Lenalidomide Is Safe and Active in Waldenstrom Macroglobulinemia (WM) 1 Updated Results from a Multicenter, Open-Label, Dose-Escalation Phase 1b/2 Study.

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Lenalidomide Is Safe and Active in Waldenstrom Macroglobulinemia (WM) 1 Updated Results from a Multicenter, Open-Label, Dose-Escalation Phase 1b/2 Study of Single-Agent Oprozomib in Patients with Waldenström Macroglobulinemia (WM) 2 1 Leleu X et al. Proc ASH 2014;Abstract Siegel DS et al. Proc ASH 2014;Abstract 1715.

Lenalidomide Is Safe and Active in Waldenstrom Macroglobulinemia (WM) Leleu X et al. Proc ASH 2014;Abstract 4478.

Background Lenalidomide (LEN) has proven to be safe and effective for multiple myeloma, especially as treatment for elderly patients. However, in a study of patients with Waldenström macroglobulinemia (WM), the combination of LEN at 25 mg/d and rituximab resulted in clinically significant acute anemia (Clin Cancer Res 2009;15:355). The anemia did not improve in most patients when the LEN dose was reduced, and no cause was apparent for the observed anemia. Study objective: To evaluate incremental doses of single- agent LEN in patients with WM to determine the maximum tolerated dose (MTD) and possibly to determine the cause of LEN-associated anemia in patients with WM. Leleu X et al. Proc ASH 2014;Abstract 4478.

RV-WM-0426 Phase I/II Study Design Eligibility (n = 17) Relapsed/refractory (R/R) WM LEN (PO daily) 21/28-day cycle 15 to 20 then 25 mg x 1 year Cohorts of 3-6 patients Primary endpoint: LEN MTD determination Phase I dose escalation Phase II LEN (PO daily) 21/28-day cycle MTD of 15 mg* (n = 9) * At LEN dose of 20 mg, 2 patients had dose-limiting toxicities. Therefore, the MTD was established at 15 mg/d. Leleu X et al. Proc ASH 2014;Abstract 4478 (Abstract only).

Baseline Patient Characteristics Leleu X et al. Proc ASH 2014;Abstract 4478 (Abstract only). Characteristic n = 17 Median age (range)69 years (48-81) Male/female70%/30% IPSS Grade 353% Median hemoglobin level11.2 g/dL Median M spike level26.5 g/L Prior exposure to rituximab47% Prior transplantNone

Efficacy Summary Overall response (minimal response or better) on an intent-to- treat basis at LEN 15 mg/d = 36%. –Additionally, 2 patients had prolonged stable disease. A transient initial increase of the M spike (flare effect) was observed in 5 patients. With a median follow-up of 36 months: –35% of patients have a progression-free survival >24 months. –14 patients experienced disease progression, with a median time to progression of 16 months. One patient has died, with a 5-year overall survival of 91%. Leleu X et al. Proc ASH 2014;Abstract 4478 (Abstract only).

Adverse Event Summary The most common adverse event (AE ≥10%) was fatigue of at least Grade 2 reported in 50% of patients Grade ≥3 hematologic AEs at LEN 15 mg/d: –Anemia = 14% –Neutropenia = 43% –No thrombopenia was observed Grade ≥2 nonhematologic AEs: 78% Two patients with Grade 3 nonhematologic AEs: Nephrotic syndrome and cramps No second primary cancer or thromboembolic events were reported Patients requiring dose reduction: 21% (median time of 7 months) Patients requiring drug interruption due to AEs: 35% (median time of 4 months) Leleu X et al. Proc ASH 2014;Abstract 4478 (Abstract only).

Author Conclusions The MTD of LEN in R/R WM is 15 mg/d administered daily for 21 of 28 days. LEN is active in the treatment of R/R WM, and the safety profile appeared manageable, essentially of Grade 2 intensity. Future studies may investigate combinations with LEN and continuous therapeutic effect in WM at the determined MTD. Leleu X et al. Proc ASH 2014;Abstract 4478 (Abstract only).

Updated Results from a Multicenter, Open-Label, Dose- Escalation Phase 1b/2 Study of Single-Agent Oprozomib in Patients with Waldenström Macroglobulinemia (WM) Siegel DS et al. Proc ASH 2014;Abstract 1715.

