1. Chronic myeloid leukaemia
David Marin,
Imperial College London

2. Survival of 246 patients who received Interferon therapy within the UK Medical Research Council's CML-III trial ( )
Survival of 224 patients who received first line imatinib therapy therapy in Hammersmith Hospital ( )

3. 28 May 2001
2001

4. 1998 (C30H35N7SO4) Imatinib mesylate (STI571 - Glivec)
(From Novartis Pharma)

5. Mechanism of action of imatinib
Bcr-Abl
Bcr-Abl
Substrate
Substrate P P P Y
ATP
Imatinib P
Y = Tyrosine
P = Phosphate

6. Bosutinib
(SK-606)
Ponatinib

7. Selectivity of Tyrosine Kinase Inhibitors
Target kinases for the 4 TKIs
Selectivity of Tyrosine Kinase Inhibitors
Imatinib
(Phos. IC50)
PDGFR
72 nM
>
Kit
99 nM
BcrAbl
221 nM
Src
>1000 nM
Nilotinib
20 nM
75 nM
209 nM
Dasatinib
0.1 nM
1.8 nM
2.9 nM
18 nM
Bosutinib
3 nM
85 nM
>3000
>10000 nM
1. Manley PW, et al. Proc Am Assoc Cancer Res 2007;48:772.
2. Weisberg E, et al. Cancer Cell 2005;7:1129.
3. Remsing Rix LL, et al. Leukemia 2009;23:477.

8. Comparison of Kinase Inhibitors: Toxicity
Imatinib
(STI571)
Gleevec*
Nilotinib
(AMN 107)
Tasigna*
Dasatinib
(BMS354825)
Sprycel*
Bosutinib
(SK606)
Hematologic ++ +
Pleural Effusions -
+++
Hepatic
Pancreatitis
GI Bleeding
Platelet Function ?
Immune
Diarrhea
Q-Tc +? 8

9. Licensed First Line Second Line Imatinib Nilotinib Dasatinib Bosutinib
1st and 2nd line
Gold standard
No published experience
Nilotinib
Early data suggest small advantage over Imatinib
40-50% CCyR
Dasatinib
Bosutinib
No (1st line soon)
Not yet clear, maybe slightly better than imatinib
Ponatinib
No (2nd line soon?)
No yet tried
10-30% of responses in 3rd line (T315I active)

10. ¿Darling, Should not you check whether the patient is responding?
Darling, this morning I saw a new patient with CML and I prescribed him a TKI.
I have done my duty!
¿Darling, Should not you check whether the patient is responding?

11. Patients who fail to achieve CCyR progress to advance phase (n=204)
Probability of PFS
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
Months from starting imatinib therapy 60 54 48 42 36 30 24 18 12 6
0.1
0.0
p<0.0001
Marin, Blood 2008

12. Patients who achieve CCyR do well and patients who fail to achieve CCyR do badly (IRIS data)
Estimated rate (95% CI)
at 42 months:
n= % (89%, 96%)
n= % (66%, 92%)

13. TKI therapy only prolongs live on those patients who achieve CCyR
2G-TKI responders, n=67,
aRR=0.05, p=0.003
Time from diagnosis (years) 7 6 5 4 3 2 1
Provability of OS
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
Imatinib responders, n= 179,
aRR= 0.18, p<0.0001
Interferon controls, n =246,
aRR=1
TKI non responders, n= 37
aRR= 0.76, p=0.65
Ibrahim, Haematologica 2011

14. Patients must achieve CCyR
How we know that the patient has achieved CCyR?
When the patient has to achieve CCyR?
How we make sure that the patient remains in CCyR?

15. Patients must achieve CCyR
How we know that the patient has achieved CCyR?
When the patient has to achieve CCyR?
How we make sure that the patient remains in CCyR?

16. Patients must achieve CCyR
How we know that the patient has achieved CCyR?
When the patient has to achieve CCyR?
How we make sure that the patient remains in CCyR?

