere maintenance

•Mutation

•Exons 8 à 11

•C-Kit et WT •Proliferation

•Senescence

•Short telomeres

•SCF

•Spontaneous Regression

•Tumor progression - Genetic instability - ALT

•Agressive Mastocytosis •Télomere maintenance

•Cytosine

•5-me-Cytosine •5-hme-Cytosine

•Dnmt

•Tet2

•Inhibitors

•(e.g. RG108)

Tet2 is involved in the conversion of 5 meC to 5hmeC at specific genomic loci

•Mutations in SMP and AML

•CMML++

•CMML is associated with MS

Tet2 mutations are frequent and are correlated to aggressive disease

•Mastocytosis Patient Cohort:

•Bone marrow derived Tet2-deficient mast cells infected with c-KitD816V have a competitive growth advantage

Confirmed in two independent Tet2-KO models (lacz and flox)

Consistent whether infections are done using « young » or « old » MC cultures (old > 80 days culture with IL3)

•CD

11

7

•Tet2(+/+)

•GFP

•Tet2(+/-) •Tet2(-/-)

•cKitD816V+ •cKitD816V+ •cKitD816V+

•SRSF2-P95 Hotspot Mutation is Highly Associated with Aggressive Forms of Mastocytosis and Mutations in Epigenetic Regulator Genes •Katia Hanssens, Fabienne Brenet, Julie Agopian, Sophie Georgin-Lavialle, Gandhi Damaj, Laure Cabaret, Maria Olivia Chandesris, Paulo de Sepulveda, Olivier Hermine, Patrice Dubreuil *§ and Erinn Soucie* (Haematologica; in press)

•ASSOCIATED HEMATOLOGICAL MALIGNANCIES

Travis 1988

Horny 2004

Sotlar 2010

Pardanani 2009

Damaj et al 2013

AHNMD; n (%) 20 (33) 22 (33) 48 134 (40%) 62

Myeloid % 82 90 83 89 82

MDS % 32 9 8 3 28

CMML % 39 27 23 16

MPN % 9 21 45 16

AL % 10 21 3 5

Lymphoid % 11 18

Lymphoma% 6 5 8

MM% N=2 10 4 5 (MGUS)

CLL% 2

•*Damaj et al, CEREMAST, Unpublished data

Sotlar J Pathol

2010

Horny JCP,

2004

Pardanani Blood 2009

Tefferi Leuk,emia

2009

Traina Plosone

2012

*Damaj 2013

N 48 20 134 23 8 62

D816; n(%) 45 (94) 16 (80) 50 (63) 44 (86)

JAK-2; n(%) na na 6 (8) 2 (7.5)

TET-2; n(%) na na na 8 (35) 5 (62) 12 (32)

ASXL1; n (%) na na na 2(25) 6 (17)

FGFR4; n(%) na na na 7 (18)

CBL; n(%) (12.5)

GENE MUTATIONS IN SM-AHNMD (1)

TET2, ASXL1 are positive, only in the myeloid AHNMD

•*Damaj et al, CEREMAST, Unpublished data

•Figure 1

•P = 0.003 •ASXL1 negative. median OS: 92.33 (95% CI, not reached)

•AXSL1 positive: median OS: 12.86 (95% CI, 5.56 – 20.17)

•

Gandhi Damaj1,2,3, Magalie Joris1, Olivia Chandesris2,4, Katia Hanssens5, Erinn Soucie5, Danielle Canioni6, Brigitte Kolb7, Isabelle Durieu8, Emanuel Gyan9, Cristina Livideanu10, Stephane Chèze11, Momar Diouf12, Reda Garidi13, Sophie Georgin-Lavialle14, Vahid Asnafi15, Ludovic Lhermitte15, Christian Lavigne16, David Launay17, Michel Arock18,19, Olivier Lortholary20, Patrice Dubreuil5* and Olivier Hermine2,3,4*

Mastocytosis Heterogeneity and c-kit

•MDS

•CMML

•AML

•Sarcoma

•MCL

•Indolent

Masotcytosis

•Agressive

mastocytosis

•C-kit 816 V

•Tet2

•ASXL1

•JAK2,

• FIP1L1-PDGFR,

•CMML

•Regression

•C-kit 816 V

•negative

•C-kit 816 V

•Other ?

•C-kit 816 V

•Pediatric forms

•Other ckit mutations

•WT c-kit

•Adult Forms

•Sarcoma

•MCL

•Other ckit mutations

•WT c-kit

•Others SMP

•other ?

•NHL

•Agressive

•Masotcytosis

(rare)

•Cytokines (CD40L)

•Tet2

•ASXL1

•C-kit 816 V

•Tet2

•ASXL1

•others

•Tet2

Diagnosis

Urticaria pigmentosa

Bone involvement

Osteosclerosis

Mastocytosis Diagnosis

1. DARIER ’S SIGN FOR CUTANEOUS MASTOCYTOSIS (Skin involvement is not required)

2. HISTOLOGY FOR CUTANEOUS AND/OR SYSTEMIC

MASTOCYTOSIS (required)

- TOLUIDINE BLUE

- ANTI -TRYPTASE STAINING

- CD117+, CD2+ and/or CD25+, CD15-

3. MAST CELL MEDIATORS

- Total tryptase >20ng/ml

- Soluble C-kit level

Major and Minor WHO Criteria of Systemic Mastocytosis (SM criteria)*

Major criterion:

Multifocal dense infiltrates of mast cells

(>15 mast cells in aggregates) in bone marrow biopsies and/or in sections of other extracutaneous organ(s)

Minor criteria:

a. >25% of all mast cells are atypical cells

(type I or type II) on bone marrow smears or are spindle-shaped in mast cell infiltrates detected on sections of visceral organs

b. KIT point mutation at codon 816 in the bone marrow or another extracutaneous organ

c. mast cells in bone marrow or blood or another extracutaneous organ expresses CD2 or/and CD25

d. Baseline serum tryptase concentration >20 ng/ml (in case of an unrelated myeloid neoplasm is not valid as an SM criterion)

If at least one major and one minor or three minor criteria

are fulfilled

the diagnosis is systemic mastocytosis = SM

*SM criteria have been defined by the WHO in 2001 and confirmed in 2008 and 2016.

Treatment

Prognosis

•Blood 2009

Prognosis

•Blood 2009

•Indolent Mastocytosis >80%

•Agressive Mastocytosis

Therapeutic decision

• Agressive disease : Reduction of life expectancy

and organ failure

• Indolent disease : No life expectancy reduction,

no organ failure , Handicap associated with

symptoms (patient vs physician)

Protocols for treatment of Indolent

Mastocytosis

Should we treat these patients ?

On what basis ?

What should be the end points of treatment ?

Identification of all systemic manifestations in patients suffering from

mastocytosis

• From 2004, 363 mastocytosis patients and 90 controls in France were asked to rate their overall disability (OPA score) and the severity of 38 individual symptoms.

• A specific questionnaire (AFIRMM V1), encompassing these 38 symptoms, has been created and validated.

PLoS ONE. 2008 May 28;3(5):e2266

Identification of all systemic manifestations in patients suffering from

mastocytosis

Course of Tumoral mass (3 months)

•Patient ISM

•53 years old

•Cognitive impairment

•IRM/ASL: artérial spin labelling, Flow blood in the brain

•Perfusion MRI

•Control

•Hyperperfusion of central grey nuclei : 11 patients with cognitive imapirement vs 33 controls

•p

•Hypoperfusion of the anterior Cingulum antérieur in 10 patients with depression and mastocytosis Vs. 18 patients with Mastocytosis but not depressed

•p

•IDO

•Hypothesis

•TNFa

•

•Tryptophane

•Kynurenine

•Acid

•xanthurenic

•Acid

•quinolenic

•Neurotoxicity

•Oxidative stress

•apoptosis

•-

•+

•Cognition (?)