Background Oprozomib (OPZ) is an oral proteasome inhibitor that has shown promising activity in patients with hematologic cancer. An ongoing Phase Ib/II study is evaluating 2 schedules of OPZ administration (modified-release tablets) in patients with relapsed disease (Proc ASH 2013;Abstract 3184). –18 patients included in response evaluation on OPZ 5/14 schedule (n = 13 with multiple myeloma, n = 5 with WM) and 15 patients included in response evaluation on OPZ 2/7 schedule (n = 12 with multiple myeloma, n = 3 with WM) –Clinical benefit rate for patients with WM = 80% (5/14 schedule) and 0% (2/7 schedule) Study objective: To report updated safety and efficacy results from the subset of patients with WM enrolled in the ongoing Phase Ib/II study of OPZ. Siegel DS et al. Proc ASH 2014;Abstract 1715.

Ongoing Phase Ib/II Study Design (NCT ) Eligibility (Target: n = 364) Hematologic cancer and relapse after ≥1 line of therapy Primary endpoint Phase Ib: OPZ maximum tolerated dose (MTD) determination, safety and tolerability Primary endpoint Phase II: Best overall response rate (ORR, minimal response or better) Phase Ib dose escalation* Phase II OPZ 240 mg PO on 5/14 schedule (initial schedule opened to enrollment) * Starting dose was 150 mg/d and doses were escalated in 30-mg increments; MTD determination included all 106 patients enrolled on the study. Siegel DS et al. Proc ASH 2014;Abstract 1715 (Abstract only); 2/7 schedule: OPZ PO d1, 2, 8 and 9 of 14-day cycles 5/14 schedule: OPZ PO daily d1-5 of 14-day cycles

Baseline Characteristics for Patients with WM Siegel DS et al. Proc ASH 2014;Abstract 1715 (Abstract only). Characteristic Phase Ib 2/7 schedule (n = 8) Phase Ib 5/14 schedule (n = 11) Phase II 5/14 schedule (n = 17) Median age, years (range) 61.5 (50-77)69.0 (56-79)62.0 (44-85) Median prior regimens, n (range) 3 (1-8)5 (1-10)3 (1-7) Prior bortezomib exposure, n (%) Naïve Sensitive Refractory 3 (38) 1 (13) 2 (25) 2 (18) 3 (27) 4 (36) 3 (18) 11 (65) 3 (18)

ORR for Patients with WM Siegel DS et al. Proc ASH 2014;Abstract 1715 (Abstract only). Phase Ib patient group (n = 19)* ORR 2/7 schedule (n = 8)38% 5/14 schedule (n = 11)73% Bortezomib refractory (n = 4)75% Phase II patient group (n = 17) All patients, 5/14 schedule (n = 17)59% Carfilzomib naïve (n = 16)56% Bortezomib refractory (n = 3)67% * All 19 patients in the Phase Ib portion were carfilzomib naïve.

Select Adverse Events (AEs) by OPZ Schedule in Patients with WM Siegel DS et al. Proc ASH 2014;Abstract 1715 (Abstract only). Phase Ib 2/7 schedule (n = 8) Phase Ib 5/14 schedule (n = 11) Phase II 5/14 schedule (n = 17) Event Any grade n (%) Grade 3-4 n (%) Any grade n (%) Grade 3-4 n (%) Any grade n (%) Grade 3-4 n (%) Hematologic AEs Anemia1 (13) 4 (36)1 (9)1 (6)0 (0) Thrombocytopenia4 (50)2 (25)3 (27)0 (0) Neutropenia3 (38)2 (25)3 (27)1 (9)0 (0) Nonhematologic AEs Nausea5 (63)0 (0)7 (64)1 (9)13 (76)1 (6) Diarrhea2 (25)0 (0)6 (55)2 (18)10 (59)1 (6) Constipation2 (25)0 (0)4 (36)0 (0)10 (59)0 (0) Fatigue2 (25)0 (0)6 (55)2 (18)8 (47)0 (0)

Author Conclusions The MTD of OPZ was 300 mg/d in the 2/7 schedule (data not shown) and 240 mg/d in the 5/14 schedule as determined from all patients enrolled with hematologic cancer. In patients with WM who received single-agent OPZ, the most common Grade 3 AEs were neutropenia and diarrhea. –Grade 4 AEs were infrequent Additional measures will be taken to improve gastrointestinal tolerability. Single-agent OPZ continues to have promising antitumor activity in patients with WM. Enrollment on the 2/7 schedule is continuing; the target for the Phase II portion of the study is 66 patients. Extended-release OPZ tablets will be introduced and assessed for safety, activity and pharmacokinetics. Siegel DS et al. Proc ASH 2014;Abstract 1715 (Abstract only).