1. LAM Research and Upcoming Trials Lisa R. Young, MD 2016 Regional TSC & LAM Conference Vanderbilt University Nashville, TN April 16, 2016

2. Overview The Team at Vanderbilt Top 10 Breakthroughs in LAM Research Current LAM Research and Trials

3. Lymphangioleiomyomatosis (LAM) VERY MILDMODERATE SEVERE F. McCormack; he LAM Foundation

4. Chylothorax Renal angiomyolipoma (AML) Pneumothorax Clinical manifestations of LAM Lymphatic spread F. McCormack; The LAM Foundation Abdominal LAM * * * *

5. On a personal note 2002: Attended LAMposium for the 1 st time 2003: Became involved in LAM research with Frank McCormack  Pneumothorax management  VEGF-D as a biomarker  CAST: Cincinnati Angiomyolipoma Sirolimus Trial  MILES Trial: Multicenter International LAM Efficacy of Sirolimus 2006-11: Served as pulmonary consultant to Cincinnati TSC clinic 2012: Established LAM clinic at Vanderbilt

6. Mission of The LAM Foundation * The LAM Foundation urgently seeks safe and effective treatments, and ultimately a cure for LAM, through advocacy and the funding of promising research.

7. Mission of The LAM Clinics * To improve the care and treatment of LAM patients

8. Goals of The Vanderbilt LAM Clinic  Foster the multidisciplinary expertise needed to care for LAM patients  Facilitate access to the latest advances in LAM care  Facilitate the research needed to improve treatment for LAM

9. Our Clinical Team Lisa Young, MD Kevin Ess, MD, PhD John Worrell, MD Adam Guttentag, MD Joyce Johnson, MD Pulmonary Pediatric Neurology Radiology Radiology Pathology LAM Clinic Director TSC Clinic Director Jamie Dwyer, MD Edward Gould, MD Peter Bream, MD Amir Bhatt, MD Kevin Haas, MD Nephrology Nephrology Interventional Radiology Adult Neurology Adult Neurology

10. LAM Research History: (My) Top 10, with apologies to those overlooked!

11. 1995: The LAM Foundation Founded in Cincinnati by Sue and Fran Byrnes Breakthrough #1 Frank McCormack, MD Scientific Director

12. AJRCCM 2005 #2 1998: NHLBI LAM Registry Initiated studies that have been critical to learning about how LAM affects different women

13. Fruit fly biologists discover how the TSC1/2 complex controls cell growth. Ito and Rubin, Cell 1999 TSC1 TSC2 mTOR #3 TSC1/TSC2 inhibits mTOR, a master switch that integrates vital input in cells.

14. ‘Sporadic’ LAM is caused by somatic mutations in tuberous sclerosis genes. #4 PNAS, 2000 Am J Hum Genet 1998

15. LAM is common in women with TSC. (26-39% in initial studies) #5 Mayo Clinic, Costello/Ryu (Mayo Clin Proc 2000) NIH, Moss/Kristof (Am J Resp Crit Care Med 2001) Cincinnati, Franz/McCormack (Am J Resp Crit Care Med 2001)

16. LAM in TSC patients (TSC-LAM) Severity is highly variable. Many asymptomatic and don’t progress Some women do experience progressive lung disease. Increasing prevalence of cystic lung disease with age in females with TSC Cudzilo/Young, Chest 2013

17. Sporadic LAM vs. TSC-LAM FeatureSporadic LAMTSC-LAM Asymptomatic cases identifiedOccasionallyDefinitely Progressive lung diseaseMostSome but not all PneumothoraxYes (2/3rds)Yes AngiomyolipomasYes (1/3rd)Yes (approx. 90%) Lymphangioleiomyomas or chylous complications Yes 30%More rare (9%) Neurologic involvementNoYes Sirolimus treatment considered Yes Lung transplant consideredYes

18. LAM is metastatic. (It spreads within the body). Karbowniczek, AJRCCM, 2003 The cells that comprise the LAM lesion that recurred in the transplanted lungs were derived from the recipient. #6

19. LAM Cells Spread to the Lungs Crino, Nathanson, Henske NEJM 2006

20. Rapamycin inhibits the growth of LAM cells and tumors in animal models. #7 Corrects defect in eye cell growth in TSC flies (Zhang Genes Dev 2000) Inhibits the growth of LAM cells isolated (Goncharova JBC 2002) Causes kidney tumor apoptosis and regression in TSC rats (Kenerson Canc Res 2002) Causes regression in hepatic LAM-like lesions in TSC mice (El-Hashemite Canc Res 2003)

21. Bissler et al. N Engl J Med 2008 Open label trial 23 subjects Escalating dose sirolimus Primary endpoint: AML size by MRI Secondary endpoint: pulmonary function AML tumor volume Months On sirolimus Off sirolimus 0 6 12 18 24 #8 Rapamycin (sirolimus) shrinks AMLs and may improve lung function in LAM. Another small study was also published from the UK at this time.