•serotonin

•Low serotonin

•Depression ?

•Proteases

•Histamine

Others

•ASL

•abnormalities

Fig 2

Eviction of mast cells stimulants: depend on the patient history

Aim at inhibiting mediator release by mast cell or mediators effects.

- Anti-H1 : pruritus, flush and sometimes GI pains.

- Anti-H2 : essentially GI pains.

- Aspirin : for flushing, tachycardia, but may cause vascular collapse!!!

- Corticoids : for local treatment of cutaneous lesions, ascite, malabsorption, GI cramps

(budesonide: corticoïde à délitement entéral)

- Cromoglycate disodium : non specific mediator release symptoms

- Anti-leucotriènes (montelukast-singulair): for respiratory manifestations

- Epinephrin : Hypotension

- Biphosphonates : bone pain and bone loss

SYMPTOMATIC THERAPIES OF MASTOCYTOSIS

Cytoreductive treatment

• Interferon alpha

• Cladribine

• Kinase inhibitors

• Thalidomide

• Rapamycine

Cytoreductive Treatments

• High dose steroids

• Alpha Interferon (?)

• Cladribine

• Kinases Inhibitors

• Thalidomide

• mTOR inhibitors (Rapamycine, Temsirolimus)

• Bone marrow transplantation

• Treatment of AHNMD

Cladribine Treatment • 0.14 mg/kg 5 days a week in 2 hour infusion or

subcutaneously

• 1 to 6 cycles repeated every 4 to 12 weeks

• Usually no premedication with corticosteroids or

antihistaminic

• Antibiotic prophylaxis with Co-trimoxazole and Valaciclovir

•Clinical response

•Clinical improvement for

• 10/11 mediator release

symptoms including

anaphylaxis

• 5/6 mast cell infiltration-related

symptoms including urticaria

pigmentosa, and organomegaly

(P

•38 patients (80%) comprising 11 CR, 17 MR and 10 PR.

•Progression free survival

•Median PFS = 3.7 (0.1-8.6)

•Overall survival

•Whole group

•Median OS = 8.2 (0.1-9.1) years

•According to WHO sub-types

Discussion on Cladribine

2-CdA is active in mastocytosis

Its activity seems to be more pronounced on fatigue, flush, GI

symptoms and pruritus, skin infiltration

Median duration of response remains to be precisely determined but

some patients have long term responses

Haematological toxicities and infections were manageable and were

more frequent in the aggressive forms of the disease

Further work is needed to determine optimal therapy schedule and

usefulness of maintenance therapy to prevent relapse

15e Colloque de la Recherche de la Ligue contre le cancer, Nice, 24-25 janvier 2013

Oncogenic Mutations of c-kit in Mastocytosis

1

2

Oncogenic Signal

Adult Mutations 85%

Clonal disease +++

No regression

Pediatric Mutations 75%

Clonal disease +++

Regression Sarcoma

Human

Dogs

Exons 8 to 11 Exon 17 WT

Effect of STI 571on proliferation of cell lines

with juxtamembrane or V814 c-kit mutations

0

20

40

60

80

100

120

0 0.1 1 10

µM

% C

PM

Ba/F3 Kit+IL3

Ba/F3 Kit+SCF

∂27

FMA 3

KIT G559

IC2 V814

P815 (V814)

c-kit Mutations in Mastocytosis

NH2

COOH

c c

c c

c c

c c

F522C

Akin et al. Blood. 103:3222, 2004

•Location: Exon 10 (Transmembrane)

•Type: Germline

•Clinical features:

Childhood onset CM

SSM in early 20s

Well-differentiated phenotype

•Functional studies: Gain-of-function

•Inhibition by imatinib: Yes (in vitro and clinically)

Therapy with imatinib in a patient with transmembrane c-kit

mutation: Proof of concept

0 25 50 75 100 1250

50

100

150

200

Days

Try

pta

se (

ng

/ml) 100 mg/d

200 mg/d

300 mg/d

400 mg/d

Akin, Fumo, Yavuz, Lipsky, Neckers, Metcalfe. Blood, 103:3222, 2004

Signaling of PI-3k/Akt/mTOR •C-KIT

•- •PI •3 kinase

•AKT

•- •m •TOR

•1 •Cyclin D •CDK’s

•G •1 •S

•Cell division

•G •0 •(resting cell)

•+ •P-p70S6k

•Translation/apoptosis

•4EBP/eIF4E

•RAPAMYCINE

•BMMC

•c-kit wt •BMMC

•c-kit 816

•La mutation D816V du c-kit confère à la cellule BMMC la sensibilité à la Rapamycine

•Lignée BMMC •cellules mastocytaires dérivées de moelle osseuse de souris

•transgéniques pour le c-kit humain

Rapamycin and MS

•Stop IFN

•CDA 1

•CDA 2

•Start IFN

•Start Rapamycin

PKC412 (N-benzyl staurosporine)

• Inhibits PKC, VEGFR,

Kit, PDGFR, flt3

• Phase I/II trials in

hematologic and solid

tumors

– Nausea, vomiting,

diarrhea, fatigue

• Inhibits D816V c-kit

•Gotlib et al. Blood, in press, 2005

•BAF3 D816V cells

Baseline Patient and Disease Characteristics.

Gotlib J et al. N Engl J Med 2016;374:2530-2541

Best Overall Response to Midostaurin in the Primary Efficacy Population.

Gotlib J et al. N Engl J Med 2016;374:2530-2541

Overall Survival

•Median duration of follow-upa: 27 months (range: 11-38)

Kaplan-Meier Estimate for Overall Survival Median

ASM Not reached

MCL 22.6 months

•a Time from treatment start to data cut-off.

Deaths, n

12

9

3

•Prospective survey of PKC412 compassionate use for adult patients suffering from AdSM in France. Survival

curves in PKC412 treated and control groups at the last follow-up in April 2015.

Baseline TMSAS

Best TMSAS value

on treatment

Lack of energy Feeling drowsy

Diarrhea

Feeling bloated

Difficulty concentrating

Difficulty sleeping

Cough

Dry mouth

Pain

Weight loss

Worrying

Shortness of breath

Feeling nervous

Sweats Dizziness

Feeling irritable

Feeling sad

Itching Lack of

appetite Nausea

Change in way food tastes

Swelling of

arms/legs

Skin changes

Problems with sex

Vomiting

Numbness in hands/feet

Urinary problems

Don’t look like myself

Difficulty swallowing

Mouth sores

Constipation

Hair loss

Decreased Frequency of MSAS Symptoms

(n = 79)

TITLE: HEMATOPOIETIC STEM CELL TRANSPLANTATION FOR

ADVANCED SYSTEMIC MASTOCYTOSIS

Authors: Celalettin Ustun1, Andreas Reiter2, Bart L Scott3, Ryotaro Nakamura4,

Gandhi Damaj5, Sebestian Kreil2, Ryan Shanley6, William J. Hogan7, Miguel-

Angel Perales8, Tsiporah Shore9, Herrad Baurmann10, Robert Stuart11, Bernd

Gruhn12, Michael Doubek13, Jack W. Hsu14, Eleni Tholouli15, Tanja Gromke16,

Lucy A. Godley17, Livio Pagano18, Andrew Gilman19, Eva Maria Wagner20, Tor

Shwayder21, Martin Bornhäuser22, Esperanza B. Papadopoulos8, Alexandra

Böhm23, Gregory Vercelotti1, Maria Teresa Van Lint24, Christoph Schmid25,

Werner Rabitsch26, Vinod Pullarkat27, Faezeh Legrand28, Ibrahim Yakoub-

agha29, Wael Saber30, John Barrett31, Olivier Hermine32, Hans Hagglund33,

Wolfgang R. Sperr34, Uday Popat35, Edwin P.Alyea36, Steven Devine37, H.

