1. Treatment Approaches in Relapsed CML Jorge Cortes, MD Professor of Medicine Deputy Chair, Department of Leukemia The University of Texas MD Anderson Cancer Center Houston, TX

2. A 50-year old female presented with LUQ pain and splenomegaly 10 cm/BCM. Her WBC was 105 x 10 9 /L, Plts 800 x 10 9 /L. BM shows 5% blasts, 4% basophils. CG show 100% Ph, no clonal evolution. She has a perfect match brother. Your treatment plan is:  Allogeneic BMT ASAP  Imatinib 400 mg QD  Imatinib 400 mg BID  Dasatinib 100 mg QD  Nilotinib 400 mg BID Case Study: Question 1

3. Patient has now received imatinib 400 mg QD for 12 months. CG at 12 months shows Ph+ 10%. You would now proceed to:  Allogeneic BMT  Continue Imatinib 400 mg QD  Imatinib 400 mg BID  Dasatinib 100 mg QD  Nilotinib 400 mg BID Case Study: Question 2

4. Patient has now received imatinib for two years, the second year at imatinib 800 mg/D. Repeat CG show Ph+ 0%, QPCR is.15%. You would now proceed with:  Allogeneic BMT ASAP  Send sample for mutation studies and decide accordingly  Continue Imatinib 400 mg BID  Dasatinib 100 mg QD  Nilotinib 400 mg BID Case Study: Question 3

5. Patient is now on imatinib 800 mg/D for the past 40 months. Repeat CG shows Ph+ 40%, and a mutation screen identifies the T359C mutation. Your next approach is:  Allogeneic BMT ASAP  Consider MK 0457  Continue Imatinib 400 mg BID  Dasatinib 100 mg QD  Nilotinib 400 mg BID Case Study: Question 4

6. The patient achieved a compete cytogenetic response. One year later, cytogenetic analysis shows 50% Ph+ metaphases. A T315I mutation is detected. Your approach now is:  Allogeneic SCT  Imatinib 400 mg BID  Increase Dasatinib to 140 mg QD  Change to Nilotinib 400 mg BID  Consider Homoharringtonine Case Study: Question 5

7. Results with Imatinib in Early CP CML – The IRIS Trial 364 (66%) patients on imatinib on study Projected results at 6 years: – CCyR 87% – Event-free survival 83% – Transformation-free survival 93% If MMR at 12 mos: 100% If CCyR, no MMR: 98% – Survival 88% Annual rate of transformation: 1.5%, 2.8%, 1.6%, 0.9%, 0.6%, and 0% Hochhaus et al; Blood 2007; 110: abst# 25

8. Criteria for Failure to Imatinib Time (mo) Response FailureSuboptimal 3No HRNo CHR 6 100% Ph+ ≥ 35% Ph+ 12≥ 35% Ph+≥ 5% Ph+ 18≥ 5% Ph+ No MMR (<3-log  BCR-ABL/ABL) AnyLoss of CHR Loss of CCgR Mutation Clonal Evolution Loss of MMR Mutation Baccarani et al. Blood 2006; 108: 1809-20

9. Survival Post Imatinib Failure by CML Phase Kantarjian et al. Cancer 2007; 109: 1556-60

10. Inhibition of Bcr-Abl ATP-binding T315I-active Non-kinase Inhibition Bcr-AblAbl & Src ImatinibDasatinibMK-045717-AAG NilotinibBosutinibKW-2449HDAC INNO-406XL228HHT AZD 0530PHA-739358ATO ON 012380

11. Outcome After Imatinib Dose Increase 102 patients with imatinib dose escalation after imatinib failure (N = 85), suboptimal (N = 9), or other (N = 8) Dose  from 400  800 (N = 86) or 300  600 (N = 16) Median follow-up after dose  : 50 mo (range 3-83) % outcome after dose  2-year (%) from dose  CCyRMMR Loss CCyR EFSTFS Failure39818 8586 Cytogenetic491017 Hematologic12433 Suboptimal0/11/9 (11)088100 Other4/4 ** 4/8 (50)0100 Median time to cytogenetic response 9 mos Jabbour et al. Blood 2007; 110: abst# 1035

