MabThera ® and Autologous Stem Cell Transplant (ASCT)

ASCT: Protocol Debulking/ Mobilization Regimen BM/Stem Cell Harvest and “Purging” High-Dose Chemoradiotherapy Stem Cell Transplant

ASCT for Relapsed NHL Higher response and survival rates than with chemotherapy alone –Aggressive NHL – PARMA Study EFS 45% vs 12% –Indolent NHL – CUP trial: PFS 63% vs 33% (P=0.004) 40%-70% relapse rate after ASCT –Possible explanations  Residual lymphoma in patient  Reintroduction of malignant cells with transplant after ex vivo purging

MabThera ® + HDT/ASCT for Relapsed NHL: Rationale In vivo purging agent Ex vivo purging agent Combination with conditioning therapy Post-transplant adjuvant immunotherapy

In Vivo Purging With MabThera ® : Protocol Buckstein et al. Semin Oncol. 1999;26(5 suppl 14):115; Mangel et al. Blood. 2000;96(suppl 1):383a. Abstract CBVLeukapheresis MabThera  G-CSF * Stem cell transplant Weeks * Days

In Vivo Purging With MabThera ® : Median PB CD34+ Cell Count Day 5Day 4Baseline CD34+ x 10 6 /L No MabThera ® MabThera ® purging Buckstein et al. Semin Oncol. 1999;26:115; Mangel et al. Blood. 2000;96(suppl 1):383a. Abstract 1655.

In Vivo Purging With MabThera ® : Response Clinical100 CR38 CRu 63 Molecular* (6 mo post-transplant)100 % of Patients (N=16) * Among the 7 patients who presented with the bcl-2 rearrangement. Response Buckstein et al. Semin Oncol. 1999;26:115. Mangel et al. Blood. 2000;96(suppl 1):383a. Abstract 1655.

In Vivo Purging With MabThera ® : Toxicity Lung toxicity 63 Interstitial pneumonitis38 Symptomatic hypoxia (hospitalization required) 13 No significant difference in times to neutrophil engraftment or platelet independence between MabThera ® and control groups % of Patients (N=16) Buckstein et al. Semin Oncol. 1999;26:115; Mangel et al. Blood. 2000;96(suppl 1):383a. Abstract 1655.

MabThera ® In Vivo Purging and Maintenance after HDT/ASCT in Relapsed Follicular Lymphoma: Protocol Buckstein et al. Blood. 2002;100:647a. Abstract * 3 MU/m 2 t.i.w.; † 375 mg/m 2 Study 1 No purgeHDT IFN maintenance* for 2 years Study 2 HDT MabThera ® maintenance † weekly x 4 at 2 and 6 months Study 3 HDT IFN maintenance* for 2 years + MabThera ® maintenance † weekly x 6 at 3 months MabThera ® in vivo purge †

MabThera ® In Vivo Purging and Maintenance after HDT/ASCT in Relapsed Follicular Lymphoma: Patient Characteristics Buckstein et al. Blood. 2002;100:647a. Abstract 2547.

MabThera ® In Vivo Purging and Maintenance after HDT/ASCT in Relapsed Follicular Lymphoma: Results Buckstein et al. Blood. 2002;100:647a. Abstract * Only 10 evaluable patients

MabThera ® In Vivo Purging and Maintenance after HDT/ASCT in Relapsed Follicular Lymphoma: Molecular and Clinical Responses 10/12 MabThera ® patients had durable molecular remissions at last follow-up (18-34 months) Clinical relapse in 6/10 patients was preceded by detection of MRD Median RFS has not been reached for the MabThera ® and MabThera ® -IFN cohorts compared with 3.3 years for IFN Buckstein et al. Blood. 2002;100:647a. Abstract 2547.

MabThera ® In Vivo Purging and Maintenance after HDT/ASCT in Relapsed Follicular Lymphoma: Event-free Survival Buckstein et al. Blood. 2002;100:647a. Abstract Patients Event-free (%) Months Interferon MabThera ® / Interferon MabThera ® P=0.12

MabThera ® In Vivo Purging and Maintenance after HDT/ASCT in Relapsed Follicular Lymphoma: Summary HDT/ASCT with MabThera ® in vivo purge and maintenance –Produces high rates of complete clinical remission of up to 90% –Reduces stem cell graft contamination –Achieves PCR-negativity in virtually all patients by 9 months post-ASCT Buckstein et al. Blood. 2002;100:647a. Abstract 2547.