Joachim Deeg3, Daniel Weisdorf1, Cem Akin38, Peter Valent34

ITK for indolent diseases

• New ITK

• Inhibiton of Mast cell activation

• Cytoreductive on Mast cells

• Not cytoreductive on other cells

• Not toxic (short term and long term)

– Genotoxic, carcinogenic

– Cardiotoxic (Abl++, Src, VEGF, Herg chanel, etc)

0,0

0,2

0,4

0,6

0,8

1,0

1,2

1,4

1010,10,050,01

DO

49

0 n

m

AB 1010 (µM)

Inhibition of c-Kit phosphorylation

•Masitinib formula: C28H30N6OS

•Molecular weight:

•AB1010 (mesylate salt): 594.76

•AB1003 (free base): 498.66

•Masitinib® belongs to the ATP binding pocket molecules kinase inhibitor 2-amino-4-aryl-thiazole family

•c-Kit •c-Kit

•Proliferation

•AB1010

•Proliferation

•AB1010

•Anti-c-Kit

•Anti-Phospho Kit Tyr 729

•Anti-Phospho Tyr 4G10

M

e

N

S

N

H

N

H

O

N

N

N

M

e

0,0

0,2

0,4

0,6

0,8

1,0

1,2

1,4

1010,10,050,01

DO

49

0 n

m

AB 1010 (µM)

Inhibition of c-Kit phosphorylation

•Masitinib formula: C28H30N6OS

•Molecular weight:

•AB1010 (mesylate salt): 594.76

•AB1003 (free base): 498.66

•Masivet® belongs to the ATP binding pocket molecules kinase inhibitor 2-amino-4-aryl-thiazole family

•c-Kit •c-Kit

•Proliferation

•AB1010

•Proliferation

•AB1010

•Anti-c-Kit

•Anti-Phospho Kit Tyr 729

•Anti-Phospho Tyr 4G10

M

e

N

S

N

H

N

H

O

N

N

N

M

e

•Masitinib

•Masitinib selectivity

•Data from Ambit analysis

•(http://www.kinomescan.com/TREEspot/TREEspot.aspx)

•Data from AB Science)

•122

Masitinib demonstrated efficacy in improving handicaps associated with

mastocytosis

•Trend for a better response in patients started with the

•highest dose of 6 mg/kg/day

0

5

10

Wee

k 0

Wee

k 12

Wee

k 24

Week 0

Week 12

Week 24

0

1,5

3

Wee

k 0

Wee

k 12

Wee

k 24

0

4

8

12

16

Wee

k 0

Wee

k 12

Wee

k 24

0

7

14

Wee

k 0

Wee

k 12

Wee

k 24

patients with pruritus score ≥6 (n=14)

patients with at least 1 flush/day (n=16)

patients with Hamilton score ≥10 (n=13)

patients with pollakiuria: miction ≥8/Jour (n=7)

•-49,9%

•-63,7%

•-50%

•-36,9%

•Mictions/day

•Depressive

•status

•Pruritus Score

•Flushes/day

•PP population

Effects of Masitinib on psychiatric

symptoms

ASL MRI outcome

•Before Masitinib therapy •Six months after Masitinib therapy

•Le masitinib a démontré une activité dans deux études de phase 2 dans les deux variantes génétiques de la maladie, avec ou sans mutation D816.

Prurit Flush Dépression Asthénie

AB04010 sans

D816V

AB06013

avec D816V

AB04010

sans D816V

AB06013

avec D816V

AB04010

sans D816V

AB06013

avec D816V

AB06013

avec D816V

% de variation entre le niveau de référence et la semaine 12 (LOCF)

N 19 21 17 6 3 9 13

Moyenne ± SD

-33.5 ± 43 -45.0 ± 52 -70.1 ± 50 -60.3 ±50 -40.6 ± 48 -44.2 ± 33 -38.1 ±28

P-value 0.016 0.002 0.002 0.047 NS 0.002

Caractéristiques des patients

Masitinib Placebo p-value

Odd ratio (CI95%)

Critère principal

4H75% Le taux de réponse cumulée à 75% sur les handicaps de prurit, ou de bouffée de chaleur, ou de dépression ou d’asthénie

mITT/MDF

mITT/OC

18.7%

24.1%

7.4%

7.9%

0.0076*

0.0014*

3.63

4.90

•* Avec 10,000 re-randomisation en population mITT ; Résultats calculés selon la méthode MDF (Missing Data Equal Failure). Ainsi, si une donnée est manquante en raison de l’absence du patient lors d’une visite protocolaire, la réponse est considérée négative. ; OC: Cas observés

Critères secondaires

3H75% Le taux de réponse cumulée à 75% sur les handicaps de prurit, ou de bouffée de chaleur, ou de dépression

mITT/MDF 24.7% 9.8% 0.0071 3.06

2H75% Le taux de réponse cumulée à 75% sur les handicaps de prurit, ou de bouffée de chaleur

mITT/MDF 27.2% 10.7% 0.038 2.63

Prurit 75% Le taux de réponse cumulée à 75% sur les handicaps de prurit

mITT/MDF 22.0% 7.3% 0.0322 3.13

Analyses supportives

Flush75% Le taux de réponse cumulée à 75% sur les handicaps de bouffée de chaleur

mITT/MDF 39.9% 19.0% NS 3.03

Dépression (Hamilton 75%) Le taux de réponse cumulée à 75% sur les handicaps de dépression

mITT/MDF 18.6% 7.6% NS 2.71

Asthénie (FIS 75%) Le taux de réponse cumulée à 75% sur les handicaps d’asthénie

mITT/MDF 7.7% 3.2%

•Les analyses sur la réponse par patient ont confirmé le bénéfice pour les patients.

•AB06006 –Analyses supportives – Période W8-W24

Analyses supportives

Patient ayant 2 handicaps lors de leur entrée dans l’étude Nombre de patients ayant une réponse (75 %) pour au moins 2 handicap(s) au cours de la période globale

mITT/MDF 21.0% 0% NA

Patient ayant 3 handicaps lors de leur entrée dans l’étude Nombre de patients ayant une réponse (75 %) pour au moins 3 handicap(s) au cours de la période globale

mITT/MDF 12.5% 0% NA

Patient ayant 4 handicaps lors de leur entrée dans l’étude Nombre de patients ayant une réponse (75 %) pour au moins 4 handicap(s) au cours de la période globale

mITT/MDF 16.7% 0% NA

Masitinib Placebo p-value Odd ratio

(CI95%)

Analyses supportives

RÉPONSE PAR PATIENT à 75% Nombre de patients ayant une réponse (75%) pour au moins 1 handicap au cours de la période globale

mITT/MDF 26.7% 12.8% 0.0193 2.48

mITT / OC 34.1% 13% 0.005 4.90

•mITT population : population en intention de traiter modifiée •Ces résultats sont calculés selon la méthode Missing Data Equal Failure (MDF). Ainsi, si une donnée est manquante en raison de l’absence du patient lors d’une visite protocolaire, la réponse est considérée négative.

•OC: Cas observés – NA : Non applicable

•Le pourcentage de patients répondeurs à 50% est supérieur à 60% sur prurit, flush, et dépression.

•AB06006 - Analyse supportive – Taux de réponse par patient et par handicap

Alnalyse Handicape Niveau de réponse

Taux de réponse sous Masitinib

Au moins une réponse sur le

handicap

Prurit 75% 46%

50% 60%

Flush 75% 69%

50% 75%

Dépression (Hamilton) 75% 30%

50% 65%

Asthénie (FIS)

75% 14%

50% 27%

•Non GEE model. Analysis per patient

Masitinib Placebo p-value Odds

ratio(CI95%)

Analyses à long terme

4H75% Le taux de réponse cumulée à 75% sur les handicaps de prurit, ou de bouffée de chaleur, ou de dépression ou d’asthénie

mITT/MDF 17.2% 7.1% 0.0102 3.37

mITT/OC 27.1% 10.2% 0.0031 3.66

3H75% Le taux de réponse cumulée à 75% sur les handicaps de prurit, ou de bouffée de chaleur, ou de dépression

mITT/MDF 22.1% 8.6% 0.0030 3.10

mITT/OC 35.1% 12.1% 0.0003 3.87

•Le bénéfice observé au cours des six premiers mois de traitement était maintenu à 2 ans.

