Myelodysplasia: Recent Advances James M. Rossetti, D.O. Associate Director, Blood and Marrow Transplantation Program Western Pennsylvania Cancer Institute

Myelodysplastic Syndromes Incidence in U.S. 15-25,000 cases per year Prevalence in U.S. 55,000 cases Types of MDS 2/3 of the cases belong to the lower risk categories

Myelodysplastic Syndromes: Predisposing Factors Unknown in more than 80% of patients Older age (Median age > 60 yrs, 70% > 50 yrs) Secondary MDS Ionizing radiation Chemotherapy Industrial chemicals Hair dyes

Myelodysplastic Syndromes CLINICAL PARADOX OF Variable cytopenias in a hypercellular bone marrow

Myelodysplastic Syndromes: Dysplastic Features

Myelodysplastic Syndromes: Biologic Features Driving the Phenotype Genetic abnormalities Epigenetic DNA modification Accelerated apoptosis Proliferation Stromal dysregulation Medullary angiogenesis

Myelodysplastic Syndromes: Cytogenetic Abnormalities About half of MDS patients present with a genetic abnormality Chromosomal Abnormality Frequency in Primary MDS –5/del(5q) 10%–20% +8 10% –7/del(7q) 5%–10% –Y 10% 17p- 7% del(20q) 5% t(11q23) 5%–6% Complex karyotypes 10%–20% Heaney ML et al. N Engl J Med. 1999;340:1649 Rosenfeld C et al. Leukemia. 2000;14:2

MDS - Therapeutic Challenge Ineffective Hematopoiesis AML Evolution

Evolution of MDS Classification Systems Based on survival and blast number WHO 1997, 2001 Based on survival and blast number FAB IPSS IPSS-BM Path 1976, 1982 2003 1997 ALIPs, CD-34+ Increase risk within IPSS categories Based on time to AML; % blasts, karyotype, # of cytopenias FAB=French American British Classification WHO=World Health Organization IPSS=International Prognostic Scoring Systems 1. Bennett JM, Catovsky D, Daniel MT et al. Proposals for the classification of the acute leukemias, French-American-British (FAB) co-operative group. Br J Haematol. 1976;33:451-458. 2. Bennett JM, Catovsky D, Daniel MT et al. Proposals for the classification of the myelodysplastic syndromes. Br J Haematol. 1982;51:189-199. 3. Harris NL, Jaffe ES, Diebold J et al. World Health Organization classification of neoplastic diseases of the hematopoietic and lymphoid tissues: report of the Clinical Advisory Committee meeting-Airlie House, Virginia, November 1997. J Clin Oncol. 1999;17:3835-3849. 4. Brunnig R, Bennett JM, Flandrin G et al. Myelodysplastic syndromes: introduction. In: Jaffe ES, Harris NJ, Stein H et al, eds. Pathology and Genetics of Tumours of Haematopoietic and Lymphoid Tissues. Lyon, France: IARC Press; 2001:63-73. 5. Greenberg P, Cox C, LeBeau MM et al. International scoring system for evaluating prognosis in myelodysplastic syndromes. Blood. 1997;89:2179-2088. 6. Verburgh E, Achten R, Maes B et al. Additional prognostic value of bone marrow histology in patients subclassified according to the International Prognostic Scoring System for myelodysplastic syndromes. J Clin Oncol. 2003;21:273-282.

Myelodysplastic Syndromes: Survival Based on FAB Classification RA (Refractory anemia) <5% blasts 70 60 RARS (RA with 15% ringed sideroblasts) 50 40 RAEB (RA with excess of blasts) 5%–20% blasts Mean Survival (Months) 35 35 30 18 RAEB-t (RA with excess of blasts in transfor-mation) 21%–30% blasts 20 12 6 10 CMML (Chronic myelo-monocytic leukemia) RA RARS CMML RAEB RAEB-t Low Risk High Risk Bennett JM et al. Br J Haematol. 1982;51:189 Gallagher A et al. Haematologica. 1997;82:191