12. Dasatinib in CML Chronic Phase After Imatinib Failure (START-C) 387 pts; IM resistance 74%; median CML duration 61 mos; dasatinib 70 mg BID ParameterPercent CHR91 MCyR / CCyR62 / 53 MMR47 24-mos PFS / OS80 / 94 Dose reductions 73%; median dose 101 mg/d Grade 3-4 ↓ plts 49%, neuts 50%; pleural effusions 26% (grade 3-4 9%) Stone et al. Blood 2007; 110: abst# 734

13. Duration of MCyR to Dasatinib in CML CP 036912151821242730 Stone et al. Blood 2007; 110: abst# 734 Months 100 80 60 40 20 0 % without loss of MCyR 24-month response rates 45% CCyR 55% MCyR 37% MMR 84% Months 24-month response rates 78% CCyR 82% MCyR 78% MMR 036912151821242730 100 80 60 40 20 0 97% Imatinib Resistance Imatinib Intolerance

14. PFS and Overall Survival with Dasatinib in CML CP by Imatinib Failure Progression was defined as increasing WBC count, loss of CHR / MCyR, AP / BP, or death Stone et al. Blood 2007; 110: abst# 734 100 80 60 40 20 0 03691215182124273033 Months 96% 92% 88% 75% Months 03691215182124273033 100 80 60 40 20 0 100% 98% 94% Imatinib Resistance Imatinib Intolerance Overall Survival Progression-Free Survival

15. Phase II Studies of Dasatinib After Imatinib Failure Response Percent by Disease Stage CP N = 387 AP N = 174 MyBP N = 109 LyBP N = 48 ALL N = 46 Hematologic9164503949 CHR9150262935 NEL-14767 Cytogenetic6240475862 Complete5333274654 Partial97762 ASH 2007; abst# 470, 734

16. 100 80 60 40 20 0 PFS with Dasatinib in CML After Imatinib Failure Months 036912151821242730 Months 036912151821242730 100 80 60 40 20 0 03691215182124273033 Months 88% 75% 100 80 60 40 20 0 03691215182124273033 Months 100 80 60 40 20 0 64% 46% MyBP (Median 5.6 mo) LyBP (Median 3.1 mo) All (Median 3.3 mo) Non T315I (Median 5.7 mo) CPAP ALL BP

17. Dasatinib vs HD Imatinib in CML (START-R) 150 pts post failure of IM 400-600 mg/d Randomized (2:1) to dasatinib 70 mg BID vs IM 400 mg BID; median FU 15 mos Endpoint: CG response at 12 weeks  crossover Outcome Percent Response DasatinibHD IMP value CHR93820.03 MCyR53330.017 CCyR44180.002 MMR29120.028 PFS better with dasatinib (HR 0.14; p<0.0001) More grade 3-4  plts (57% vs 14%) and neuts (63% vs 39%), and pl. effusions (17% vs 0%) with dasatinib Kantarjian et al. Blood 2007; 110: abst# 736

18. PFS with Dasatinib vs HD IM by Prior Imatinib Dose P=0.0033 Prior imatinib dose: 600 mg P=0.0562 Per cent PFS 100 80 60 40 20 0 Dasatinib Imatinib Prior imatinib dose: 400 mg 03691215182124273033 Months Kantarjian et al. Blood 2007; 110: abst# 736

19. Optimal Dose and Schedule of Dasatinib IN CML CP after Imatinib Failure Parameter 100mg QD N = 166 50mg BID N = 166 140mg QD N = 163 70mg BID N = 167 P- value MCyR64586258NS CCyR46 4750NS Anemia101819170.105 Neutropenia344643 0.123 Thrombocytopenia223440380.003 Pleural effusion10162018NS Interruption586669710.047 Reduction33455457<0.001 Shah et al. JCO 2007; 25; (Abst # 7004)

20. Better Outcome on Dasatinib with Earlier Intervention Patients on dasatinib studies analyzed by failure status on imatinib: loss of CG response vs loss of CHR Status at IM FailureNo.% CCyR% 1-yr PFS Loss of MCyR152 50-83 [69] 87-100 [95] Loss of CHR147 14-50 [24] 58-93 [84] Kantarjian et al. Blood 2007; 110: abst# 1036