•AB06006 – Analyses à long terme sur le critère principal et les critères secondaires

•Période W8-W96

•mITT population : population en intention de traiter modifiée •Ces résultats sont calculés selon la méthode Missing Data Equal Failure (MDF). Ainsi, si une donnée est manquante en raison de l’absence du patient lors d’une visite protocolaire, la réponse est considérée négative.

•OC: Cas observés

Masitinib Placebo p-value

Tryptase - Patients ayant un niveau de tryptase ≥20 µg/L au moment de

leur entrée dans l’étude 46 44

0.0001 Variation relative moyenne par rapport à la valeur de référence

Moyenne±SD -18.0 ± 21.4 2.2 ± 26.9

Urticaire Pigmentaire (UP) - Patients ayant de l’urticaire pigmentaire

au moment de leur entrée dans l’étude 33 36

0.0210 Variation relative de surface corporelle couverte d’urticaire pigmentaire

(Correction de Wallace par rapport à la valeur de référence) -12.34 ± 26.41 15.91 ± 59.79

Signe de Darier – Nombre de patients (au moment de leur entrée dans

l’étude) 37 37

0.0187 Taux de disparition du Signe de Darier (oui/non) chez les patients ayant

le Signe de Darier lors de leur entrée dans l’étude 18.92% 2.70%

•Le masitinib a démontré une activité sur les marqueurs objectifs de l'activation et de l’excès des mastocytes

•AB06006 – Analyses d'efficacité basées sur des critères d’évaluation objectifs

•Période W8-W96

•Chez les patients ayant la mutation D816V, le masitinib a été capable de réduire la surface couverte d’urticaire pigmentaire après un traitement à long terme.

•AB06013 – Effets sur la peau chez un patient de sexe masculin avant (2007) et après (2008, 2014) traitement avec le masitinib

•.

•09-2007 VELA •03-2008 VELA

•(+ 6 mois)

•04-2014 VELA

•(+ 6.5 ans)

•Dr Stéphane BARETE – Service de dermatologie Hôpital Tenon

Masitinib

(pm=1321)

Placebo

(pm=1031) Delta

Au moins un événement indésirable

(indépendamment de la causalité) 5.3 6.1 -0.8

Décès 0.0 0.1 -0.1

Effet indésirable sérieux non mortel (SAEs) 2.1 1.8 0.3

Effet indésirable sévère (CTCAE grade 3/4) 3.2 2.9 0.3

Effet indésirable entraînant le retrait du patient (non mortel) 1.5 0.4 1.1

Effet indésirable conduisant à une réduction de dose 1.4 0.1 1.3

•. Pm = patient-mois. Incidence: Le numérateur est le nombre de patients avec au moins un événement indésirable, le dénominateur est la somme de la durée d'exposition (en mois). Le taux est calculé pour 100 patients-mois. Delta = masitinib moins placebo

•L'incidence des événements indésirables sur la période globale de l’étude était comparable entre les bras de traitement masitinib et placebo, sans effets toxiques mortels

•AB06006 – Incidence (pour 100 patients-mois) des événements indésirables

•Période globale de l’étude

L'incidence des effets indésirables était une mesure plus pertinente que la fréquence des effets indésirables, dans la mesure où certains patients ont reçu du masitinib pendant plus de 2 ans

La durée moyenne du traitement était de 18,9 mois pour le masitinib et de 16,4 mois pour le placebo

•La mastocytose systémique indolente est une maladie sévère et invalidante qui représente un fort besoin médical non satisfait.

•Mastocytose

•Mastocytose indolente

•(cutanée ou systémique)

•Mastocytose Agressive

•Pas de symptôme ou

•symptômes sans handicap •Symptômes avec handicap

•Médicaments cytoréducteurs

•Interferon

•Cladribine

•Temsirolimus+ Arac

•Anticorps

•PKC412

•Allogreffe

•Traitement symptomatique ou non

•Traitement symptomatique

•Anti H1, 2, Cromolyn, etc

•Pas de handicap •Handicap

•Pas d’autre traitement

•IFN, 2CDA,

•Masitinib ?

Masitinib does not inhibit c-kit D816 V ??

•Bien qu'il ne bloque pas la mutation D816V, le masitinib semble capable d'inhiber la dégranulation lors d’une hyperactivation des mastocytes. •

•Le masitinib inhibe l'hyperactivation des mastocytes FcƐR-dépendent

•The RBL-2H3 rat mast cell leukemia cell line is heterozygous for KIT, carrying both wild-type (WT) and exon 17 mutation alleles D817V . These cells have constitutive activation of KIT and are capable of degranulation upon FcɛRI-stimulation by ovalbumin (OVA). OVA administration induces β-hexosaminidase release (an established biomarker of mast cell degranulation) from these constitutive activated mast cells, whereas no degranulation is induced by stem cell factor (SCF, the ligand for c-Kit) activation.

HYPOTHESIS

•MCAS

•MSI

•Families of MCAS and Mastocytosis

C-Kit D816V mutation is not the only mutation that explains different phenotypes of the disease

One or many mutations, probably germ line mutations, are responsible of mast cell activation symptoms and MCAS

Could this mutation play a role in other inflammatory diseases?

- Absence of correlation between : pathologic mast cell burden and intensity of mast cell activation symtoms in the same patient

- Use of Masitinib (tyrosine kinase inhibitor): relieves mast cell activation symptoms (non efficient when D816V is mutated)

•Crit Rev Oncol Hematol. 2015 Feb;93(2):75-89. doi: 10.1016/j.critrevonc.2014.09.001. Epub 2014 Sep 28.

•The genetic basis of mast cell activation disease - looking through a glass darkly. Molderings GJ.

http://www.ncbi.nlm.nih.gov/pubmed/?term=Molderings GJ[Author]&cauthor=true&cauthor_uid=25305106http://www.ncbi.nlm.nih.gov/pubmed/?term=Molderings GJ[Author]&cauthor=true&cauthor_uid=25305106

• Mastocytose et maladies inflammatoire mastocytoses familiales

• Mastocytose et maladies inflammatoires mastocytoses familiales

•159

Comparaison

des 2 populations

nb % forme familiale nb % forme familiale prévalence

Polyarthrite rhumatoïde 600 000 1,00% 6% 100 1,38% 19% 3,00E-04

Spondylarthrites Ankylosantes 200 000 0,32% 10% 34 0,47% 17% 2,00E-02

Sclérose en plaques 60 000 0,10% 6% 44 0,61% 20% 2,00E-44

Maladie de Crohn 70 000 0,11% 25% 35 0,48% 17% 6,00E-21

Atteints de Mastoçytose (7247 inds)population Française

Spectrum of MCAS

•Mastocytosis

•Other diseases

•RA, psoriasis,

•MS,IBD,PS,ICys

•Depression

•Idiopathic

•Mast cell activation

Spectrum of MCAS

•Mastocytosis

•Other diseases

•RA, psoriasis,

•MS,IBD,PS,ICys

•Depression

•Idiopathic

•Mast cell activation

•C-kit+ X • X

•X =kinase inhibited by Masitinib

Spectrum of MCAS

•Mastocytosis

•C-kit*

•PLCgamma2*?

•Other?

•PLCgamma2*?

•other

•Other diseases

•RA, psoriasis,

•MS,IBD,PS,ICys

•Depression

•Idiopathic

•Mast cell activation

•PLCgamma2*?