WHO Revised MDS Classification MDS/MPD CMML-1 (<10% BM blasts) CMML-2 (10-19% blasts) CMML-Eos (AEC>1500/L) JMML MDS RA - RA* - RCMD RSA - RARS - RCMD-RS 5q- Syndrome RAEB-1 (5-9% BM blasts) RAEB-2 (10-19%;Auer rods) MDS-U^ AML The World Health Organization has recommended changes in the IPSS/IWG classification system, to incorporate additional prognostic factors and some cytogenetic elements as well. The major difference between the WHO and the FAB is that single lineage dysphasia's meet the threshold for the diagnosis. The other major change is the elimination of RAEB-t, lowered the threshold for AML down to >20% blasts. WHO also created the new category of myelodysplastic/myeloproliferative, including juvenile myelomonocytic leukemia, the pediatric counterpart of CMML, as well as CMML in adults. Within the latter category, CMML is broken down into three different types: type 1, with <10% blasts in marrow; type 2, with 10-19% blasts, and a third subtype called CMML with eosinophilia (this is the type that is very sensitive to imatinib mesylate Gleevec treatment). The remainder of the WHO classification incorporates more traditional types of MDS. The WHO has broken these down with the goal of adding more prognostic specificity to the categories. 5q- syndrome is now recognized as a separate entity. There is a new category, MDS-unclassified, for those patients with a dysplastic lineage other than erythroid. Because the WHO classification lacks the prognostic detail of the IPSS system, the latter is still used in clinical trials. 20% blasts *Single lineage erythroid dysplasia. ^MDS-U denotes single non-erythroid lineage dysplasia. Harris N, et al. J Clin Oncol 1999;17:3835.

IPSS: International Prognostic Scoring System All 3 prognostic variables required to generate IPSS score Score Value Prognostic Variable 0 0.5 1.0 1.5 2.0 Bone marrow blasts (%) <5 5–10 – 11–20 21–30 Karyotype* Good Intermediate Poor – Number of cytopenias** 0/1 2/3 – – – *Good = normal, -Y, del(5q), del(20q); Intermediate = other karyotypic abnormalities; Poor = complex (3 abnormalities) or chromosome 7 abnormalities **Hb <10 g/dL; ANC <1800/L; platelet count <100,000/L Greenberg PL et al. Blood. 1997;89:2079 Greenberg PL, Cox, C, LeBeau M et al. International scoring system for evaluating prognosis in myelodysplastic syndromes. Blood. 1997;89:2079-2088.

Survival and Evolution to AML by IPSS Parameter Low Int-1 Int-2 High Score 0 0.5–1.0 1.5–2.0 2.5 Median survival, yr 5.7 3.5 1.2 0.4 25% AML evolution, median, yr 9.4 3.3 1.1 0.2 From diagnosis in untreated patients Greenberg PL et al. Blood. 1997;89:2079

Cytogenetic abnormalities found in 24% of RA and 29% of RARS patients FAB versus IPSS Cytogenetic abnormalities found in 24% of RA and 29% of RARS patients List A, Molldrem J, Sanders, J. Prognosis and treatment of myelodysplastic syndromes. Slide show presented at: Annual Meeting of the American Society of Clinical Oncology; June 5, 2004; New Orleans, La. Slide 11.

Outcomes of Allogeneic Stem Cell Transplant in Patients With MDS Only curative therapy is high-dose chemotherapy with allogeneic BMT Up to 50% cure rate Morbidity and mortality increases with age Allogeneic SCT appropriate for fewer than 5% of MDS patients Non-ablative SCT increasingly an option (?)

Transplant at Progression Allogeneic Stem Cell Transplantation for MDS: Approximation of Life Expectancy (Years) Immediate Transplant Transplant in 2 Years Transplant at Progression Low 6.51 6.86 7.21 Int-1 4.61 4.74 5.16 Int-2 4.93 3.21 2.84 High 3.20 2.75 From Cutler C, et al. A Decision Analysis of Allogeneic Bone Marrow Transplantation for Myelodysplastic Syndromes: Delayed Transplantation for Low Risk Myelodysplasia is Associated with Improved Outcome. Blood 2004- 1st Ed Publication. Prepublished online March 23, 2004; D01.1182/Blood-2004-01-0338. Copyright American Society of Hematology, used with Permission.