21. Nilotinib in CML Chronic Phase Post Imatinib Failure 320 pts with imatinib resistance (71%) or intolerance (29%) Median age 58 yrs; median CML duration 58 mo Nilotinib 400 mg PO BID ≥ 6 mos OutcomePercent - CHR77 - CG response76 MCyR / CCyR57 / 41 - 18-month OS / PFS91 / 64 Kantarjian et al. Blood 2007; 110: abst# 735 Median dose 790 mg/d Grade 3-4 ↓ plts 28%, neuts 30%; lipase elevation 15% (pancreatitis <1%), bilirubin 8%

22. Nilotinib in CML-CP Duration of Major CG Response Kantarjian et al. Blood 2007; 110: abst# 735

23. Response Percentage CP N = 321 AP N = 129 MyBP N = 105 LyBP N = 31 Ph+ALL N = 39 HR7754221929 CHR7726111326 Cytogenetic Major5731384851 Complete4119293234 ASH 2007 Phase II Studies of Nilotinib After Imatinib Failure

24. Time to Progression with Nilotinib in CML After Imatinib Failure le Coutre et al. Blood 2007; 110: abst# 471 70% 57% Months 78% 64% Months CPAP

25. Bosutinib (SKI–606) in CML and Ph+ ALL Src-Abl inhibitor; 30x more potent than IM – No inhibition of PDGFR, c-kit 152 CP pts; median time from Dx 65 mos; 76% IM resistant Bosutinib 400-600 mg/d; Phase II 500 mg/d Response in CP (N=56)% CHR89 Cytogenetic81 – Major 41 – Complete30 G 3-4 toxicity: rash 7%, thrombocytopenia 14%, neutropenia 9% Cortes et al. Blood 2007; 110: abst# 733

26. Phase I INNO-406 Abl/Lyn kinase inhibitor 25-55x more potent than imatinib Inhibits 17/18 Bcr-Abl mutants Not MDR dependent; good CNS penetration; active against F317C/L/V 41 pts: 21 CP, 7 AP, 6 BP, 7 ALL 32 pts received ≥ 2 TKIs INNO-406 30 mg SD → 480 mg BID Responses: – 2 CG CR + 1 CG major + 1 CG minor / 7 CP post IM failure – 1 CG CR + 2 HR in ≥ 2 TKI failures DLT transient LFT  ; phase II 240 mg P.O. BID Kantarjian et al. Blood 2007; 110: abst# 469

27. Survival Post Imatinib Failure in CP by Treatment Kantarjian et al. Cancer 2007; 109: 1556-60

28. Survival Post Imatinib Failure in AP by Treatment Kantarjian et al. Cancer 2007; 109: 1556-60

29. Time to Response to 2 nd Generation TKI 113 pts with CML CP receiving nilotinib (N = 43) or dasatinib (N = 70) after imatinib failure. MCyR or CCR (59) P = 0.003 mCyR or CHR (27) Response at 12 mo % AP/BP/Death/CHR loss Next Year MCyR or CCyR3% mCyR or CHR17% Failure to achieve mCyR by 3 or 6 mos = 3-7% chance of reaching MCyR at 12 mo (vs > 50% if mCyR at 3-6 mos). Tam et al. Blood 2007; 110: abst# 1931

30. Hematologic Response to 2 nd Generation TKI in Advanced Stage CML After IM Failure 136 pts: CML AP (N = 87), BP (N = 60) or Ph+ ALL (N = 7) treated with dasatinib (N = 73) or nilotinib (N = 81) after imatinib failure MCyR 35%; 46% no CHR at time of MCyR Most common causes of no CHR: thrombocytopenia (88%), neutropenia (35%), immature cells (31%) Fava et al, Blood 2007; 110: abst# 1944

31. Complete CyR Partial CyR Complete HR No response Response to Dasatinib by BCR-ABL Mutation in CML CP After Imatinib Failure Cellular IC 50 (nM) DasatinibImatinib N M244V1.32000 17 L248V1500 9 G250E/V1.81350–3900 23 Y253F/H/K1.3–10>10000 14 E255K/V5.6–134400–8400 10 D276G1500 3 T315I>1000>10000 3 F317L7.41050 4 M351T1.1930 15 E355G400 6 F359C/I/V2.21200 8 L387M2.01000 2 H396P/R0.6–1.13850–4200 17 Other 30 Stone et al. Blood 2007; 110: abst# 734

