1. Biological Characterization
MDS phenotype
Environment Adhesion
Genetic Loss of Heterozygosity
Molecular Gain of Function
Epigenetic Gene Silencing
Immunologic Effectors
Angiogenic Molecules
TREATING PATHOGENESIS

2. EPIGENETICS
Alteration of the heritable state of gene expression causing disruption of gene function (loss of function), in cancer
Gene silencing mediated by:
DNA methylation (DNA Methyltransferase)
Histone de-acetylation (Histone deacetylase)
RNA interference (post-transcriptional)
MicroRNA
Epigenetic events reversible
Potentially targets for cancer therapy (gene reactivation)

5. CALGB 9221 A Randomized Phase III Controlled Trial of Subcutaneous Azacitidine in Myelodysplastic Syndromes No
Continue until Endpoint +
* Minimum duration of supportive care = 4 months unless transform to AML; death or plts š 20 x 109/L at week 8 or later
QOL – Quality of Life Assessment
M = Bone Marrow Aza C – Azacitidine S.C. 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 C75mg/m2/d x 7 days q28 x 4
Exit
Criteria
Yes
Aza C (dose as per arm #2) A E
Response
Continue Rx
No Response
- Off Study
Day
Silverman L, et al. J Clin Oncol :
Kornblith AB, et al. J Clin Oncol :

6. Analysis of Response SC AZA Crossover No. Evaluated 92 99 49
PR 0 (0%) 15 (16%) ** 2 ( 4%)
Improved 5 (5%) 38 (37%) ** 16 (36%)
Total 5 (5%) 60 (60%) ** 23 (47%)
P - value * < 0.01 **<0.001
Silverman L, et al. J Clin Oncol :

7. Time to AML Transformation
P=.001
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. J Clin Oncol :

8. Probability of Survival
Silverman L, et al. J Clin Oncol :
0.0
0.2
0.4
0.6
0.8
1.0
Probability of Survival
Months
Induction Azacitidine
Crossed before 6 months
Did not cross before 6 months 10 20 30 40 50 5 15 25 35 45 12 24 42 54 6 18 36 48
Azacitidine
Supportive Care
p=0.1
p=0.03

9. Survival: FAB Classification
Silverman L, et al. J Clin Oncol : 10 20 30 40 50
0.0
0.2
0.4
0.6
0.8
1.0
Probability of Survival
Months
Aza/Low
Supp Care/Low
Aza/High
Supp Care/High

10. Confirmatory Trial Design
Patient
Randomized
Azacitidine 75 mg/m2 x 7 days
Every 28 days
Standard of care
Options 1)
Best Supportive Care 2)
Low Dose 3)
Standard Chemotherapy
vs Standard of care
Low Dose Ara-C
Primary endpoint: Time to leukemic transformation or death
Chris Mitchell Make consistent with other two schematics

11. Cytotoxicity vs Hypomethylation

12. Low Dose DAC 135mg/m2, c.i./72 h 15 mg/m2, tid/Dx3, i.v.
15 mg/m2, tid/Dx3, s.c.
Kantarjian, Blood 2006

13. Median response duration 36 weeks
Cumulative analysis of 177 MDS patients treated with low-dose decitabine within 4 Phase II studies in Europe and the USA
Toxic death 7%
Progressive disease
18%
Stable disease
20%
Improvement
14%
Partial response
10%
Not evaluable
RESPONSE RATE
49%
Median response duration
36 weeks
Median survival
15 months
2 years survival
31%
(Wijermans, Lübbert et al., Ann. Hemat. 2005)

14. Report of Phase III Trial of Decitabine in advanced MDS
170 pts, DAC 15 mg/m2, tid/Dx3 Q 6 wks, 10 cycles
IPSS No. DAC SC P
Int HR
All pts
Median time to AML or death (months)

15. Time to AML
P=0.16

16. Time to AML
P=0.028

17. Combination Therapy for MDS/AML
AZACITIDINE + PHENYLBUTYRATE
AZACITIDINE + SAHA (Vorinostat)
AZACITIDINE + MS-275
AZACITIDINE + Gemtuzumab Ozogamicin
DECITABINE + VALPROIC ACID

18. CANDIDATE DRUGS FOR EPIGENETIC THERAPY
DNMT inhibitors Vidaza, Dacogen, zebularine,
DNMT antisense and siRNA
HDAC inhibitors

19. HDAC inhibitors Short-chain fatty acids (SCFA) Butyrate derivatives,
Valproic acid
Hydroxamic acids
Trichostatin A , SAHA, Pyroxamide, LAQ824, ITF2375
Epoxyketone-containing cyclic tetrapeptides
Trapoxins
Non-epoxyketone-containing cyclic tetrapeptides
FK228, Apicidin
Benzamides
MS-275, CI-994
MGCD0103

20. Pharmion Corp. MethylGene Taiho HDAC programme
MGCD 0103
Profile:
HDAC1,2,3 and 11 inhibitor
Oral
Lacks cardiac toxicity (Herg channel negative) characteristic of the class.
Appears synergistic with Vidaza

21. MG-0103 Clinical Studies in Cancer
001
002
003
004
Ph I solid
Ph I – MDS, leukemia
3-week cycle
# Patients 12 28 23 3
005
Ph I/II – azacitidine
combo MDS
006
Ph I/II – gemcitabine
combo pancreatic
007
Ph II – AML
008
Ph II – Lymphoma
Status
Closed
56 mg/m2
70 mg/m2
53 mg/m2
90 mg total
At sites
Underway

22. MG-0103 Clinical Studies in Cancer
When the highly promising Vidaza, ATRA, Valproate studies in HR MDS/AML and Phase II MGCD0103 studies are completed 0103 will progressively replace valproate

23. HDAC class3 Sirtuins
Treatment of BCL6-expressing Burkitt lymphoma cells with cambinol (Sirt1 inhibitor) induced apoptosis, accompanied by hyperacetylation of BCL6 and p53. Acetylation inactivates BCL6 and activates p53 and other checkpoint pathways*
*Heltweq, Cancer Res, 2006