Allogeneic Stem Cell Transplantation for MDS Cutler, C. S. et al. Blood 2004;104:579-585 Copyright ©2004 American Society of Hematology. Copyright restrictions may apply.

SURVIVAL AFTER MYELOABLATIVE TRANSPLANTS FOR MYELODYSPLASTIC SYNDROMES, 1996-2001, Age > 20 Years 100 20 40 60 80 HLA-identical sibling, RA/RARS (N = 254) PROBABILITY, % Unrelated, RA/RARS (N = 92) Unrelated, RAEB/RAEB-T/CMML (N = 257) HLA-identical sibling, RAEB/RAEB-T/CMML (N = 648) 1 2 3 4 6 5 YEARS

International Working Group Criteria: Hematologic Improvement Erythroid response, if Hgb <11 g/dL Major: Rise by >2; transfusion independence Minor: Rise by 1–2; reduce transfusion dependence by 50% Platelet response, if <100,000/L Major: Rise by >30k; transfusion independence Minor: Rise by 50% (at least 10,000/L) Neutrophil response, if ANC <1500/L Major: Rise by 100% or 500/L Minor: Rise by 100% but <500/L Cheson BD et al. Blood. 2000;96:3671

International Working Group: Response Criteria in MDS CR: duration 2 months BM: <5% blasts; no dysplasia; normal maturation Blood: Hgb >11 g/dL; ANC >1500/L; platelets >100,000/L; no blasts; no dysplasia PR: same as for CR, except blast decrease by >50% or lower FAB Stable disease (SD): no progression for 2 months Progressive disease (PD) Cheson BD et al. Blood. 2000;96:3671

Survival Rates Before (1980s) and After (1990s) the Use of Chemotherapy 1.0 0.8 0.6 0.4 0.2 0.0 50 100 150 200 260 310 360 410 460 520 Weeks Survival Probability Era Total Fail 1980s 162 155 1990s 307 246 With Permission of E Estey, MD

Erythropoietin for MDS EPO response rate 15-20% Best if EPO level < 200-500 U/l Dose 10,000 u/day (or 40,000 u twice a week) Best responses in low grade MDS Hellstrom-Lindberg, 1995

Darbepoetin Alfa for MDS May induce response in EPO non-responders Low EPO level may not be as important (?) Newer studies suggest higher doses more effective

EPO + G-CSF for MDS Higher responses to EPO + G-CSF (reduced caspase induced apoptosis) Synergy as late addition of G-CSF converts non-responders to PR and CR RA, RARS, RAEB – 38% RR Duration 24 months Hellstrom-Lindberg, 1998

Predictive Model British Journal of Hematology, 2003

Bimonthly PRBC Transfusions Epo + G-CSF  Synergy 81 year old female diagnosed with MDS-RARS in 6/94: Hgb (G/DL) Bimonthly PRBC Transfusions Epo Epo + G-CSF

Strategies Directed at the BM Microenvironment Immunomodulatory (ATG, cyclosporine) Anti-TNF Antiangiogenic (VEGF-A) Cytoprotective (amifostine)

Immunosuppressive Therapy for MDS ATG  steroids  cyclosporine: 40 – 70% responses in hypoplastic MDS Responses greatest in younger patients, shorter duration, and HLA DRB1*15 Responses 5 years or more

Thalidomide in MDS Anticytokine Antiangiogenic Immune modulator

Thalidomide Phase II Trial 16/83 (19%) RBC transfusion responders Rare responders in WBC or PLT Intolerant of > 200mg/day 16 weeks to respond (12-20) Response was 29% in patients completing 12 weeks of therapy Raza, 2001

Survival Curve: After Starting Treatment With Thalidomide Response Code 1.2 Responders Responders-alive 1.0 Non-responders .8 Non-responders-alive Cum Survival .6 .4 .2 -200 200 400 600 800 1000 1200 1400 Survival in days Median non-responders = 317 days Median responders = none reached P =< 0.0005