32. Response to Nilotinib in CML CP after Imatinib Failure by Mutation Mutation IC 50 (nM) No. Percentage MCyRCCyRMMRProgressed No Mutation8360422523 IC 50 ≤150 nM 4562402931 IC 50 >150 nM Y253H7008130038 E255K/V548/79183801475 F359C/V258/16110 0090 Others3358422039 Hughes et al. Blood 2007; 110: abst# 320

33. EFS by Mutations in CML CP Treated with 2 nd Generation TKI after IM Failure Jabbour et al, Blood 2007; 110: abst# 1941 87/169 (51%) pts treated had mutation CP 31, AP 41, BP 15 Mutations classified into high, intermediate, and low sensitivity to dasatinib or nilotinib based on IC50 Low IC 50 No Mutation Intermediate IC 50 P = 0.43 P = 0.0004 No significant difference in AP or BP

34. Inducible Mutations in Mutagenesis Studies with AMN and BMS Mutants induced by saturation, selection, or induced (ENU) Mutations: imatinib 20, nilotinib 10, dasatinib 9 Drug Concentration LowIntermediate AMNL248V, G250E, F359C, L384M, L387F Y253H, E255K/(V), T315I BMSL248V, Q252H, E255K/V, V299L T315I, F317C/L/V Bradeen et al. Blood. 2006; 108: 2332-8; Ray et al. Blood. 2007; epub ahead of print; von Bubnoff et al. Blood. 2006; 108: 1328-33. Burgess et al. PNAS. 2005; 102: 3395-400.

35. 34 67% patients Total match H396P/R (2) E453K (1) + F359V/C (3) + F311I/L (2) D276G (1) + E255K (1) + Y253H (3) + Q252H (1) M244V (1) In vitro models* This series N=15 NILOTINIB 80% patients Total match T495R (1) + F317L (5) + V299L (3) G250E (1) In vitro models* This series N=10 DASATINIB Occurrence of Mutations Predicted from In Vitro Models Cortes et al. Blood 2007 [e-pub ahead of print] *Burgess et al. PNAS 2005; 102: 3395-400; von Bubnoff et al. Blood 2006; 108: 1328-33; Bradeen et al. Blood 2006; 108: 2332-8.

36. Impact of Clonal Evolution in Response to Dasatinib or Nilotinib CE in 60/242 pts (25%) with CML AP treated with nilotinib (30) or dasatinib (30) after IM failure Double Ph 28%, chr 8 (17%), chr 17 (17%), other 35%) Response: CHR 80%, CCyR 40%, PCyR 6% Verma et al, Blood 2007; 110: abst# 2949

37. 2 nd Generation TKI in Newly Dx CML Dasatinib 37 pts with previously untreated CML CP Dasatinib 100 mg SD or 50mg BID Median FU 18 mos Nilotinib 32 pts with CML CP previously untreated Nilotinib 400 mg BID Median FU 6.5 mos Cortes et al. Blood 2007; 110: abst# 29 & 30

38. 37 TKI in Newly Diagnosed CML Parameter Percent response IM400 N = 50 IM800 N = 205 Dasatinib N = 39 Nilotinib N = 14 CG CR 3 mo37627296 6 mo548294100 12 mo6586100 MMR (12 mos) 24472545 Cortes et al. Blood 2007; 110: abst# 29 & 30

39. HHT in CML with Mutation T315 I 19 pts: 11 CP, 4 AP, 4 BP Failure on IM (19), dasatinib (10), nilotinib (8), MK457 (3) HHT 1.25 mg SQ BIDx14 Q4 wks until CHR → x 7 Q4 wks T315I undetectable in 4 CP and 1 AP Responses: – CP: 5 CHR, 1 mCyR, 2 CCyR – AP: 1 HI, 2 PHR, 1 mCyR Khoury et al. Blood 2007; 110: abst# 1050

40. A 50-year old female presented with LUQ pain and splenomegaly 10 cm/BCM. Her WBC was 105 x 10 9 /L, Plts 800 x 10 9 /L. BM shows 5% blasts, 4% basophils. CG show 100% Ph, no clonal evolution. She has a perfect match brother. Your treatment plan is:  Allogeneic BMT ASAP  Imatinib 400 mg QD  Imatinib 400 mg BID  Dasatinib 100 mg QD  Nilotinib 400 mg BID Case Study: Question 1