•other

Other =Inhibited by Masitinib

Cancer Allergy

Autoimmunité

Alloreactivity

Acute

chronic

Mastocytosis

Inflammation

fibrosis Neurological

And

Psychiatric

Diseases

Preliminary evidence suggests that masitinib may be able to reverse hypoperfusion in mastocytosis patients, with a concomitant improvement in cognitive functions.

•Functional disorders

associated with mastocytosis do

not appear in conventional MRI

but appear on MRI measuring cerebral blood

flow.

•Could this also be the case in Alzheimer's

disease?

•Representative images from mastocytosis patient comparing ASL-MRI •before masitinib treatment (A) and after 6 month treatment (B)

•A •B

•PRECLINICAL DATA – ASL-MRI OBSERVATIONS

•BRAIN BLOOD PERFUSION: SIMILARITY MASTOCYTOSIS AND ALZHEIMER’S DISEASE

•Representative images from a control patient (Fig. A&B), an AD patient (Fig. C), and a mastocytosis patient (Fig. D), illustrating

the impaired cognitive functions.

•[Figs. A&C] Alzheimers Dement. 2012 Jan; 8(1): 51–59. [Figs. B&D] Pr Bodaert Pr O. Hermine. Hôpital Necker-Paris.

•C

•Patients

•Alz

heim

er

•D

•Mas

tocy

tosi

s

•B

•Heal

thy

volu

nteer

•A

•Control

•Heal

thy

volu

nteer

• Measurement of cerebral blood flow using arterial spin

labeling MRI reveals similar

hypoperfusion patterns between

mastocytosis patients with

impaired cognitive functions (memory and/or attention) and AD patients

167

PUTATIVE MECHANISM OF ACTION OF MASITINIB IN ALZHEIMER’S DISEASE

has been hypothesized that phosphorylated tau could trigger a

neurodegenerative cascade that may require the expression of

cell cycle markers in neurons prior to the apoptotic process [72].

Moreover, Fyn overexpression was found to accelerate synapse

loss and the onset of cognitive impairment in the J9 (APPswe/

Ind) transgenic AD mouse model, while blocking the Fyn

expression rescued synapse loss in the J20 (APPswe/Ind)

mice [73]. While tau is generally considered an axonal protein,

it does have a role in dendrites as well. It has been demon-

strated that tau participates in postsynaptic targeting of Fyn to

dendrites [74,75]. In dendrites, Fyn is capable of interacting with

NMDARs, thus regulating receptor activity [75,76]. Fyn kinase

could potentiate the neurotoxic process through the phosphory-

lation of the subunit 2 (NR2B) of the NMDAR in dendritic

spines, which results in stabilization of the receptor’s interaction

with the postsynaptic density protein PSD-95. The exact mech-

anism of b-amyloid–Fyn–NMDAR interaction likely involves

the formation of the complex between b-amyloid, the prion

protein (PrP) and the metabotropic glutamate receptor

5 (mGluR5) which can promote Fyn activation, ultimately

leading to the phosphorylation of the NR2B [74,77–79]. As men-

tioned above, tau plays a key role by delivering Fyn

postsynaptically.

Interestingly, saracatinib (AZD0530) is another Src inhibitor

which targets Fyn. Although at the beginning this drug was

developed for cancer treatment, it was abandoned for this

application. Currently, two clinical trials are testing the efficacy

of saracatinib in early-stage AD ([80] and [81]).

In conclusion, treatment with masitinib may provide dual

benefits in AD pathology. On the one hand, inhibition of the

MCs may reduce neuroinflammation via MCs–glia axis

modulation. On the other hand, cognitive

improvementsasaresult of Fyn inhibition

are likely independent of b-amyloid pro-

duction and amyloid plaqueload (FIGURE 2).

Safety & tolerability

Based on a number of clinical trials

which considered masitinib for a range of

conditions including AD, the drug

appears to be well tolerated in humans.

The majority of the reported AEs are

consistent with other TKIs already on the

market. Edema, rash, nausea, vomiting

and diarrhea are commonly reported.

However, these AEs are generally tran-

sient and are well within the acceptable

thresholds for this type of symptomatic

treatment. For an in-depth overview of

the safety data reported in clinical trials,

refer to Table 4 of [9] and Table 3 of [47].

Conclusion

The failure of AD treatments developed

over the last few decades demonstrates the

complexity of the underlying pathology. Masitinib may not be

an all-encompassing cure-all for the disease, but depending on

the results of ongoing and future clinical trials, it may have a

chance to becomean additional disease-modifying compound in

the arsenal of physicians aiming to treat this debilitating

condition.

Expert commentary

Over the years, a number of hypotheses have been proposed to

explain the etiology of AD. These include: the amyloid cascade

hypothesis, mitochondrial hypothesis, dendritic hypothesis, cell

cycle hypothesis and the inflammatory hypothesis [4–8,10–12,18].

If one assumes that each of these hypotheses describes an aspect

of the disease, then the complexity of AD pathology becomes

apparent. With the involvement of multiple signaling cascades,

it is quite possible that a single drug could target more than

one pathway. Such is the case of masitinib, a TKI which is

capable of both c-kit and Fyn inhibition.

Increased production of b-amyloid may be a cause of early-

onset familial AD. As a result of genetic mutations affecting

APP processing, excessive accumulation of b-amyloid in the

brain leads to senile plaque formation. Since amyloid plaques

are clearly not a component of a healthy brain, immune system

response is eventually activated. Indeed, previous studies have

shown the existence of an inflammatory process around the

plaques, which presumably favors the loss of neighboring neu-

rons [82–87]. Activated microglia would then be responsible for

the generalized cerebral inflammation. If that was the principal

driving force behind AD-related neurodegeneration, then the

NSAID treatment would be expected to be of great benefit to

AD sufferers. This is not entirely the case, however, as only

Inhibition of neuroinflammator y

process Glial cells

Modulation of NMDA

receptor

Inhibition of

tau phosphorilation

Inhibition of FYN kinase

Memory process improvement

Prevention of cell cycle re-entry

Mast cellsMasitinib

Neuron

Figure 2. A proposed mechanism w hereby masit inib could exert neuroprotect ive

effects in Alzheimer’s disease. Fyn signaling in the hippocampus is, at least partially,

regulating cell cycle re-entry, neuronal memory process, tau phosphorylation and also

NMDA receptor. In addition, masitinib inhibits c-kit receptor in mast cells and, thus, the

neuroinflammatory process.

NMDA: N-methyl-D-aspartate.

Drug Prof ile Folch, Petrov, Ettecho et a l.

doi: 10.1586/14737175.2015.1045419 Expert Rev. Neurother.

Exp

ert

Rev

iew

of

Neu

roth

erap

euti

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om i

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B-Amyloid Substance

CD47

Masit inib for the treatment

of mild to moderate

Alzheimer’s diseaseExpert Rev. Neurother. Early online, 1–10 (2015)

Jaume Folch1,

Dmitry Petrov2,

Miren Ettecho2,

Ignacio Pedros1,

Sonia Abad2,

Carlos Beas-Zarate3,4,

Alberto Lazarowski5,

Miguel Marin6,

Jordi Olloquequi7,

Carme Auladell8 and

Antoni Camins* 2,6

1Unitat de Bioquimica i Biotecnologı́a,

Facultat de Medicina i Ciències de la

Salut, Universitat Rovira i Virgili, Reus,

Tarragona, Spain2Unitat de Farmacologia I Farmacognòsia,

Facultat de Farmàcia, Institut de

Biomedicina (IBUB), Centrosde

Investigacion Biomedica en Red de

EnfermedadesNeurodegenerativas

(CIBERNED), Universitat de Barcelona,

Barcelona, Spain3Departamento de Biologı́a Celular

y Molecular, C.U.C.B.A., Universidad

de Guadalajara and Division de

Neurociencias, Sierra Mojada 800, Col.

