1. The National CML Society 2012 CML UPDATE “What’s New? What’s Coming?” Luke Akard MD Co-Director Indiana Blood and Marrow Transplantation Program

2. Ph + CML Clinical Issues About 5000 cases per year in the US Incidence increases with age –About half of patients are over age 65 –More frequent in men: 1.9:1 ration –Incidence 1.5 per 100,000 per year Survival has improved over the past decade Most are asymptomatic, 85% chronic phase at diagnosis

3. CML Overview Malignant bone marrow disease –Increased numbers of bone marrow cells –Increased numbers of mature white blood cells in the blood stream, –Often with an increase in the red cells and platelets as well In 1961 the Philadelphia Chromosome was found to be associated with CML

4. Chromosome analysis—requires cultured cells analyzed in metaphase

5. DNA RNA Protein

6. CML Overview Three phases of disease –Chronic Phase 3-5 years –Accelerated Phase 3-18 months –Blast Phase 3-6 months Treatment overview (non-HSCT) –1970s chemotherapy busulfan, hydroxyurea –1980’s-1990’s interferon +/- Ara-C –2000 imatinib –2006, 2007 dasatinib, nilotinib

7. IRIS Trial: 5 Year Response to Gleevec Druker B et al. N Engl J Med 2006;355:2408-2417

8. IRIS trial data from the first 6 years of Imatinib as initial therapy of CML At 6 years, 98% of patients will have had a complete hematologic response, 88% OS 83% will have had a complete cytogenetic response What about loss of response or failures? YearEventsAP/BC 1 3.3% 1.5% 2 7.5 2.8 3 4.8 1.6 4 1.5 0.9 5 0.9 0.6 6 0.4 0.0 Hochhaus et al Blood 110:15a, 2007

9. Imatinib Has Changed CML Monitoring Complete hematologic response Complete cytogenetic response Major molecular response

10. Hematologic Response Complete CHR Platelets < 450,000, WBC < 10,000, no immature granulocytes or basophils, no spleen Anything less is not complete LeukemiaNet guidelines for CBC –Every 2 weeks until CHR confirmed –Every 3 months thereafter If not in CHR at 3 months on Gleevec, virtually no chance of responding to it. Baccarani et al Blood 108:1809, 2006

11. Cytogenetic Response Bone Marrow Exam (vs. blood FISH) Complete: Ph+ 0% CCyR Partial: Ph+ 1%-35% Minor: 36%-65% Minimal: 66%-95% None: Ph+ >95% Major: Complete + partial MajCyR LeukemiaNet guidelines for monitoring –Baseline then every 6 months until CCyR then every 12 months

12. IRIS trial data: Cytogenetic Response Impact of failure to respond to imatinib Survival: –No MCyR @ 12 months: 81% vs 97% 5y OS –No CyCR @ 18 months: 90% vs 99% 5y OS –No MCyR @ 18 months: 80% vs. 95% 5y OS Future response if stay on imatinib: –No CyR at 6 months, <20% chance CCyR –If PCyR @ 12 months, 64% likely to obtain CCyR –If no MCyR @ 12 months, still 36% obtain CCyr

13. Fluorescent in situ hybridization (FISH) does not require cultured Cells in metaphase

14. Molecular Response Complete: no transcript detectable Major: <=0.10 (3 log or 1000 fold decrease) –Requires quantitative pcr for bcr-abl to assess falling level –Can not assess response, other than complete, from qualitative pcr bcr-abl. LeukemiaNet guidelines –Check every 3 months –Perform mutational analysis in case of failure or suboptimal response Baccarani et al Blood 108:1809, 2006 Mutation analysis available using –Molecular MD, 2611 SW 3 rd Ave. Portland OR 97201 tel 503-459-4975.

