1. Clinical Case Nº1 Dr. Giovanni Grignani

2. Patient medical history (I) 53-year-old woman Mild form of anxiety-depression treated with paroxetine 20 mg per day. 18 months before admission to our center: Total hysterectomy because of a uterine lump Diagnosis Uterine leiomyosarcoma: 11 cm wide, high grade of cellular atypia and 23 mitosis x 10 HPF Diagnosis Uterine leiomyosarcoma: 11 cm wide, high grade of cellular atypia and 23 mitosis x 10 HPF No tumor cells in abdominal washing After CT scan: No adjuvant therapy was proposed No tumor cells in abdominal washing After CT scan: No adjuvant therapy was proposed

3. One year after surgery: Lung metastases Patient was referred to a thoracic surgeon for a lung metastasectomy Three months after ending adjuvant chemotherapy: a new pulmonary metastasis was detected The patient was referred to our center Pathologic report: 4 nodules of LMS (15, 14, 11 and 9 mm of largest diameters) Pathologic report: 4 nodules of LMS (15, 14, 11 and 9 mm of largest diameters) No signs of residual disease Adjuvant chemotherapy: 4 cycles of doxo 75 mg/m 2 + ifo 9 g/m 2 /21 days with G-CSF support Adjuvant chemotherapy: 4 cycles of doxo 75 mg/m 2 + ifo 9 g/m 2 /21 days with G-CSF support Patient medical history (II) Toxicity as expected

4. Metastasis in the left inferior lung lobe Asymptomatic with PS: 0 CT scan: three further small nodules Due to the short time elapsed between previous surgery and relapse: Patient description The patient declined metastasectomy

5. Starting a chemotherapy treatment is clearly the next step, but what treatment would you use? a.Anthracycline +/- Ifosfamide b.Anthracycline +/- Dacarbazine c.Trabectedin d.Gemcitabine +/- Docetaxel e.Pazopanib f.Dacarbazine +/- Gemcitabine g.Ifosfamide monotherapy Soft tissue and visceral sarcomas: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 2014

6. Anthracycline + ifosfamide is not an option due to the early relapse after the adjuvant therapy and the risk of cumulative toxicity. The option of ifosfamide monotherapy should also be discarded, ESMO clinical guidelines indicate that its activity in leiomyosarcoma patients is far less convincing on available retrospective evidence (no benefit from ifosfamide, with significantly decreased OS compared with doxorubicin monotherapy; p=0.0247). 1-2 In the pazopanib registration study, 168 leiomyosarcoma patients were included. Compared with placebo, pazopanib significantly prolonged progression-free survival (4.9 vs 1.9 months; HR=0.37; p< 0.001) 3-4 not showing specific advantage in U-leiomyosarcoma. 5 Important facts to be taken into account 1. The ESMO / European Sarcoma Network Working Group. Ann Oncol. 2012;23(Suppl7):vii92–vii99;2. Sleijfer S, et al. Eur J Cancer. 2010;46:72–83; 3. van der Graaf W, et al. The lancet. 2012;379(9829):1879-86; 4. Votrient ® Summary of product characteristics. Available at: http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/001141/WC500094272.pdf; 5. Ray-Coquard I, et al. J Clin Oncol 32:5s, 2014 (suppl; abstr 10579)http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/001141/WC500094272.pdf

7. Gemcitabine + docetaxel: Phase II trial in 51 U-LMS patients as second line treatment: 1 ORR: 27%; Median PFS: 5.6 months; Median OS: 14.7 months Acceptable tolerability, but half of patients required at least one red blood cell transfusion and 12.5% received at least one platelet transfusion. Pulmonary toxicity was reported as grade 2 in 8.3%, grade 3 in 6.2% and grade 4 in 2% of patients. G-CSF recommended (high risk of febrile neutropenia) Trabectedin monotherapy has shown activity in 66 U-LMS patients who had failed a median of three previous cytotoxic lines (including 100% anthracycline ± ifosfamide; 87% gem ± docetaxel): 2 ORR: 16% + SD: 35%; Median PFS: 3.3 months; Median OS: 14.4 months Good tolerability and lack of cumulative toxicity. Treatment choice between… 1. Hensley M, et al. Gynecol Oncol. 2008;109:323-8; 2. Sanfilippo R, et al. Gynecol Oncol. 2011;123(3):553-6.