Thalidomide Major Side Effects Sedation Constipation Neuropathy

Revlimid (lenalidomide) Encouraging early response rates in low-grade MDS: 10 –40% CR + PR Largely devoid of thalidomide side effects Like thalidomide, mainly erythroid responses Well tolerated, but thrombocytopenia is dose limiting

5q- Syndrome: A Subset of MDS Isolated chromosome 5q deletion Hematologic features Refractory anemia Mild leukopenia Atypical megakaryocytes, normal to elevated platelets Transfusion dependence Extended survival with low frequency of AML transformation

Revlimid (lenalidomide) 5q- Syndrome Very high response rate 10/12 reversed the cytogenetic abnormality Now more than 70 patients treated – many with excellent responses May see an early aplastic phase during treatment Recently FDA approved for low-risk MDS patients with transfusion dependence and 5q-

Lenalidomide Phase II Experience ADVERSE EVENTS MDS-003 (5q-) MDS-002 (non-5q-) Neutropenia 57.0% 24.0% Thrombocytopenia 58.0% 19.0% Pruritis 32.0% 21.0% Rash 28.0% 22.0% Diarrhea 13.0% Fatigue 12.0% Constipation NR 14.0% PATIENT DEATHS Deaths 15 (10.1%) 20 (9.3%) Suspected drug related by investigator 2 (1.4%) 2 (0.9%) List. ASCO 2005 Plenary Session. Celgene data on file.

TRISENOX® (arsenic trioxide) Mechanisms of Action Differentiation G1 arrest (p21,p27) SMRT corepressor-P Histone acetylation DNA-MT inhibition Apoptosis NF-B inhibition Bcl-2 downregulation Microtubule disruption Caspase activation Angiogenesis VEGF suppresion COX-2 repression Endothelial apoptosis

Study Design Multi-center, open-label, 2-stage Two patient cohorts Lower-risk MDS (IPSS Risk Category Low or Int-1) Higher-risk MDS (IPSS Risk Category Int-2 or High) 4-week cycles ATO given 5 days per week for 2 weeks followed by 2 weeks with no dosing ATO 0.25 mg/kg/dose given as a 1 to 2 hour IV infusion

Disease Response Summary Patients with Response (as defined in the IWG Criteria): Lower Risk Higher Risk Patients Patients Complete Remission 0 1 Hematologic Response 6 3 Stable Disease 11 4 Progressive Disease 0 5 Total (CR + HR) 6 (35%) 4 (31%) List A et al. 7th Intl Symposium on MDS. 2003;Abstract 112179.

Study Design European multicenter, open-label, 2-stage Two patient cohorts Lower-risk MDS (IPSS Risk Category Low or Int-1) Higher-risk MDS (IPSS Risk Category Int-2 or High) 16-week cycles ATO given 5 days for 1 week, followed by 2 doses/week for at least 15 weeks ATO 0.30 mg/kg/dose given as a 1 to 2 hour IV infusion (loading), followed by 0.25 mg/kg/dose twice weekly

Conclusions There were hematologic responses in 9 of 37 (24%) evaluable MDS patients Treatment led to transfusion independence or decreased transfusion requirements in 6 patients Some platelet and WBC responders Twenty-three additional patients (62%) maintained stable disease Responses seen within 8 to 12 weeks of therapy Responses were durable, lasting up to 300+ days (range 90-300+ days)

Myelodysplastic Syndromes: Epigenetic DNA Modifications Epigenetic Gene Silencing DNA hypermethylation - Promoter, global DNA hypermethylation common in MDS Therapeutic Strategy DNA methyltransferase inhibitors (eg, azacitidine, decitabine) promote hypomethylation of DNA, allowing expression of previously silenced genes

Decitabine Phase III Trial: Study Design Open-label, multicenter, 1:1 randomized study in U.S. and Canada Int-1, Int-2 and High Risk MDS patients eligible Primary Endpoints: Response, Time to AML/death R A N D O M I Z E D Decitabine + Supportive Care* 15mg/m2/q8h x 3days q6wks (N=89) Stratification - IPSS - Prior chemo - Type of MDS - Site Eligible Patients (n=170) Supportive Care *ABX, GFs and/or Transfusions (N=81) Saba et al. Proc ASCO. 2005; Poster Presentation.