High-dose MabThera ® In Vivo Purge + HDT/ASCT in Relapsed B-Cell Lymphoma: Protocol Khouri et al. Blood. 2002;100:645a. Abstract Schema 1 (n=27) MabThera ® 375 mg/m 2 Cyclophosphamide 4-7 g/m 2 Day MabThera ® 1,000 mg/m 2 Day MabThera ® 375 mg/m 2 MabThera ® 1,000 mg/m 2 Ifosfamide 3.33 g/m 2 Etoposide 300 mg/m 2 Schema 2 (n=15) GM-CSF 250 µg/m 2 G-CSF 10 µg/kg G-CSF 6 µg/kg b.i.d

High-dose MabThera ® In Vivo Purge + HDT/ASCT in Relapsed B-Cell Lymphoma: Eligibility Criteria Inclusion Age  65 years CD20 + lymphoid malignancies beyond first remission Marrow involvement reduced to  5% with pretransplant salvage chemotherapy ECOG performance status 0-2 Left ventricular ejection fraction  50% Pulmonary function test  50% Exclusion Hepatitis HIV-positive Khouri et al. Blood. 2002;100:645a. Abstract 2538.

High-dose MabThera ® In Vivo Purge + HDT/ASCT in Relapsed B-Cell Lymphoma: Patient Characteristics No. of patients42 Median age in years 51 (range) (20-65) HistologyAggressive86% Follicular14% IPI score 0-171% CR post-salvage chemotherapy45% Median prior treatments 2 Khouri et al. Blood. 2002;100:645a. Abstract 2538.

High-dose MabThera ® In Vivo Purge + HDT/ASCT in Relapsed B-Cell Lymphoma: Overall and Disease-free Survival 91% 1-year disease-free survival 93% 1-year overall survival Khouri et al. Blood. 2002;100:645a. Abstract Months Post-transplant Cumulative Proportion Surviving OS DFS n=42

High-dose MabThera ® In Vivo Purge + HDT/ASCT in Relapsed B-Cell Lymphoma: Tolerability Khouri et al. Blood. 2002;100:645a. Abstract 2538.

High-dose MabThera ® In Vivo Purge + HDT/ASCT in Relapsed B-Cell Lymphoma: Summary MabThera ® in vivo purging and consolidation achieved –1-year OS of 93% –1-year DFS of 91% No additional risk of toxicity or infection Comparison of high-dose vs standard MabThera ® purging is warranted Khouri et al. Blood. 2002;100:645a. Abstract 2538.

Magni et al. Blood. 2000;96:864. Cyclophosphamide Cytarabine MabThera  Melphalan Mitoxantrone + melphalan Weeks 0369 *** * Stem cell transplant In Vivo Purging With MabThera ® : Protocol

Magni et al. Blood. 2000;96:864. Age (y)Median 4346 (range) (34-58)(36-53) HistologyFL47%70% MCL 47%30% MALT 6%— StageIII27%10% IV 73%90% Bulky disease>10 cm — 30% Sites of involvementNodal93%100% Extranodal 13%30% BM100% 100% PB40% 30% HDT (n=10) M + HDT (n=15) In Vivo Purging With MabThera ® : Patient Characteristics

In Vivo Purging With MabThera ® : PCR-Negative Harvests Magni et al. Blood. 2000;96:864. Post- Cyclophosphamide Patients With PCR- Negative Harvests (%) Post- Cytarabine (P=0.007) M + HDT HDT

Clinical70100 Molecular70100 % of Patients Response HDT (n=10) M + HDT (n=14)* In Vivo Purging With MabThera ® : Response Magni et al. Blood. 2000;96:864. * Evaluable patients.

In Vivo Purging With MabThera ® : Protocol Flinn et al. Biol Blood Marrow Transplant. 2000;6:628. Preparative Regimen Day 1: MabThera  Day 4: Cyclophosphamide Day 5+: G-CSF Leukapheresis HDT Cyclophosphamide Total body irradiation Stem Cell Transplant Post-transplant Therapy MabThera  G-CSF

No. of patients25 Age (y)Median 51 (range) (33-67) HistologyFL (center)44% MCL28% CLL/SLL20% Lymphoplasmacytic4% Marginal zone4% No. of prior Median1 treatments (range) (1-3) Remission status 1 st complete 48% (at baseline) 1 st partial 24% 2 nd partial20% 3 rd partial8% In Vivo Purging With MabThera ® : Patient Characteristics Flinn et al. Biol Blood Marrow Transplant. 2000;6:628.

In Vivo Purging With MabThera ® : Response Flinn et al. Biol Blood Marrow Transplant. 2000;6:628. Successful mobilization 92 (N=25;  2.0 x 10 6 CD34+ cells/kg) Clinical* (n=11) CR55 PR 27 Stable disease18 Molecular † (after in vivo purging; n=7) 86 % of PatientsResponse * Response was evaluated in 11 of the 12 patients who did not have CRs at trial entry. † Prior to in vivo purging, 7 patients had t(11:14) or t(14:18) detectable by PCR.

