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.