17. Total number of leukaemia cells13
Leucocytosis 10
100 12 10 10
Ph-chromosome pos 11 10 1 10 10
0.1
RT-PCR positive 9 10
BCR-ABL/ABL ratio (%)
(Ph-negative)
0.01 8 10
0.001 7
Total number of leukaemia cells 10
0.0001 6 10 5 10 4 10
RT-PCR negative 3 10 2 10 10
Adapted from Lin et al. Genes Chromosomes and Cancer 1995

18. Total number of leukaemia cells
Metaphases
Transcript
level at
diagnosis 10 1
0.1
0.01
0.001
100
BCR/ABL/ABL ratio (%)
Total number of leukaemia cells
1011
1010
109
108
107
1012
1013
High WBC
Metaphases
Normal WBC
CHR

19. Cumulate incidence of CCyR
PFS and probability of CCyR according to the haematological response at 3 months 60 54 48 42 36 30 24 18 12 6
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
CHR, n=216
Cumulate incidence of CCyR
Probability of PFS
No CHR, n=8
PFS: p=0.002
CCyR: p=0.0003
Months from starting imatinib therapy
Marin, Blood 2008

20. Total number of leukaemia cells
Transcript
level at
diagnosis 10 1
0.1
0.01
0.001
100
BCR/ABL/ABL ratio (%)
Total number of leukaemia cells
1011
1010
109
108
107
1012
1013
Metaphases
CHR
Metaphases
MiCyR

21. Total number of leukaemia cells
Transcript
level at
diagnosis 10 1
0.1
0.01
0.001
100
BCR/ABL/ABL ratio (%)
Total number of leukaemia cells
1011
1010
109
108
107
1012
1013
Metaphases
CHR
MiCyR
MiCyR
Metaphases
MCyR

22. Total number of leukaemia cells10 1
0.1
0.01
0.001
100
BCR/ABL/ABL ratio (%)
Total number of leukaemia cells
1011
1010
109
108
107
1012
1013
Metaphases
CHR
MiCyR
MCyR
MCyR
Metaphases
CCyR

23. Total number of leukaemia cells10 1
0.1
0.01
0.001
100
BCR/ABL/ABL ratio (%)
Total number of leukaemia cells
1011
1010
109
108
107
1012
1013
Metaphases
CHR
MiCyR
MCyR
CCyR
CCyR
Metaphases
MMR

24. Total number of leukaemia cells10 1
0.1
0.01
0.001
100
BCR/ABL/ABL ratio (%)
Total number of leukaemia cells
1011
1010
109
108
107
1012
1013
Metaphases
CHR
MiCyR
MCyR
CCyR
MMR
MMR
Metaphases
CMR

25. Patients must achieve CCyR
How we know that the patient has achieved CCyR?
When the patient has to achieve CCyR?
How we make sure that the patient remains in CCyR?

26. Probability of CCyR according
to the cytogenetic response at 3 and 6 months (n=204) 60 54 48 42 36 30 24 18 12 6
0.0
Months from start of imatinib therapy
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
Cumulative incidence of response
1-35% Ph+
36-95% Ph+
96-100% Ph+
A, 3 months
B, 6 months
p<
p<
de Lavallade, JCO 2008

27. Patients must achieve CCyR
How we know that the patient has achieved CCyR?
When the patient has to achieve CCyR?
How we make sure that the patient remains in CCyR?