Independencia, Guadalajara, Jalisco

44340, Mexico4Centro de Investigacion Biomedica de

Occidente (CIBO), Instituto Mexicano del

Seguro Social (IMSS), Jalisco 44340,

Mexico5Instituto de Investigacionesen

Fisiopatologı́a y Bioquı́micaClı́nica

(INFIBIOC), Facultad de Farmacia y

Bioquı́mica, Universidad de Buenos

Aires (UBA), BuenosAires, Argentina6Centro de Biotecnologı́a, Universidad

Nacional de Loja, Av. Pı́o Jaramillo

Alvarado y Reinaldo Espinosa, La

Argelia, Loja, Ecuador7Facultad de Cienciasde la Salud,

Universidad Autonoma de Chile, Talca,

Chile8Departament de Biologia Cellular,

Facultat de Biologia, Universitat de

Barcelona, Barcelona, Spain

* Author for correspondence:

camins@ub.edu

Alzheimer’s disease (AD) is a degenerative neurological disorder that is the most common

cause of dementia and disability in older patients. Available treatments are symptomatic in

nature and are only sufficient to improve the quality of life of AD patients temporarily.

A potential strategy, currently under investigation, is to target cell-signaling pathways

associated with neurodegeneration, in order to decrease neuroinflammation, excitotoxicity,

and to improve cognitive functions. Current review centers on the role of neuroinflammation

and the specific contribution of mast cells to AD pathophysiology. The authors look at

masitinib therapy and the evidence presented through preclinical and clinical trials. Dual

actions of masitinib as an inhibitor of mast cell–glia axis and a Fyn kinase blocker are

discussed in the context of AD pathology. Masitinib is in Phase III clinical trials for the

treatment of malignant melanoma, mastocytosis, multiple myeloma, gastrointestinal cancer

and pancreatic cancer. It is also in Phase II/III clinical trials for the treatment of multiple

sclerosis, rheumatoid arthritis and AD. Additional research is warranted to better investigate

the potential effects of masitinib in combination with other drugs employed in AD treatment.

KEYWORDS: Alzheimer . inflammation . masitinib . neurodegeneration . tau

Alzheimer’s disease (AD) was first described

over a century ago by the physician Alois

Alzheimer, but still, more than 100 years later,

the root cause of the disorder is not

completely understood [1]. Currently available

pharmaceutical interventions are inadequate

and provide only slight improvement in dis-

ease symptoms [2,3]. Recently, researchers have

made a number of breakthroughs in uncover-

ing the molecular mechanisms involved in dis-

ease pathogenesis [4,5]. This work has led to

the identification of novel molecular targets

and drug candidates, some of which are

already on the market, with others in various

stages of preclinical and clinical development.

As the loss of cholinergic neurons in the

frontal cortex and the hippocampus is a prom-

inent histopathological feature of AD and

other dementias, initial drug development

efforts have focused on restoring central cho-

linergic transmission [3]. Acetylcholinesterase

inhibitors (AchEIs), which include donepezil,

rivastigmine and galantamine, are indicated for

the treatment of patients with mild to moder-

ately severe Alzheimer’s dementia [2,3]. These

compounds increase cholinergic transmission

by inhibiting acetylcholinesterase at the synap-

tic cleft. Unfortunately, the therapeutic efficacy

of AchEIs is limited and the available drugs in

this class do not halt disease progression [2,3,6].

Cognitive decline in AD patients has also

been linked to neuronal damage as a result of

excitotoxicity caused by the persistent overacti-

vation of N-methyl-D-aspartate receptor

(NMDAR) by the amino acid glutamate [7,8].

Memantine is an NMDAR antagonist admin-

istered for the treatment of moderate to severe

AD, which reduces glutamatergic excitotoxic-

ity [3,9]. However, just as with AchEIs, the

beneficial effects of memantine are modest,

and the treatment is largely palliative.

Another key aspect of AD pathology which

hasbeen thesubject of intensiveresearch interest

(with vast financial resources invested) concerns

elucidating the exact role b-amyloid peptide

plays in disease progression. It is well known

that AD is neuropathologically characterized by

senile(amyloid) plaques, consistingof extracellu-

lar deposits of b-amyloid protein, and by the

intraneuronal neurofibrillary tangles, comprising

informahealthcare.com 10.1586/14737175.2015.1045419 Ó 2015 Informa UK Ltd ISSN 1473-7175 1

Drug Prof ile

Exp

ert

Rev

iew

of

Neu

roth

erap

euti

cs D

ownl

oade

d fr

om i

nfor

mah

ealt

hcar

e.co

m b

y 16

1.11

6.33

.27

on 0

5/11

/15

For

per

sona

l us

e on

ly.

Masit inib for the treatment

of mild to moderate

Alzheimer’s diseaseExpert Rev. Neurother. Early online, 1–10 (2015)

Jaume Folch1,

Dmitry Petrov2,

Miren Ettecho2,

Ignacio Pedros1,

Sonia Abad2,

Carlos Beas-Zarate3,4,

Alberto Lazarowski5,

Miguel Marin6,

Jordi Olloquequi7,

Carme Auladell8 and

Antoni Camins* 2,6

1Unitat de Bioquimica i Biotecnologı́a,

Facultat de Medicina i Ciències de la

Salut, Universitat Rovira i Virgili, Reus,

Tarragona, Spain2Unitat de Farmacologia I Farmacognòsia,

Facultat de Farmàcia, Institut de

Biomedicina (IBUB), Centrosde

Investigacion Biomedica en Red de

EnfermedadesNeurodegenerativas

(CIBERNED), Universitat de Barcelona,

Barcelona, Spain3Departamento de Biologı́a Celular

y Molecular, C.U.C.B.A., Universidad

de Guadalajara and Division de

Neurociencias, Sierra Mojada 800, Col.

Independencia, Guadalajara, Jalisco

44340, Mexico4Centro de Investigacion Biomedica de

Occidente (CIBO), Instituto Mexicano del

Seguro Social (IMSS), Jalisco 44340,

Mexico5Instituto de Investigaciones en

Fisiopatologı́a y Bioquı́micaClı́nica

(INFIBIOC), Facultad de Farmacia y

Bioquı́mica, Universidad de Buenos

Aires (UBA), BuenosAires, Argentina6Centro de Biotecnologı́a, Universidad

Nacional de Loja, Av. Pı́o Jaramillo

Alvarado y Reinaldo Espinosa, La

Argelia, Loja, Ecuador7Facultad de Cienciasde la Salud,

Universidad Autonoma de Chile, Talca,

Chile8Departament de Biologia Cellular,

Facultat de Biologia, Universitat de

Barcelona, Barcelona, Spain

* Author for correspondence:

camins@ub.edu

Alzheimer’s disease (AD) is a degenerative neurological disorder that is the most common

cause of dementia and disability in older patients. Available treatments are symptomatic in

nature and are only sufficient to improve the quality of life of AD patients temporarily.

A potential strategy, currently under investigation, is to target cell-signaling pathways

associated with neurodegeneration, in order to decrease neuroinflammation, excitotoxicity,

and to improve cognitive functions. Current review centers on the role of neuroinflammation

and the specific contribution of mast cells to AD pathophysiology. The authors look at

masitinib therapy and the evidence presented through preclinical and clinical trials. Dual

actions of masitinib as an inhibitor of mast cell–glia axis and a Fyn kinase blocker are

discussed in the context of AD pathology. Masitinib is in Phase III clinical trials for the

treatment of malignant melanoma, mastocytosis, multiple myeloma, gastrointestinal cancer

and pancreatic cancer. It is also in Phase II/III clinical trials for the treatment of multiple

sclerosis, rheumatoid arthritis and AD. Additional research is warranted to better investigate

the potential effects of masitinib in combination with other drugs employed in AD treatment.