Gianni et al. Bone Marrow Transplant. 2002;29(suppl 1):10–13. MabThera ® In Vivo Purging in Previously Untreated Mantle Cell Lymphoma: Protocol Days Reinfusion MabThera ® CyclophosphamideCytarabineMelphalan Mitoxantrone + melphalan Collection 1 2 3

No. of patients28 Age (y)Median 49 Ann Arbor stageIII7% IV93% IPI score1–275% 314% 4–511% Molecular rearrangement bcl-1 46% IgH36% Probe N/A18% B symptoms Yes 38% Size of mass >10 cm 29% LDH level Abnormal 36% MabThera ® In Vivo Purging in Previously Untreated Mantle Cell Lymphoma: Patient Characteristics Gianni et al. Bone Marrow Transplant. 2002;29(suppl 1):10–13.

Clinical96 (n=27*) Molecular100 (n=20) % of Patients Response MabThera ® In Vivo Purging in Previously Untreated Mantle Cell Lymphoma: Response *Evaluable patients Gianni et al. Bone Marrow Transplant. 2002;29(suppl 1):10–13.

MabThera ® In Vivo Purging in Previously Untreated Mantle Cell Lymphoma: 3-Year Survival OS MabThera ® + sHDT (n=28) 100 Years Percent EFS Historical controls (n=39)* OS *CHOP-like regimen Percent Years EFS Gianni et al. Bone Marrow Transplant. 2002;29(suppl 1):10–13.

MabThera ® after HDT/ASCT in Follicular and Mantle Cell Lymphoma: Protocol 6 x VACOP-B VIPEVIPE VIPEVIPE TBI/Cy 12 Gy/120 mg/kg 4 x MabThera ® 375 mg/m 2 /week CD34+ selection NR/PD off study Or equivalent treatment (e.g., CHOP) Week – Brugger et al. Ann Oncol. 2002;13(suppl 2):38. Abstract 113.

MabThera ® after HDT/ASCT in Follicular and Mantle Cell Lymphoma: Patient Characteristics No of patients*30 Age (y) Median 49 (range) (31–59) SexMale53% Female47% HistologyFollicular lymphoma67% Stage III45% Stage IV55% Mantle cell lymphoma33% Stage III/IV30% Stage IV70% Brugger et al. Ann Oncol. 2002;13(suppl 2):38. Abstract 113. * Evaluable patients

Total157 Lymphopenia 56 Thrombocytopenia–1 Nausea 1– Infection 6– Neurologic pain 1– Thyroiditis 1– Other 1– Grade 4Grade 3 MabThera ® after HDT/ASCT in Follicular and Mantle Cell Lymphoma: Grade 3/4 Adverse Events Brugger et al. Ann Oncol. 2002;13(suppl 2):38. Abstract 113.

Before TBI/Cy13 After TBI/Cy47 After MabThera ® 50 6 months59 9 months74 12 months91 24 months91 % of Patients in CR MabThera ® after HDT/ASCT in Follicular and Mantle Cell Lymphoma: Clinical Response Brugger et al. Ann Oncol. 2002;13(suppl 2):38. Abstract 113.

MabThera ® after HDT/ASCT in Follicular and Mantle Cell Lymphoma: Molecular Response Brugger et al. Ann Oncol. 2002;13(suppl 2):38. Abstract 113. PCR-negative (%) * ** *P=0.0077; **P<0.001 P= Pre-HDTPost-HDTPost-6 months MabThera ® post-HDT

MabThera ® In Vivo Purge + Maintenance with HDT/ASCT in Previously Untreated Mantle Cell Lymphoma: Protocol **CBV HDT CHOP x 4–8 cycles *R G-CSF Day 0 Weeks 8–11 Weeks 24–27 Collection Immunotherapy (two courses of MabThera ® ) *In vivo purge (R) MabThera ® 375 mg/m 2 day 5 G-CSF 10 µg/kg/day, days 4, 3, 2, 1, 0 Stem cell collection day 0 (1, 2) **HDT Cyclophosphamide 1, 8 g/m 2 days 6–3 Carmustine 500 mg/m 2 day 2 Etoposide 2.4 g/m 2 36 hour CI day 7 Mangel et al. Blood. 2001;98(suppl 1):677a. Abstract Reinfusion

MabThera ® In Vivo Purge + Maintenance with HDT/ASCT in Previously Untreated Mantle Cell Lymphoma: Patient Characteristics No. of patients14 Age (y)Median52 (range)(41–65) SexMale50% Female50% ECOG PS 0–1100% Stage IV (BM involvement)86% Low/low-intermediate IPI score93% B Symptoms21% LDH (IU/l)Median 195 (range) (144–402) Cycles induction chemotherapyMedian6 (range)(4–8) Mangel et al. Blood. 2001;98(suppl 1):677a. Abstract 2833.