28. Months from start of imatinib
How to monitor the patient and desired responses
MiCyR?
MCyR?
CCyR? {
G-Banding {
MMR?
Early detection
of relapse
RQ-PCR
100 10
CCyR 1
3 log
BCR/ABL/ABL ratio (%)
0.1
FISH negative
0.01
0.001
Level of detection
0.0001 3 6 9 12 15 18 21 24 27
Months from start of imatinib

29. So, what is the best first line therapy?

30. Study Design and EndpointsR A N
D O M I Z ED *
Nilotinib 300 mg BID (n = 282)
N = 846
217 centers
35 countries
Nilotinib 400 mg BID (n = 281)
Imatinib 400 mg QD (n = 283)
Follow-up
5 years
Primary endpoint: MMR at 12 months
Key secondary endpoint: Durable MMR at 24 months
Other endpoints: CCyR by 12 months, time to MMR and CCyR, EFS, PFS, time to AP/BC on study treatment, OS including follow-up
*Stratification by Sokal risk score 30 30

31. Dasatinib Versus Imatinib Study In Treatment-naïve CML: DASISION (CA180-056). Design
Imatinib 400 mg QD (n=260)
Dasatinib 100 mg QD (n=259)
N=519
108 centers
26 countries
Follow-up
5 years
Randomized*
*Stratified by Hasford risk score
Primary endpoint: Confirmed CCyR by 12 months
Secondary/other endpoints: Rates of CCyR and MMR; times to confirmed CCyR, CCyR and MMR; time in confirmed CCyR and CCyR; PFS; overall survival

32. CCyR Rates* by 12 Months and Overall
P < .001
P < .0001
P = .017
P < .001
% CCyR
n = n = n = 283
n = n = n = 283
Among patients who had a cytogenetic assessment at 18 months (n = 442/846), the rates of CCyR were:
99%, 99%, and 89% for nilotinib 300 mg BID, 400 mg BID, and imatinib
Data cut-off: 2Jan2010
*ITT population 32

33. DASISION: First-Line Dasatinib vs. Imatinib in CML-CP. CCyR rates (ITT)
Dasatinib 100mg QD Imatinib 400mg QD
P=0.0011
CCyR
(%)
Mo 3 Mo 6 Mo 9 Mo 12
By analysis of time to CCyR, likelihood of achieving CCyR at any time ~50% higher with dasatinib than with imatinib (stratified log-rank P<0.0001; HR=1.53)

34. Patient Disposition Nilotinib 300 mg BID n = 282 Nilotinib 400 mg BID
Imatinib 400 mg QD
n = 283
Still on treatment
80%
81%
75%
Discontinued, % 20 19 25
Disease progression*
<1
<1 4
Suboptimal response/
treatment failure*# 6 2 8
Adverse events 5 10 8
Abnormal lab. values 2 2 1
Overall, 80% and 81% of patients remained on study in the nilotinib 300 mg BID and 400 mg BID arms, while 75% of patients remained on the imatinib arm
Thus, more patients discontinued imatinib (25%) compared with nilotinib 300 mg BID (20%) or 400 mg BID (19%)
Importantly, more patients discontinued imatinib due to disease progression to AP/BC, and suboptimal response or treatment failure as defined by the ELN
Discontinuation due to adverse events or laboratory abnormalities was lowest for nilotinib 300 mg BID
Death 1
Protocol violation 2 2 1
Other reason 4 3 3
*Investigator assessment of criteria
#Patients were required to discontinue nilotinib 300 mg BID for suboptimal response but could remain on nilotinib 400 mg BID
Data cut-off: 2Jan2010 34

35. DASISION: First-Line Dasatinib vs. Imatinib in CML-CP
DASISION: First-Line Dasatinib vs. Imatinib in CML-CP. Treatment Discontinuations
% Patients
Dasatinib 100 mg QD
n=258
Imatinib 400 mg QD n=258
Still on treatment
84.5
81.4
Discontinued
15.5
18.6
Treatment failure including progression
5.0
8.9
Study drug toxicity
4.3
Adverse event unrelated
1.2
0.4
Other reason*
4.2
*Includes consent withdrawal, pregnancy, lost to follow-up and death

36. Outcome in 282 patients treated with imatinib
first line in Hammersmith Hospital
94%
6% death non CML
10% death because the CML
84%
77%
7% alive but not in CCyR
29% in CCyR but not on imatinib
48%
48% in CCyR on imatinib