Decitabine Phase III Trial: Results Decitabine (n=81) Supportive Care (n=81) Overall Response (IWG)* 17% 0% Complete Response 9% Partial Response 8% Hematologic Improvement (IWG) 13% 7% Median Time to Response 89d (55-153) N/A Median Duration of Response 266d (131-346) Median Time to AML/Death** 12.1 months 7.8 months *p<0.01 **p=0.16 Saba et al. Proc ASCO. 2005; Poster Presentation.

Decitabine Phase III Trial: Adverse Events Decitabine (n=83) Supportive Care (n=81) Grade 3 Grade 4 Neutropenia 10% 77% 25% Thrombocytopenia 22% 63% 27% 16% Anemia 11% 1% 14% Febrile neutropenia 17% 6% 4% 0% Pneumonia 13% 2% 7% - Major grade 3/4 adverse event: Febrile neutropenia Saba et al. Proc ASCO. 2005; Poster Presentation.

CALGB 9221 A Randomized Phase III Controlled Trial of Subcutaneous Azacitidine in Myelodysplastic Syndromes M 57 29 113 1) Supportive Care* QOL RA RARS RAEB RAEB-T CMML S t r a i f y R n d o m z e 2) Aza C 75mg/m2/d x 7 days q28 Exit Criteria No Continue until Endpoint Yes Aza C (dose as per arm #2) A E Response Continue Rx No Response - Off Study Day * Minimum duration of supportive care = 4 months unless transform to AML; death or plts ≤ 20 x 109/L at week 8 or later QOL – Quality of Life Assessment M = Bone Marrow Aza C – Azacitidine S.C. Silverman L. The Oncologist 2001. 6 (S5): 8-14. Silverman L, et al. J Clin Oncol 2002. 18:2414-26. Kornblith AB, et al. J Clin Oncol 2002. 18:2427-39

CALGB Trial of Azacitidine vs. Supportive Care Transformation to Treatment Response Time to leukemia or death* AML as 1st event Aza C CR = 7% 21 months 15% (n = 99) PR = 16% Improved = 37% (Overall = 60%) Supportive care CR = 0% 13 months 38% (n = 92) PR = 0% Improved = 5% (Overall = 5%) Quality of life significantly improved with treatment: fatigue (P = 0.001), dyspnea (P = 0.0014), physical functioning (P = 0.0002), positive affect (P = 0.0077), and psychological distress (P = 0.015) *Not IWG Criteria of Response; Cross-over design did not allow proof of survival advantage. Silverman LR et al. J Clin Oncol. 2002;20:2429

Response Rates (CR + PR + Major HI) Using IWG MDS Response Criteria by Study 41 40 36 Percent of Patients 18 7 8421 Azacitidine N=48 9221 Azacitidine N=99 9221 Supportive care only N=41 8921 Azacitidine N=70 9221 Azacitidine after Supportive care N=51 IV SC Silverman et. al. ASH Meeting Dec 9-13, 2005. Abstract 2526 and Poster Presentation.

Time to AML Transformation Remaining Event-Free Probability of 0.0 0.2 0.4 0.6 0.8 1.0 6 12 18 24 30 36 42 48 54 Azacitidine Supportive Care Months + p=0.007 Silverman L, et al. Randomized Controlled Trial of Azacitidine in Patients with MDS: A Study of the CALGB J Clin Oncol 2002. 18:2414-26. Reprinted with permission from the American Society of Clinical Oncology.