41. A 50-year old female presented with LUQ pain and splenomegaly 10 cm/BCM. Her WBC was 105 x 10 9 /L, Plts 800 x 10 9 /L. BM shows 5% blasts, 4% basophils. CG show 100% Ph, no clonal evolution. She has a perfect match brother. Your treatment plan is:  Allogeneic BMT ASAP  Imatinib 400 mg QD  Imatinib 400 mg BID  Dasatinib 100 mg QD  Nilotinib 400 mg BID Recommended approach: Imatinib 400 mg QD Case Study: Question 1

42. Patient has now received imatinib 400 mg QD for 12 months. CG at 12 months shows Ph+ 10%. You would now proceed to:  Allogeneic BMT  Continue Imatinib 400 mg QD  Imatinib 400 mg BID  Dasatinib 100 mg QD  Nilotinib 400 mg BID Case Study: Question 2

43. Patient has now received imatinib 400 mg QD for 12 months. CG at 12 months shows Ph+ 10%. You would now proceed to:  Allogeneic BMT  Continue Imatinib 400 mg QD  Imatinib 400 mg BID  Dasatinib 100 mg QD  Nilotinib 400 mg BID Recommended approach: Imatinib 400 mg BID Case Study: Question 2

44. Patient has now received imatinib for two years, the second year at imatinib 800 mg/D. Repeat CG show Ph+ 0%, QPCR is.15%. You would now proceed with:  Allogeneic BMT ASAP  Send sample for mutation studies and decide accordingly  Continue Imatinib 400 mg BID  Dasatinib 100 mg QD  Nilotinib 400 mg BID Case Study: Question 3

45. Patient has now received imatinib for two years, the second year at imatinib 800 mg/D. Repeat CG show Ph+ 0%, QPCR is.15%. You would now proceed with:  Allogeneic BMT ASAP  Send sample for mutation studies and decide accordingly  Continue Imatinib 400 mg BID  Dasatinib 100 mg QD  Nilotinib 400 mg BID Recommended approach: Continue imatinib 400 mg BID Case Study: Question 3

46. Patient is now on imatinib 800 mg/D for the past 40 months. Repeat CG shows Ph+ 40%, and a mutation screen identifies the T359C mutation. Your next approach is:  Allogeneic BMT ASAP  Consider MK 0457  Continue Imatinib 400 mg BID  Dasatinib 100 mg QD  Nilotinib 400 mg BID Case Study: Question 4

47. Patient is now on imatinib 800 mg/D for the past 40 months. Repeat CG shows Ph+ 40%, and a mutation screen identifies the T359C mutation. Your next approach is:  Allogeneic BMT ASAP  Consider MK 0457  Continue Imatinib 400 mg BID  Dasatinib 100 mg QD  Nilotinib 400 mg BID Recommended approach: Dasatinib 100 mg QD Case Study: Question 4

48. The patient achieved a compete cytogenetic response. One year later, cytogenetic analysis shows 50% Ph+ metaphases. A T315I mutation is detected. Your approach now is:  Allogeneic SCT  Imatinib 400 mg BID  Increase Dasatinib to 140 mg QD  Change to Nilotinib 400 mg BID  Consider Homoharringtonine Case Study: Question 5

49. The patient achieved a compete cytogenetic response. One year later, cytogenetic analysis shows 50% Ph+ metaphases. A T315I mutation is detected. Your approach now is:  Allogeneic SCT  Imatinib 400 mg BID  Increase Dasatinib to 140 mg QD  Change to Nilotinib 400 mg BID  Consider Homoharringtonine Recommended approach: Allogeneic SCT or Homoharringtonine Case Study: Question 5

50. Take Home Message – CML 2008 Imatinib effective in most patients –High-dose? Dose optimization and adequate monitoring more important then ever Sub-optimal responses: –  dose imatinib (400 mg → 800 mg) –New TKI? Failure: –Dasatinib, nilotinib –Others (Bosutinib, INNO 406) Frontline use of new TKI? T315I: HHT, XL-228, PHA-739538