15. Molecular Testing in CML TubeRNAcDNA PCR products 1 Day ReportExtraction RT 1 Day Sequencing 1.0 Day 0.5 Day Long range PCR QRT- PCR 0.5 Day LEVELS QRT-PCR MUTATION T315I FRET MUTATION SEQ WT T315I 5%

16. IRIS study MMR definition* 03/0506/0509/0512/0503/0604/0605/06 0.001 0.01 0.1 1 10 100 Date BCR-ABL/control gene (%) MEDIAN STANDARDIZED BASELINE VALUE ON 30 UNTREATED PATIENTS 3 log reduction from standard baseline * Hughes et al. NEJM 349; October 9 2003 4.5 log0.0032% 4 log0.01% 3 log 0.10% Log reduction from standardized baseline Internation al Scale MMR = 0.1% International Scale

17. Molecular Response to Imatinib IRIS trial 4 year follow-up data –MMoR 53% @ 1 year –CMoR 7% @ 1 year –MMoR 80% @ 4 years –4 log reduction 22% 1 year 44% 4 years –If CCyR at 1 year, impact of MMoR MMoR @ 12 months 100% 5 yr RFS Less than MMoR @ 12 months 97% 5 yr RFS Druker et al NEJM 355:2408-17, 2006

19. Side Effects of Imatinib Decrease Over Time Superficial edema Nausea Muscle cramps Musculoskeletal pain Diarrhea Rash Fatigue Headache Abdominal pain 18% 15% 23% 21% 23% 14% 11% 12% 15% 5% 3% 7% 6% 5% 2% 3% Adverse Event, All Grades 2yr 4yr Kantarjian et al Blood 108:605a, 2006

20. Pregnancy and Imatinib 180 mothers 71% exposed in 1 st trimester, 26% in all trimesters Outcome known in 125 pregnancies 63 (50%) normal live infants 35 elective abortions (3 after fetal defects) 18 (14%) spontaneous abortions 12 fetal abnormalities, including 4 cases with bony defects Pye et al Blood 108:132a, 2006 Half of pregnancies have progressive disease following interruption of imatinib Ault et al JCO 24:1204, 2006

21. Failure to respond to Imatinib 3 months 6 months 12 months 18 months Anytime No HR stable/prog dis Less than CHR, no CgR Ph+ > 95% Less than PCgR Ph+>35% Less than CCgR Loss of CHR, loss of CCgR

22. Suboptimal Response to Gleevec 3 months 6 months 12 months 18 months Anytime Less than CHR Less than PCgR Ph+>35% Less than CCgR Less than MMolR 3 logs or more Additional chromosome abn in Ph+ cells, loss of MMolR

23. Why Do Some Patients Fail To Respond To Imatinib? Multiple Causes For Drug Resistance 1.Mutations in the tyrosine kinase (50-75+%) Multiple sites of mutation have been found, with T315I being the most unresponsive to imatinib, dasatinib, and nilotinib 2.Increased transcription of bcr-abl or increased tyrosine kinase activity (10%) 3.Diminished cellular uptake of drug, drug pumps (5%) 4.Bcr-abl independent pathways 5.Patients do not take their medication.

24. Mutant Kinase Domains in bcr-abl Over 50 mutations have been identified to date Some mutations confer only moderate resistance, so dose escalation can be successful Evaluating for mutations in imatinib resistance may have clinical usefulness in the future.

25. Treatment Options If Imatinib Fails Young patients with appropriate bone marrow donors— consider allogeneic transplant Four other tyrosine kinase inhibitors with demonstrated benefit for Gleevec failures

26. Second line TKI Therapy Dasatinib Haematologica 95:232, 2010 –85 patients treated with 70 mg bid or 100 qd –75% MCyR, 68% CCyR –90% OS at 2 years Nilotinib Blood 117:1141, 2011 –321 patients failed 600 mg + imatinib –59% MCyR, 44% CCyR –If CCyR 56% MMR –CCyR durable 84% CCyR at 2 years, OS 87%

27. Second Line TKI Therapy Bosutinib Blood 118:4567, 2011 –200 patients imatinib resistant –53% MCyR, 41% CCyR – If CCyR 64% MMR –OS 2 years 92% Ponatinib early results PACE trial ASH 118:abs 109, 2011 –3-6 month follow-up, 94% failed > 2 TKI’s –188 CP patients (48 with T315I mutation) –46% MCyR, 32% CCyR (51% MCyR, 48% CCyR with T315I mutation)