37. Outcome in 135 patients treated with second line
dasatinib or nilotinib in Hammersmith Hospital
Probability
Time (years) from the onset of second line therapy
OS, 82%
C-CCyRS, 54%
EFS, 35%

38. Outcome in 135 patients treated with second line dasatinib or nilotinib according to the cytogenetic response achieved at 12 months
Time (years) from the onset of second line therapy
Probability of cCCyR-S
p=0.008
CCyR at 12 months, n=48
no CCyR at 12 months, n=51

39. Outcome in 135 patients treated with second line dasatinib or nilotinib according to the cytogenetic response achieved at 12 months
Time (years) from the onset of second line therapy
Probability
CCyR at 12 months, n=48
no CCyR at 12 months, n=51

40. It is far from certain which is going to be the best line therapy as the log term benefit of a modest improvement in the CCyR rate induced by a given drug may be easily overcome by a higher therapy discontinuation rate on that drug

41. the molecular response achieved at 3 months
Cumulative incidence of CCyR in patients treated with dasatinib first line therapy in the SPIRIT-II trial according to
the molecular response achieved at 3 months
Cumulative incidence of CCyR
Time from diagnosis (months)
3 months BCR-ABL/ABL <10%
3 months BCR-ABL/ABL >10%
p=0.02

42. Cumulative incidence of CCyR in the SPIRIT-II trial according to the treatment arm and the molecular response achieved at 3 months
Time from diagnosis (months)
Cumulative incidence of CCyR
3 months BCR-ABL/ABL <10%
3 months BCR-ABL/ABL >10%
Dasatinib
Imatinib

43. The key principles of therapy are:
Promptly identification of the high risk patients
Change of therapy according to tolerance and response

44. What is the best why to detect who is not doing well?

45. Probability of CCyR according
to the cytogenetic response at 3 and 6 months (n=204) 60 54 48 42 36 30 24 18 12 6
0.0
Months from start of imatinib therapy
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
Cumulative incidence of response
1-35% Ph+
36-95% Ph+
96-100% Ph+
A, 3 months
B, 6 months
p<
p<
de Lavallade, JCO 2008

46. We can do better than that!

47. We can identify what is the 3 months transcript level that predicts for overall survival with the maximal sensitivity and specify

48. Survival in 282 patients treated with imatinib first line in Hammersmith Hospital according to the molecular response achieved at 3 months
BCR-ABL/ABL<10% OS= 93.3%
Probability of survival
BCR-ABL/ABL>10% OS= 54%
p<0.0001
Time from onset of imatinib therapy (years)

49. Outcome in 282 patients treated with imatinib first line in Hammersmith Hospital according to the molecular response achieved at 3 months
BCR-ABL/ABL<10%, c-CCyRS= 91%
Probability of c-CCyRS
BCR-ABL/ABL>10% c-CCyRS= 48%
p =0.0002
Time from onset of imatinib therapy (years)

50. Evolution of the transcript level in 282 patients treated
with imatinib first line therapy
Off
Imatinib
CMR
BCR-ABL1/ABL1 (log)
high transcript level at 3 month
low transcript level at 3 month

51. 8-year cumulative incidence of CMR on imatinib therapy according
to the BCR-ABL1 transcript level at 3 months.
Cumulative incidence of CMR
Time from onset of therapy (years)
3-month transcript ratio ≤0.61% (n=57), 8-year CI of CMR of 84.7%,
p<0.0001
3-month transcript ratio >0.61% (n=222), 8-years CI of CMR of 1.5%

52. It is important to achieve MMR?

53. Months from start of imatinib
Molecular responses 10 1
0.1
0.01
0.001
100
0.0001
BCR/ABL/ABL ratio (%)
CCyR 6 9 15 18 21 24 27 3
Months from start of imatinib 12
Level of detection
3 log
FISH negative