22. Efficacy and Safety of Sirolimus in Lymphangioleiomyomatosis Francis X. McCormack, M.D., Yoshikazu Inoue, M.D., Ph.D., Joel Moss, M.D., Ph.D., Lianne G. Singer, M.D., Charlie Strange, M.D., Koh Nakata, M.D., Ph.D., Alan F. Barker, M.D., Jeffrey T. Chapman, M.D., Mark L. Brantly, M.D., James M. Stocks, M.D., Kevin K. Brown, M.D., Joseph P. Lynch, III, M.D., Hilary J. Goldberg, M.D., Lisa R. Young, M.D., Brent W. Kinder, M.D., Gregory P. Downey, M.D., Eugene J. Sullivan, M.D., Thomas V. Colby, M.D., Roy T. McKay, Ph.D., Marsha M. Cohen, M.D., Leslie Korbee, B.S.,Angelo M. Taveira-DaSilva, M.D., Ph.D., Hye-Seung Lee, Ph.D., Jeffrey P. Krischer, Ph.D., and Bruce C. Trapnell, M.D., for the National Institutes of Health Rare Lung Diseases Consortium and the MILES Trial Group* March 16, 2011 The NEW ENGLAND JOURNAL of MEDICINE Double blind, placebo control Sirolimus n=43 Placebo n=46 Moderate to severe LAM Mean FEV1: 1367 ml (48%) Mean age: 45 yrs A Major Breakthrough! 2015: FDA-Approved for LAM! #9

23. Goldberg et al. Eur Respir J 2015;46:783-794 Everolimus has been tested in one open label trial in LAM. FVC FEV1

24. Serum VEGF-D can be used to diagnose LAM. #10 Seyama et al, Lymphatic Res & Biol 2006 Clinical testing became available in 2011. McCormack et al, NEJM 2011; Young et al, The Lancet Resp Med 2013 Young/McCormack, NEJM 2008 Young/McCormack, Chest, 2010

25. And So Many More… The pace of progress in LAM and TSC science is rapid, providing new clues for possible drug targets.

26. LAM Research in Progress and Upcoming Trials

27. LAM trials that are soon to report TRAIL trial (letrozole vs. placebo) SAIL trial (hydroxycholorquine and sirolimus) NHLBI Protocol (Dr. Joel Moss); ongoing National registries in several countries

28. LAM trials that are enrolling (or will soon) SOS Trial: Safety of Simvastatin (Krymskaya) Saracatanib (Eissa) 3 by 3 phase I trial complete; phase II trial enrolling Inhaled rapamycin (LAM Therapeutics) Phase 1 trial in healthy volunteers complete MIDAS: Observational registry across LAM clinics (McCormack) COLA Trial: COX2 inhibition- Celecoxib (Kwiakowski) LAMP-1: Gleevac (C. Strange)

29. Coming Soon LAM Guidelines (ATS) Will help clinicians diagnose and manage patients with LAM Initial topics of focus: (1) Sirolimus, (2) hormonal therapy, (3) doxycycline, and (4) VEGF-D MILED Trial (F. McCormack) Early, low dose sirolimus to prevent progression to advanced disease in LAM (pending funding)

30. Kevin Ess Eric Austin Errine Garnett Abby Arkon  Why does LAM occur mostly in females with TSC (not males)?  Why is the disease severity variable?  Are there additional biomarkers that can aid in LAM diagnosis and monitoring? BUILD: Biomarker Utility in LAM Diagnosis (Vanderbilt Study funded by LAM Foundation in 2015)

31. Josh Fessel, MD, PhD: Use of 18F-Glutamine PET in the Diagnosis of LAM Pilot grant funded by The LAM Foundation in 2016 Goal: to develop a special imaging technique to aid in diagnosis and monitoring of LAM Mouse model ‘Proof of principle’ Red areas are glutamine uptake

32. Summary  There has been tremendous progress in LAM! Critical elements have included: TSC science Advocacy from The LAM Foundation and The TS Alliance  The recent FDA approval of sirolimus for LAM has led to a very high profile for the LAM community. Recognized by Dr. Francis Collins, Director of NIH Impact worldwide: Now approved in Russia, Japan, Korea  There are many unanswered questions, including how to prevent LAM, about the use of sirolimus, and the development of additional therapies.  We have more work to do together!

33. Thank You! Vanderbilt *Peter Gulleman Chelsi White Aidong Qi Rebekah Nevel *Erinne Garnett *Abby Arkon Eric Austin Kevin Ess John Worrell *Frank McCormack (Univ. Cincinnati) Members of The Cincinnati TSC Clinic The MILES Trial Investigators (and funding sources) E. Grassman/ Cincinnati TTDSL clinical lab