28. Selected Comparisons Feature T315I responses Peripheral edema Pleural effusions Grade 3-4 heme Median dose admininstered Imatinib 0 20% <10% 20% 400 qd Dasatinib 0 18% 10-35% 49% 101 mg qd 140 mg planed Nilotinib 0 <1% 1% 29% 799 mg qd 800 mg planned

29. TKI’s: Drug-Drug Interactions –Inhibitors = Drugs that may ↑ plasma levels of imatinib or nilotinib Clarithromycin Erythromycin Itraconazole Ketoconazole Inducers = Drugs that may ↓ plasma levels of imatinib or nilotinib Carbamazepine Dexamethasone Phenobarbital Phenytoin Rifampin St. John’s wort Substrates = Drugs whose plasma levels may be increased by imatinib & nilotinib –Acetaminophen –Cyclosporine –Dihydropyridine Ca ++ channel blockers –HMG-CoA reductase inhibitors (eg, simvastatin) –Pimozide –Triazolobenzodiazepines –Warfarin Grapefruit juice is also an inhibitor of Cytochrome P450- would increase levels of imatinib and nilotinib

30. Second generation TKI vs. imatinib as initial therapy Drug CCyR % Imatinib/dru g MMR % Imatinib/dru g Progression to AP/BP % Imatinib/dru g OS % Imatinb/drug Nilotinib 2 yr data Lancet Oncol 2011 77 / 8744 / 717 / 196 / 97 Dasatinib 2 yr data Blood 2012 82 / 8646 / 645/ 2.395.2 / 95.3 Bosutinib 18 month data ASH 2011 abs 455 68 / 7027 / 415 / 295 / 99

31. Can You Stop Treatment? Mechanism of action TKI vs. interferon Stop during pregnancy –Initial year of treatment vs. planned pregnancy Clinical trial Stop Imatinib STIM trial –100 patients in CMR for at least 2 years –Molecular monitoring monthly X 1 yr, then q 2 mo –61 relapses (all molecular), 3 after 7 months –5 did not return to CMR with retreatment ASH 2011 abs 603

32. The Future in CML Can we identify patients who can receive imatinib without risk as initial therapy –Molecular response at 1, 3, or 6 months Can the addition of interferon improve long term outcome? European trial suggests may be able to stop treatment after interferon maintenance. Will new combinations of treatments work better than tyrosine kinase inhibitors alone? Serial vs. sequential T315I mutation trials: HHT, Aurora kinase inhibition MK-0457, new TKI inhibitors KW-2449, XL-228

33. CML Treatments In Development Tyrosine kinase inhibitors –Ponatinib AP24534 multi kinase inhibitor trial (Ariad) T315I plus –DCC-2036 binds to different domain on bcr-abl, active in T315I –Non-ATP binding site inhibitors: AG957, ON 012380, ON01910 Aurora kinase inhibitors: Histone deacetylase inhibitors –SAHA (vorinostat), LAQ 824, LBH 589 Hedgehog pathway inhibitors –PF-04449913 –BMS833923 Homoharringtonine Omapro—plant alkaloid (Ceflatonin) CML vaccines: short bcr-abl peptides, PR1 (proteinase 3 a neutrophilic protease), HSP chaperone proteins

34. CML Treatment 2012 Newly diagnosed –400 mg/d imatinib or nilotinib 400 mg 2x/d or dasatinib 100 mg/d –Clinical trials: duration of therapy, second agents, target response Failure to achieve response or progressive disease –Switch to alternative TKI –Omapro if fail more than 2 TKI’s –Allogeneic marrow transplant for appropriate patients –Ponatinib clinical trials –Other clincal trials If present with accelerated or blast phase, use higher doses of imatinib or dasatinb and consider early allogeneic marrow transplant

35. Contact Luke Akard MD 1500 Albany Street Suite 911 Beech Grove IN 56107 317-528-5500 Fax 317-782-6316 E-mail lakard@ibmtindy.comlakard@ibmtindy.com

36. National CML Society Indianapolis CML Connection Group http://www.nationalcmlsociety.org/cml-connection-indianapolis