54. PFS is similar in patients with CCyR regardless of the depth of molecular response60 54 48 42 36 30 24 18 12 6
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
Probability of PFS
Months from starting imatinib therapy
CCyR with no MMR, n=91
CCyR with MMR, n= 41
p= 0.4
18 months
Marin et al, Blood 2008

55. PFS similar in patients with CCyR regardless of depth of molecular response
Druker BJ, et al. NEJM, 2006;355(25):

56. PFS is similar in patients with CCyR regardless of depth of molecular response
Kantarjian HM, et al. Blood. 2006;108:

57. Probability of loss of CCyR according to the level of molecular response
Marin et al, Blood 2008

58. The definition of MMR is wrong
Do not be silly!

59. Problems with MMR
The depth of the molecular response in a given patient is basically driven by the patient’s adherence to therapy
The definition of MMR is arbitrary

60. Problems with MMR
The depth of the molecular response in a given patient is basically driven by the patient’s adherence to therapy
The definition of MMR is arbitrary

61. There is a great variability in the response to imatinib. I wonder why10 1
0.1
0.01
0.001
100
BCR-ABL/ABL ratio (%)
CCyR
3 log
0.0001
Time from start of imatinib

62. Time from start of imatinib
Study design 10 1
0.1
0.01
0.001
100
BCR/ABL/ABL ratio (%)
MEMS
Imatinib plasma level
TKD
mutations
Time from start of imatinib
hOCT1 level
MDR-1 polymorphisms
BCR-ABL transcript type
BCR-ABL transcript level
Sokal score Hb
WBC
Sex
Age
We correlated all these variables with the
molecular response achieved by the patient 62

63. Microelectronic Monitoring System (MEMS 6 Trackcap)
Records the time of opening the container
Most reliable method of measuring adherence
Our patients: not told about the chip
The over adherence was studied in patients taking tamoxifen in the Waterhouse paper 63

64. 64 64

65. Long term adherence to imatinib90 80 70 60
Proportion of patients (%) 50
40.2% 40 30
25.3% 20
13.8%
12.6% 8% 10
<80%
80–90%
90–95%
95–99%
≥100%
Percentage of intended dose
Marin D, et al. J Clin Oncol 2010; 28(14): 2381–2388.

66. Lack of adherence is underestimated by conventional methods
Percentage of intended dose
≥100%
95–99%
90–95%
80–90%
<80%
Proportion of patients (%)
100 90 80 70 60 50 40 30 20 10
Self reporting
Pill count
MEMS
Marin D, et al. J Clin Oncol 2010; 28(14): 2381–2388.

67. 67

68. Well, some patients miss a few doses,
so what?

69. 6-year probability of response
Achievement of a molecular response is related to the adherence to imatinib therapy
6-year probability of response
Adherence rate n
MMR (%)
4-log (%)
CMR (%)
100%
<99% 36 51
p=0.01
91.1
58.6
p=0.02
79.9
38.6
46.7
22.7
>95%
<95% 57 30
p<0.001
94.5
29.3
77.2
15.0
p=0.002
45.2
8.2
>90%
<90% 64 23
93.7
13.9
76.0
4.3
43.8
>85%
<85% 69 18
85.8
11.8
p=0.001
69.2
5.6
p=0.007
40.8
>80%
<80% 75 12
81.2
p=0.005
63.8
p=0.04
37.1
Marin D, et al. J Clin Oncol 2010; 28(14): 2381–2388.

70. 6-year probability of MMR according to the measured adherence rate
Marin D, et al. J Clin Oncol 2010; 28(14): 2381–2388. 70

71. 6-year probability of CMR according to the measured adherence rate
Marin D, et al. J Clin Oncol 2010; 28(14): 2381–2388.