KEYWORDS: Alzheimer . inflammation . masitinib . neurodegeneration . tau

Alzheimer’s disease (AD) was first described

over a century ago by the physician Alois

Alzheimer, but still, more than 100 years later,

the root cause of the disorder is not

completely understood [1]. Currently available

pharmaceutical interventions are inadequate

and provide only slight improvement in dis-

ease symptoms [2,3]. Recently, researchers have

made a number of breakthroughs in uncover-

ing the molecular mechanisms involved in dis-

ease pathogenesis [4,5]. This work has led to

the identification of novel molecular targets

and drug candidates, some of which are

already on the market, with others in various

stages of preclinical and clinical development.

As the loss of cholinergic neurons in the

frontal cortex and the hippocampus is a prom-

inent histopathological feature of AD and

other dementias, initial drug development

efforts have focused on restoring central cho-

linergic transmission [3]. Acetylcholinesterase

inhibitors (AchEIs), which include donepezil,

rivastigmine and galantamine, are indicated for

the treatment of patients with mild to moder-

ately severe Alzheimer’s dementia [2,3]. These

compounds increase cholinergic transmission

by inhibiting acetylcholinesterase at the synap-

tic cleft. Unfortunately, the therapeutic efficacy

of AchEIs is limited and the available drugs in

this class do not halt disease progression [2,3,6].

Cognitive decline in AD patients has also

been linked to neuronal damage as a result of

excitotoxicity caused by the persistent overacti-

vation of N-methyl-D-aspartate receptor

(NMDAR) by the amino acid glutamate [7,8].

Memantine is an NMDAR antagonist admin-

istered for the treatment of moderate to severe

AD, which reduces glutamatergic excitotoxic-

ity [3,9]. However, just as with AchEIs, the

beneficial effects of memantine are modest,

and the treatment is largely palliative.

Another key aspect of AD pathology which

hasbeen thesubject of intensiveresearch interest

(with vast financial resources invested) concerns

elucidating the exact role b-amyloid peptide

plays in disease progression. It is well known

that AD is neuropathologically characterized by

senile(amyloid) plaques, consistingof extracellu-

lar deposits of b-amyloid protein, and by the

intraneuronal neurofibrillary tangles, comprising

informahealthcare.com 10.1586/14737175.2015.1045419 Ó 2015 Informa UK Ltd ISSN 1473-7175 1

Drug Prof ile

Exp

ert

Rev

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of

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y 16

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6.33

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168

ANIMAL MODEL (APPXPS1DE9): COGNITIVE EVALUATION IN A CURATIVE SETTING

Masitinib was evaluated for its effect on memory deficit in AD mice (Tg) versus using the Morris Water Maze (MWM) in a curative setting (mice aged 12-14 months)

The MWM test evaluates hippocampal-dependent learning, including acquisition of spatial memory and long-term spatial memory, which is often affected in AD.

Blinded study

During learning End of learning period

Hidden platform (target)

B Delatour et al ICM Paris

Genotype effect observed between wild-type (WT) and APPxPS1dE9 (Tg) mice treated with vehicle (Veh)

1 2 3 4 5

0

5

1 0

1 5

T o ta l d is ta n c e tra v e lle d V e h (T g v s W T 1 -5 D ) (R O M A N E 1 -2 )

d a y s

m

T g V e h (n = 8 )

W T V e h (n = 1 0 )

•Tot

al d

ista

nce (

m)

trav

elled

•by

cont

rol (V

eh)

mic

e

1 2 3 4 5

0

5

1 0

1 5

T o ta l d is ta n c e tra v e lle d M a s it in ib (T g v s W T 1 -5 D ) (R O M A N E 1 -2 )

d a y s

m

T g M a s it in ib (n = 9 )

W T M a s itin ib (n = 9 )

Disappearance of genotype effect on mice treated with masitinib

Masitinib treatment improves cognitive function, with spatial memory returning to normal levels

•Tot

al d

ista

nce (

m)

trav

elled

•by

mas

itin

ib t

reat

ed m

ice

•MWM Acquisition phase

•Preclinical Data – Animal Model • (Cognitive Evaluation in a Curative Setting)

•Percentage use of spatial strategy. ** p

•PRECLINICAL DATA – ANIMAL MODEL (HISTOPATHOLOGY - AMYLOID LOADS)

Masitinib treatment decrease the amyloid charges (Congo red +) in the hippocampus of young APP/PS1dE9 mice

Tg

Veh

(n

=6)

Tg

Masit

inib

(n

=9)

0 .0 0

0 .0 2

0 .0 4

0 .0 6

0 .0 8

A m y lo id lo a d (H ip p o c a m p u s )

***

Alzheimer’s Disease – Previous clinical data •Phase 2 Effect of Masitinib

•Alzheimers Res Ther. 2011 Apr 19;3(2):16. doi: 10.1186/alzrt75.

•Efficacy results in mild-to-moderate Alzheimer's disease

•(Phase 2 ; n=34 patients)

-8

-6

-4

-2

0

2

4

6

8

10

12

Week 0 Week 12

p=0.035

Week 24

p=0.128

Me

an

ch

an

ge

fro

m b

as

eli

ne

±s

tan

da

rd e

rro

r ADAS-ADL Masitinib Placebo

wo

rse

nin

g -

imp

rove

me

nt

•The ADCS-ADL (Alzheimer's Disease Cooperative Study-Activities of Daily Living Inventory) is a subscale of daily living assessing items such as toileting, feeding, dressing, and physical ambulation

Mastocytoses

Syndrome d’activation mastocytaire

Mastocytoses : Prolifération clonale de mastocytes Accumulation (médullaire,

cutanée++) Mutation somatique gène CKIT

Syndrome d’activation mastocytaire : Activation exagérée mastocytes Pas critères de mastocytose Plus fréquent Clinique :

• Asthénie • Flush, prurit • Douleurs ostéo-articulaires • Troubles digestifs • Troubles neuropsychiatriques • Symptômes d’allergie

Traitement : Antihistaminiques Inhibiteurs de Tyrosine Kinase

MALADIES LIEES AU MASTOCYTE

•Laboratoire d’hématologie - NEM

•Vahid Asnafi Ludovic Lhermitte

•Patrick Villarese

•Julie Bruneau

•Sophie Georgin-Lavialle

•Zakia Belaid-Choucair

•Geneviève Courtois

•Marie Bouillié

•Francine Côté

•Pascal Amireault

•Flavia Guillem

•David Sibon

•Yves Lepelletier

•Inserm U891 - Marseille

•Patrice Dubreuil

•Sébastien Letard

•Service de pathologie - NEM

•Nicole Brousse Danielle Canioni

•Sylvie Fraitag Stéphanie Leclerc-Mercier

•Gisèle, Martine, Annie, Stéphanie, Marie-Aimée…

•Service de pathologie - HMN

•Philippe Gaulard Nicolas Ortonne

•Nadine Martin

•Laboratoire de cytogénétique - NEM

•Serge Romana Isabelle Radford-Weiss

•Gwendoline Soler

•Centre de référence des mastocytoses - NEM

•Olivier Hermine Christine Bodemer

•Olivier Lortholary

•Laboratoire Télomères - Institut Curie

•Arturo Londono-Vallejo

•Irena Draskovic

Bonne année 2013!

Sophie, Patrice, Alexandre et Thibault

•Inserm U768 - NEM

•Patrick Revy

•Tangui Le Guen

•Merci

•U8147

•Plateforme d’imagerie cellulaire - Imagine

•Raphaëlle Devaux Nicolas Goudin

•Meriem Garfa-Traore

Mechanism of action of Masitinib ?