Survival: Landmark Analysis 12 24 30 42 54 6 18 36 48 Probability of Survival 0.0 0.2 0.4 0.6 0.8 1.0 Months Azacitidine Supportive Care p=0.1 0.0 0.2 0.4 0.6 0.8 1.0 Probability of Survival Months from 6-month Landmark Induction Azacitidine Crossed before 6 months Did not cross before 6 months 10 20 30 40 50 5 15 25 35 45 p=0.03 Silverman L, et al. Randomized Controlled Trial of Azacitidine in Patients with MDS: A Study of the CALGB J Clin Oncol 2002. 18:2414-26. Reprinted with permission from the American Society of Clinical Oncology.

Hazard ratio (HR)=0.52 (95% CI: 0.32, 0.85) Time to Death or AML Transformation in RAEB and RAEB-T Patients ≥ 65 Years of Age Log-rank P=0.008 Hazard ratio (HR)=0.52 (95% CI: 0.32, 0.85) 48% less risk of death or AML 92% prolongation to death or AML 9.9 month difference (95% CI: 1.5, 15.5)1 Proportion Surviving 24% difference (95% CI: 5%, 43%)2 Supportive care (N=37) Azacitidine (N=31) 24 Time (28 day months) 1 Hodges, Lehmann. Ann Math Statistics. 1963;34:598-611 2 Greenwood M. The Natural Duration of Cancer. 1926. Silverman et. al. ASH Meeting Dec 9-13, 2005. Abstract 2524 and Poster Presentation.

Median Survival: FAB-based Risk Groups Similar findings for Predicted Survival Risk Groups.

Adverse Events Leukopenia: 43% (43 Pts) Neutropenia: 58% Thrombocytopenia: 52% (51 Pts) Erythema at Injection Site: 35% N&V: 4% (6 Pts)* Treatment Related Mortality: <1% (4 Pts- 3 Infections) No Diarrhea*, Elevated Transaminases *Pertains only to adverse events with CALGB 9221. Silverman LR, et. al. J Clin Oncol 2002;20:2429-40. Silverman L. Cancer Medicine. 2000a; Edition 5:1931-46. Silverman L, et. al. Cancer Inves. 1999;17(Suppl):4-5:[5a]. Silverman LR, et. al. Proc Am Soc Clin Oncol 1998;17:53a.

Number of Patients (number of patients per patient-year of exposure) Rates of Bleeding and Infection in Patients Treated with Azacitidine vs. Supportive Care: CALGB 9221 Number of Patients (number of patients per patient-year of exposure) Azacitidine Supportive Care All Patients N=150 N=92 Infections - Total 89 (0.64) 41 (0.95) Bleeding - Total 77 (0.56) 26 (0.60) Patients with RAEB & RAEB-t  65 years N=51 N=37 Infection - Total 31 (0.38) 19 (0.76) 26 (0.32) 11 (0.44) Silverman et. al. ASH Meeting Dec 9-13, 2005. Abstract 2525 and Poster Presentation.

5-aza in MDS-RA Platelet Response 15 Eligible Major Response = 47% aTTR = 3 cycles aRD = 17 cycles+ (2 – 68) aTTR = average time to response aRD = average response duration

5-aza in RARS

5-aza in MDS Response (%)

5-aza in MDS: CMML CMML (MDS) (MPD) N 6 18 CR 33% PR 0% 22% Time to Response 1 2 Response Duration 13+ 7+

Cumulative Probability Times to First Response and from First Response to Best Response Using IWG MDS Response Criteria Cumulative Probability Time (cycles) Silverman et. al. ASH Meeting Dec 9-13, 2005. Abstract 2526 and Poster Presentation.

G-CSF Increases Hematological Response Among Patients with MDS Treated with Azacitidine Retrospective review of 86 MDS patients treated with Azacitidine (avg 10.8 cycles) 49 also received EPO, G-CSF or both, 37 did not 2 groups did not differ in number of cycles of aza received or FAB MDS subtype The addition of G-CSF improved overall hematological response, erythroid and platelet response Rossetti et al. Blood 2006;108(11):A4868.

G-CSF Increases Hematological Response Among Patients with MDS Treated with Azacitidine Treatment Overall Hematological Response P -value Aza Alone 51% (19/37) Aza + EPO 50% (6/12) P=.09 Aza + G-CSF +/- EPO 84% (31/37) Aza without G-CSF 51% (25/49) P=.003 Rossetti et al. Blood 2006;108(11):A4868.