72. Other variables are also predictive for the achievement of molecular response
MMR (%)
4-log (%)
CMR (%)
Hemoglobin
≤115 g/l
>115 g/l RR 40 47
p=0.036
59.2
80.7
1.186, p=0.012
p=0.03
39.5
69.1
1.323, p=0.01
p=0.011
14.7
47.6
1.209, p=0.07
Leukocytes
≤140 x 109/l
>140 x 109/l 44 43
p=0.012
78.8
63.1
0.996, p=0.008
p=0.022
56.7
37.6
0.996, p=0.015
p=0.17
35.4
28.1
0.996, p=0.11
BCR-ABL1/ABL1 ratio
≤100%
>100%
p=0.25
71.4
52.6
0.996, p=0.44
p=0.038
53.0
26.6
0.971, p=0.002
p=0.1
32.7
8.4
0.979, p=0.13
hOCT1 transcript level
≤0.16
>0.16 30
p<0.001
55.2
81.4
2.199, p<0.001
p=0.01
42.0
64.8
1.990, p=0.001
p=0.02
16.6
45.3
1.665, p=0.04
Imatinib plasma level
≤1 g/ml
>1 g/ml 41
60.1
83.2
2.11, p=0.01
p=0.07
68.0
2.50, p=0.06
p=0.14
23.3
44.4
2.25, p=0.09
Adherence rate
>90%
≤90% 64 23
93.7
13.9
1.093, p<0.001
76.0
4.3
1.104, p=0.002
p=0.002
43.8
RR= 1.135, p=0.012
Marin D, et al. J Clin Oncol 2010; 28(14): 2381–2388.

73. But adherence to therapy is the critical factor for achieving molecular response
MMR
adherence to imatinib therapy, RR=11.17 (p=0.001)
hOCT1 transcript level, RR=1.79 (p=0.038)
CMR
adherence to imatinib therapy, RR=19.35 (p=0.004)
Marin D, et al. J Clin Oncol 2010; 28(14): 2381–2388.

74. Imatinib plasma levels are not an independent predictor of molecular response
Adherent patients
Total population
Marin D, et al. J Clin Oncol 2010; 28(14): 2381–2388.

75. Who will sustain CCyR?

76. Time from start of imatinib
Study design 10 1
0.1
0.01
0.001
100
BCR/ABL/ABL ratio (%)
MEMS
Time from start of imatinib
hOCT1 level
MDR-1 polymorphisms
BCR-ABL transcript type
BCR-ABL transcript level
Sokal score Hb
WBC
Sex
Age
We correlated all these variables with the
molecular response achieved by the patient 76

77. Poor adherent patients have a higher probability of losing the CCyR and a lower EFS
Ibrahim, Blood 2011

78. On multivariate analysis, the adherence rate and having failed to achieve a major molecular response are the only independent predictors for loss of CCyR and discontinuation of imatinib therapy.
Ibrahim, Blood 2011

79. Probability of imatinib failure
Adherence and the achievement of MMR are the only independent predictors for outcome
Probability of imatinib failure
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
Months from enrolment
0.0 24 18 12 6
p<0.0001
CCyR, no MMR, Adherence Rate ≤85%, n=11
MMR, n=53
CCyR, no MMR, Adherence Rate >85%, n=23
p=0.003
Ibrahim, Blood 2011

80. Problems with MMR
The depth of the molecular response in a given patient is basically driven by the patient’s adherence to therapy
The definition of MMR is arbitrary

81. Total number of leukaemia cells10 1
0.1
0.01
0.001
100
BCR/ABL/ABL ratio (%)
Total number of leukaemia cells
1011
1010
109
108
107
1012
1013
Metaphases
CHR
MiCyR
MCyR
CCyR
CCyR
Metaphases
MMR

82. 166 out of 282 patients who received imatinib as first line therapy were in CCyR at 12 months
Transcript level OS
(%)
EFS
>0.1%
<0.1%
125 41
p=0.5
94.2
96.3
p=0.08
80.4
93.7