Kinase inhibitor in Mastocytosis with C-kit D816V

Melanocytes

Normal Mastocytes

Mutated Mastocytes

SCF

SCF

SCF

Urticaria pigmentosa

Symptoms

+

Tumoral Syndrome

C Findings

D816V C-Kit* WT C-Kit

WT C-Kit

ITK

•Famillial MCAS and Mastocytosis

Rapamycin and MS

•Stop IFN

•CDA 1

•CDA 2

•Start IFN

•Start Rapamycin

•Histamine, cytokines, protéases (tryptase), prostaglandines, ROS

•Variations pression

température

•Peptides, hormones

•IgE

•SCF

•c-Kit

•HOMEOSTASIE

•Mastocyte

•FcεRI

•REPONSE

•IMMUNITAIRE

•PROLIFERATION

•Système cardiovasculaire

•Vasodilatation hypotension

•Perméabilité Œdème

•Voies aériennes

•Bronchoconstriction

•Toux

•Dyspnée

•Peau

•Prurit

•Flush

•Urticaire

•DEGRANULATION

•LT régulateur

•TLRs

•Pathogènes (Bactéries, virus,

parasites)

•LB

•Cellule dendritique

•Cytokines pro-inflammatoires (TNF-α, IL-6,

IL-8 …)

•OX40L

•OX40

•4-1BBL •HLA/Ag

•FcεRI

•LT effecteur

•OX40 •4-1BB

•TCR

•TCR

•CCL2, 4, 5, 10 CXCL10

•TGFß TNF-α IL-6

•CD40L

•CD40

•Histamine, PGD, PGE TNF-α, IL-

1, IL16, IL-18

•IL-4, IL-6, IL-13

•FcεRI

•IgE/Ag

•HLA/Ag

•HLA/Ag

•BCR

•Migration

•Prolifération

•Activation

•Phénotype TH17

•Migration

•Maturation

•Activation

•Prolifération

•Activation

•Recombinaison isotypique (IgE)

•Frenzel et al, JBS 2013

Anti IgE therapy

Psychiatric symptoms and anti IgE

Treatment

• 18 years old pts, Famillial history of MCAS and Mastocytosis.

MCAS (dermographism, GI tract symptoms, Pain). No skin

lesions, no bone marrow involvement, No C-kit D816V mutation.

Nl tryptase level. History of chronic and acute hallucination

episodes. Refractory to Anti- psychotic drugs. Xolair Treatment :

total disappearance of Hallucinations.

• 45years old pts, ISM, tryptase 45ng/ml. Episodes of flushes

followed by acute aggressivness (Twice in trial because of acute

violence). No efficacy of anti-psychotic drugs. MRI shows

hypersignal in the limbic region of the white matter. Resolution of

episodes on Xollair therapy.

Role of Ustekinumab (Stelara°) anti IL12/IL23

• Young women 21 years. Past history of ISM. Flushes, GI Tract

Pain, Fatigue, depression, memory loss. Joint pain, Lumbar pain.

No clinical and Xray signs of psoriasis or spondylarthritis

• Failure to Mast cell symptomatic treatment

• Disappearance of all symptoms on Stelara treatment

(90mg/3months)

• 35 years old women. Past history of Pain+++, depression, fatigue,

GI tract pain, diarrhea, flushes, dermographism, No UP, no mast

cell infiltration. Ankylositing spondylarthritis (B27 negaive).

Failure of Mast cell mediatior inhibitor, opoid treatmemt,anti-TNF

therapy. Success of Stelara° on joint pain but also on most of the symptoms of MCAS including Psyschiatric

Cytoreductive treatment Aggressive

diseases

• Interferon alpha

• Cladribine

• Kinase inhibitors

• Thalidomide

• Rapamycine

PKC412: Discussion and perspectives

• Longer follow up and comparison with matched patients who did not receive Midostaurin is required to assess its value to improve overall survival

• Is complete response a goal to achieve ?

• Use of Midostaurin in combination (2-CDA, 5-AZA, decitabine, chemotherapy) to improve the response rate and survival particularly in AHNMD, MCL and MCS

• Use of Midostaurin before allogenous bone marrow transplantation

• Midostaurin monitoring to improve safety and response : • Compliance

• Absorption

• Drug interactions

• Organ dysfunction

Dr P Bourget, Head Chief of the Clinical Pharmacy Department of Necker Hospital

• Facing a multi-target drug and the need to treat for life / until progression, what do we know about the potential long term side effects ?

– Induction of secondary neoplasia

– Role in progression of the AHNMD

Perspective mTOR

• Temsirolimus in combination

• High efficiency of temsirolimus + high dose

ARAC in agressive and mast cell leukemia

•Idolent

•Aggressive

Mastocytosis

Indolent Mastocytosis (cutaneous or systemic)

Agressive Mastocytosis

No symptoms or symptoms without handicap

Symptoms with handicap

Symptomatic treatment

No handicap

No further treatment Further treatment: IFN, 2CDA, TKI (Masitinib)

mTOR, other

Handicap

No or symptomatic treatment

Cytoreductive drugs Demethylating

PKC412 Cladribine

Temsirolimus+ Arac Others

BMT

Treatment Strategy

• Define prognosis factors

• Define symptoms

• C-findings : ASM or AHNMD (MDS/MPN) ?

• Which treat first ? Or treat in combination

• PKC412 vs Cladribine vs mTOR inhibtion

• Chemotherapy

• Demethylating agent

MANIFESTATIONS CLINIQUES

SAM

a

40,8

%

n=

53

AEG:

42,3

%

n=55

HSM

G

32,3%

n=42 ostéoporo

se 23,8%

n=31 fracture

38.7%, n=12

HTP/asci

te 13,1%

n=17

Trouble

s

Digestif

s : 30%

n=39

Délai médian diagnostic : 12 mois à partir des premiers

symptômes

Cutan

é

TMEP

ou UP

:

25,4%

n=33

Le gène KIT avait été séquencé chez 53 patients avec 44 mutations retrouvées (83%)

GENETIQU

E

D816V, n=40 75%

OTHER, n=4 8%

Wild Type, n=4 8%

NOT FOUND,

n=5 9%

Parmi les 47 patients de la cohorte française, 32 ont eu une recherche de mutations additionnelles :

MUTATIONS ADDITIONNELLES

0

2

4

6

8

10

12

14

mutationTET2

mutationJAK 2

mutationSRSF2

mutationASLX1

mutationIDH2

mutationCBL

mutationU2AF1

mutatioNRAS

TABLEAU TYPIQUE

Clinique OMS Biologie Génétique

AEG KIT D816V

SAMA AHNMD Anémie +/- TET2

HSMG Thrombopéni

e +/- SRSF2

Troubles

digestifs +/- JAK2

ENFANTS

ADULTE

JEUNE

> 70 ANS

Signes cliniques Cutané Cutané et neuropsy AEG et

troubles dig Stade OMS CM ISM

AHNMD

Biologie N N

Anomalies NFS

Tryptase N 1,5 – 2 N 10

N

Génétique KIT 50% 89%

75%

D816V Evolution Bénigne Bénigne Morbi-

mortalité élevée

•Les sponsors…

•MERCI

Laboratoire d’hématologie

Vahid Asnafi

Ludovic Lhermitte

Patrick Villarese

Unité CNRS 8147

Olivier Hermine

Julie Bruneau

Service de pathologie NEM

Nicole Brousse

Danielle Canioni

Sylvie Fraitag

Laboratoire de cytogénétique

Serge Romana

Isabelle Radford-Weiss

Centre de référence des mastocytoses

Olivier Hermine

Chritine Bodemer

Olivier Lortholary

Stéphane Barète

Olivia Chandesris

Daniella Moura

Inserm UMR 891

Patrice Dubreuil

Sébastien Letard

Pr Jean-Marie Launay

Pr Raphaël Gaillard

Dr Harry Sokkol

Laboratoire Télomères Curie

Arturo Londono-Vallejo

•Aux patients

•Aux médecins qui incluent des patients