Azacitidine Survival Study Azacitidine Survival Trial Study Design Open label, randomized, parallel-group Patient Population: MDS with RAEB or RAEB-t IPSS score INT-2 or High Status: 358 enrolled (354 planned)- enrollment complete Aug 7, 2006. 112 investigators in 15 countries.

Azacitidine Survival Study Survival Study Design Azacitidine 75 mg/m2 x 7 days Every 28 days Standard of care options consist of: 1. Best supportive care 2. Low-dose Ara-C 3. Standard chemotherapy Patient randomized. BSC included in both arms.

Results Median survival: Aza extends overall survival by 74% 24.4 months for Azacitidine vs 15 months for conventional care regimens (p-value = 0.0001) 9.4 months median survival benefit for patients on azacitidine compared to CCR Aza extends overall survival by 74% HR = 0.58 (95% CI: 0.43-0.77) Two-year survival rate: 50.8% for azacitidine vs 26.2% for CCR (p < 0.0001)

Treatment Algorithm SCT Candidate Yes No Int-2/High Low/Int-1 Int-2/High ? MTIs AlloSCT EPO/G-CSF MTIs Thalidomide MTIs Revlimid (5q-) ? MTIs No Response Clinical Trial (HDAC, FTI)

Evaluable Patients (n = 12) Maintenance Azacitidine Post Allo-SCT in AML & High-Risk MDS: Dose/Schedule Study 5 Unrelated 7 Related Donor HLA Compatibility 8 Refractory disease 4 In remission Disease Status at Time of Transplant Patients with MDS Patients with AML 56 (25-66) years Median Age (Range) Evaluable Patients (n = 12) Soriano et al. Blood 2006;108(11):A3668.

Maintenance Azacitidine post Allo-SCT in AML & High-Risk MDS: Dose/Schedule Study At a median follow-up of 5 months post Allo-SCT, no pts had relapsed No drug-related induction of GVHD was observed All pts were 100% donor chimeras at azacitidine initiation At 8 mg/m2 /day, azacitidine produced detectable hypomethylation Soriano et al. Blood 2006;108(11):A3668.

Response Rates (CR + PR + HI) for WHO AML Patients Using MDS Response Criteria by Study 48 37 32 Percent of Patients 16 8421 Azacitidine N=25 8921 Azacitidine N=28 9221 Azacitidine as Randomized N=27 9221 Azacitidine after Supportive care N=13 9221 Supportive care N=12 IV SC Silverman et. al. ASH Meeting Dec 9-13, 2005. Abstract 1848 and Poster Presentation.

5-aza in AML ( 20% BM blasts) Percent 15 patients, mean age = 68 yrs

Azacitidine in AML: WPCI (WHO Criteria) Mean age = 68 yrs (44-80) CR = 4 (20%) PR = 5 (25%) HI = 3 (15%) ORR = 60%

5-aza in AML (BM blast count 30%) Mean age = 75 yrs (68-79) Avg. survival = 13.5 months CR = 25% PR = 50%

5-aza in AML: Survival Months CR PR SD NR = Taken to HSCT + = Mean Months CR PR SD NR Average survival in responders = 15+ months (All with PS ≤ 1 while being treated)

Azacitidine + Gemtuzumab as Induction and Consolidation in High-Risk MDS and AML 10 of 13 (77%) patients achieved a CR Reductions in BM & peripheral blasts observed in all patients 10 of 13 pts required 2 courses of induction therapy 12 of 13 pts were treated in an outpatient setting 6 of 13 pts required no hospitalization 7 of 13 pts hospitalized (median: 16 days [range: 4-47]) Nand et al. Blood 2006;108(11):A1981

Azacitidine + Gemtuzumab as Induction and Consolidation in High-Risk MDS and AML .1 .2 .3 .4 .5 .6 .7 .8 .9 1.0 Cumulative Survival 2 4 6 8 10 12 14 16 18 Months Nand et al. Blood 2006;108(11):A1981

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