83. 166 out of 282 patients who received imatinib as first line therapy were in CCyR at 12 months
Transcript level OS
(%)
EFS
>0.1%
<0.1%
125 41
p=0.5
94.2
96.3
p=0.08
80.4
93.7
>0.53
<0.53 20
146
p=0.01
81.5
94.4
p<0.0001
29.5
74.3

84. It can not be a talk about CML without mentioning KD mutations

85. I am going to try to challenge the orthodox view about kinase domain mutations

87. The points I want to make are:
The meaning of KD mutations is often misunderstood
The uses in clinical practice are very limited

88. Sensitivity studies help us to choose the best antibiotic
Sensitivity studies help us to choose the best antibiotic. Similarly mutation analysis help us to choose the best TKI
Are you sure?

89. Figure 3. MCyR rates in patients with or without a baseline BCR-ABL mutation80
Any BCR-ABL mutation
No BCR-ABL mutation 70 66 67 67 11 56 8 10 60 55
PCyR 54 12
CCyR 48 8 14 22 11 % 40 58 58 57 54 46 20 41 37 34
100 mg once daily
(n=49)
70 mg BID
(n=50)
140 mg once daily
(n=50)
50 mg BID
(n=63)
100 mg once daily
(n=98)
70 mg BID
(n=96)
140 mg once daily
(n=89)
50 mg BID
(n=86)

90. Group A, High transcript levels- mutant clone predominates10 1
0.1
0.01
0.001
100
0.0001
100 75
Percentage of mutant transcripts 50
BCR/ABL/ABL ratio (%) 25
Imatinib:
600
800
1000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
M244V
Time since the onset of imatinib therapy (months)
Interval from diagnosis to start of imatinib: 4 months
Khorashad, Leukemia 2006

91. Group B, Low transcript levels- mutant clone predominates
100
100 10 75
Percentage of mutant transcripts 1 50
0.1 25
BCR/ABL/ABL ratio (%)
0.01
Imatinib: 400
600
400
0.001
S438C
0.0001 3 6 9 12 15 18 21 24 27 30 33 35 36 39 42 45
Time since the onset of imatinib therapy (months)
Interval from diagnosis to start of imatinib: 2 months
Khorashad, Leukemia 2006

92. Group C, Variable transcript levels- mutant clone is rare10 1
0.1
0.01
0.001
100
0.0001
100 75
Percentage of mutant transcripts 50 25
BCR/ABL/ABL ratio (%)
Imatinib: 400 3 6 9 12 15 18 21 24 27 30 33 35 36 39 42 45
G250E
Time since the onset of imatinib therapy (months)
Interval from diagnosis to start of imatinib: 36 months
Khorashad, Leukemia 2006

93. What is the biological significance of KD mutations?

94. In order to answer this question we systematically screened all our CP (n=319) patients treated with imatinib for mutations regardless of whether or not they shown any sign of resistance

95. Mutation screening Mutation=0 Mutation=M244V, 55% 12 m 18 m
undetectable 5%
20%
12 m
18 m
Khorashad et al, JCO, 2008

96. Cumulative Incidence of KD Mutations
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
Cumulative incidence of KD mutations
13.9% 60 54 48 42 36 30 24 18 12 6
Months from starting imatinib therapy
Khorashad et al, JCO, 2008

97. Mutations in Patients who Achieved CCyR
214 CCyR patients: 6 (3%) with mutations
All of them lost CCyR
T315I, L387M, S417F, E459K, G459K, and M351T
Median interval from mutation detection to loss of CCyR: 20.8 months
Median interval from mutation detection to any change in the BCR-ABL transcript level: 12 months
Khorashad et al, JCO, 2008 97

98. The Development of Mutation Predicts for the Loss of CCyR
KD mutation was the only predictive factor for loss of CCyR in the multivariate analysis:
RR=3.8, p=0.005
Khorashad et al, JCO, 2008 98