% after% after% after inductionASCTMabThera ® * ORR CR CRu PR MabThera ® In Vivo Purge + Maintenance with HDT/ASCT in Previously Untreated Mantle Cell Lymphoma: Clinical Response * Based on 12 of 14 patients who had completed maintenance MabThera ® therapy 15-month median follow-up from transplantation Mangel et al. Blood. 2001;98(suppl 1):677a. Abstract 2833.

MabThera ® In Vivo Purge + Maintenance with HDT/ASCT in Previously Untreated Mantle Cell Lymphoma: Molecular Response Nine patients PCR-informative –Molecular remission achieved in seven/nine patients Five patients PCR-negative at last follow-up –Three of five at 18-month follow-up CHOP induction followed by MabThera ® + ASCT achieves high CRs in patients with previously untreated mantle cell lymphoma Molecular remission achieved in majority of patients Mangel et al. Blood. 2001;98(suppl 1):677a. Abstract 2833.

MabThera ® In Vivo Purge + HDT/ASCT in Chronic Lymphocytic Leukemia: Protocol 18 adult patients with relapsed or untreated chronic lymphocytic leukemia 4 cycles of MabThera ® -Flu*/Cy † Mobilization ESHAP BEAM Trneny et al. Blood. 2002;100:804a. Abstract Harvest ASCT *Fludarabine 3 x 25 mg/m 2 † Cyclophosphamide 3 x 300 mg/m 2

MabThera ® In Vivo Purge + HDT/ASCT in Chronic Lymphocytic Leukemia: Response Full protocol completed by 8 patients –CR achieved in 7 patients (88%) –PCR negativity achieved in 7 patients (88%) Trneny et al. Blood. 2002;100:804a. Abstract 3176.

MabThera ® In Vivo Purge + HDT/ASCT in Chronic Lymphocytic Leukemia: Summary Combination of MabThera ®, in vivo purge and HDT/ASCT leads to a high clinical and molecular complete remission rate MabThera ® does not add significantly to the toxicity of HDT/ASCT Trneny et al. Blood. 2002;100:804a. Abstract 3176.

MabThera ® EBMT LYM1 Trial: Protocol * 375 mg/m 2 every 2 months x 4, 30 days post-transplant Patients: relapsed follicular lymphoma in 2nd/3rd CR or VGPR after any treatment RANDOMIZATION MOBILIZATION + PBSC COLLECTION HDT: BEAM + PBSC INFUSION Group B: Observation Group C: MabThera ® maintenance* Group D: Observation Group A: MabThera ® in vivo purging (375 mg/m 2 weekly x 4) Group C: No purging Group B: MabThera ® in vivo purging ( 375 mg/m 2 weekly x 4) Group D: No purging Group A: MabThera ® maintenance*

MabThera ® EBMTLYM1 Trial: Eligibility Criteria Inclusion Relapsed follicular B-cell lymphoma WHO PS 0-1 Platelets >100 x 10 9 /L after induction therapy  18 years CD20 + Exclusion Impaired renal/hepatic/cardiac and pulmonary function Histologic transformation to high grade Previous radiotherapy to >30% BM CNS involvement >3 chemotherapy regimens for NHL (including re-induction chemotherapy) Previous transplant Pregnant/lactating HIV, HepB, and HepC positivity Previous malignancy <5 years

MabThera ® + ASCT: Summary CR and molecular response rates up to 100% Higher yield of PCR-negative stem cells with MabThera ® + HDT vs HDT alone Toxicity related to MabThera ® mild and transient Flinn et al. Biol Blood Marrow Transplant. 2000;6:628.

MabThera ® for B-PTLD: Eligibility Criteria Inclusion Age 1-75 years Histologically or cytologically confirmed mono- or polymorphic PTLD with  10% CD20 + lymphoma B-cells High EBV viral load after SCT ECOG performance status  3 Choquet et al. Blood. 2002;100:467a. Abstract Exclusion CNS involvement

MabThera ® for B-PTLD: Patient Characteristics Choquet et al. Blood. 2002;100:467a. Abstract SOT = solid organ transplant SCT = stem cell transplant

MabThera ® for B-PTLD: Response Choquet et al. Blood. 2002;100:467a. Abstract 1811.

MabThera ® for B-PTLD: Summary MabThera ® was effective (ORR 45%) and well tolerated This study is ongoing, and a longer follow-up is awaited Choquet et al. Blood. 2002;100:467a. Abstract 1811.