99. First detection of mutation
Example 1 10 1
0.1
0.01
0.001
100
0.0001
BCR/ABL/ABL ratio (%, blue)
Time since the onset of imatinib therapy (months)
100%
75%
50%
25% 0%
Percentage of mutant transcripts (%, red) 2 3 4 5 6 7 8 9 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
CCyR
Loss of CCyR BP
Panel A, patient 34 (E459K)
Doubling
transcript levels
First detection of mutation

100. First detection of mutation
Example 2 10 1
0.1
0.01
0.001
100
0.0001
BCR/ABL/ABL ratio (%, blue)
Time since the onset of imatinib therapy (months)
100%
75%
50%
25% 0%
Percentage of mutant transcripts (%, red) 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 v
CCyR
Loss of CCyR
Panel B, patient 29 (M351T)
Doubling
transcript levels
First detection of mutation

101. Prognostic Impact on PFS
Among 319 patients, 49 (15%) progressed to advanced phase
17 of 49 (35%) had a mutation detected before progression
14 of 17 had a mutation detected while still in CHR
median interval (detection-progression): 16.3 months
median interval (detection-loss of CHR): 13.7 months
Khorashad et al, JCO, 2008
101

102. Prognostic Impact on PFS
Multivariate analysis in the whole population (m=319), showed that KD mutations and the achievement of CCyR are the only independent predictor for PFS
CCyR (RR=0.15, p<0.0001)
Mutation detection (RR=2.3, p=0.014)
Khorashad et al, JCO, 2008
102

103. Landmark at 2 Years, PFS Khorashad et al, JCO, 2008 CCyR vs no CCyR
Mutation vs. no mutation
90%
66%
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
84%
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
35%
-- CCyR (n=143)
-- no CCyR (n=107)
Probability of PFS
Probability of PFS
--’no mutation’ group (n=225)
--’mutation’ group (n=25)
P< P= 84 78 72 66 60 52 48 42 36 30 24 18 12 6 84 78 72 66 60 52 48 42 36 30 24 18 12 6
Months from starting imatinib therapy
Months from starting imatinib therapy
Khorashad et al, JCO, 2008

104. Conclusion
TKD mutations are mere surrogate markers for genetic instability and in many cases are not the real reason for resistance
Khorashad et al, JCO, 2008

105. How should we use the mutation screening in practice?

106. Perform mutation analysis only at the moment of switching therapy
Perform a mutation analysis on a regular basis (i.e every 3 months) regardless of any sign of resistance
Caveat: it is extremely cost ineffective
Perform mutation analysis only at the moment of switching therapy

107. Frequency of baseline BCR-ABL mutations by in vitro IC50 to dasatinib (N=1043)
Unknown IC50 to dasatinib (n=83)
43 different BCR-ABL mutations 8%
IC50 ≤3 nM (n=254) M244V, G250E, Y253F/H/K, F311L, M351T, E355G, F359C/I/V, V379I, L387M, H396P/R
No BCR-ABL mutation
(n=641)
61%
24%
<1% V299L (n=1)
IC50 >3 nM
(n=44) 4%
1% Q252H (n=6)
1% F317L (n=14)
2% E255K/V (n=25)
2% T315I (n=21) IC50 >200 nM
Müller M, et al. ASH 2008: Abstract 449.

108. 2G-TKD mutations Dasatinib: T315I, T315A, V299L F317V, F317L
Nilotinib: T315I, Y253F, Y253H, E255V, E255K

109. You agree with me if you think that:
What matters is whether the patient is resistant, not if a mutation is present.
Mutation analysis may be helpful in choosing a 2G-TKI in 5%-10% of the cases
Mutations are surrogate marker for genomic instability

110. Thanks to John Goldman
and other friends who are too numerous to be mentioned individually
David, Thankfully your patients fare better than your plants