8. Both treatments have a different role in the treatment of uterine leiomyosarcoma depending on what is patient’s ultimate goal of treatment: 1 Treatment choice between… Trabectedin: High tumour control rate Long-term treatment Well-tolerated Trabectedin: High tumour control rate Long-term treatment Well-tolerated Gem/tax: Higher response rate Higher toxicity Gem/tax: Higher response rate Higher toxicity Goal of treatment: To make an advanced tumor or limited metastatic disease resectable or controlling symptomatic disease related to tumour size. Goal of treatment: Long-term tumor stabilization with good quality of life. 1. Reichardt P. Expert Rev. Anticancer Ther. 2013;13(6 Suppl.1):25-30. Main goal of treatment in our case: Asymptomatic patient Unwilling to be operated Main goal of treatment in our case: Asymptomatic patient Unwilling to be operated

9. Patient was re-evaluated after 2 cycles showing disease stability (hints of response) Toxicity was as expected (neutropenia G3, fatigue G1, transaminase elevation G2). Case evolution After 2 more cycles, asymptomatic and prolonged neutropenia G4 together with worsening of fatigue to grade 2 occurred. Trabectedin was started at the standard dose: –1.5 mg/m 2 24-hr continuous infusion every 3 weeks. Baseline After 2 cycles

10. Then, what would you do? a.Reduce trabectedin dose b.Interrupt treatment with trabectedin c.Delay next cycle for 1 week and repeat the tests then d.Continue with the same treatment

11. Absolute neutrophil count (ANC) ≥ 1,500/mm 3 Platelet count ≥ 100,000/mm 3 Bilirubin ≤ upper limit of normal (ULN) Alkaline phosphatase ≤ 2.5 ULN Albumin ≥ 25 g/L Alanine aminotransferase (ALT) and Aspartate aminotransferase (AST) ≤ 2.5 x ULN Creatinine clearance ≥ 30 mL/min Creatine phosphokinase (CPK) ≤ 2.5 ULN Haemoglobin ≥ 9 g/dL Yondelis Summary of Product Characteristics. Available at: http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/000773/WC500045832.pdf Trabectedin dosing guidelines Criteria to be met before treatment and prior to each cycle The same criteria should be met prior to re ‑ treatment. Otherwise treatment should be delayed for up to 3 weeks until the criteria are met.

12. The recommended dose must be reduced if appearance between cycles of any: –Neutropenia < 500 /mm 3 (Grade 4) lasting for more than 5 days or associated with fever or infection –Thrombocytopenia < 25,000 /mm3 (Grade 4) –Increase of bilirubin > ULN (Grade 1) and/or alkaline phosphatase >2.5 x ULN (Grade 2) –Increase of aminotransferases (AST or ALT) > 2.5 x ULN (Grade 2) which has not recovered by day 21 –Any other grade 3 or 4 adverse reactions (nausea, vomiting, fatigue…) Yondelis Summary of Product Characteristics. Available at: http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/000773/WC500045832.pdf Trabectedin dosing guidelines Dose level Trabectedin Dose Initial dose1.5 mg/m 2 1.2 mg/m 2 -21 mg/m 2 Further dose reduction and dose escalation are not recommended

13. After 2 more cycles at the reduced dose, a new CT scan showed: Case evolution Partial response of the largest lesion Complete disappearance of smaller nodules Partial response of the largest lesion Complete disappearance of smaller nodules BaselineAfter 6 cyclesAfter 2 cycles

14. At this point, patient refused surgery stating that she was willing to continue trabectedin. After 2 more cycles (total 8 cycles), a new CT scan could not detect any residual metastases. Treatment was continued performing 4 additional cycles as a maintenance therapy with adequate tolerability. Case evolution After a follow up of 14 months the patient is still in complete remission

15. Follow up: August 2014

16. This clinical case perfectly exemplifies the importance of listening to the patient. h This uterine leiomyosarcoma patient rejected a new surgery to then receive a total of 12 cycles of trabectedin in second line. k Unlike the results obtained with the two previous surgeries and adjuvant therapy, with trabectedin treatment a complete remission maintained until today was achieved (14 months after the end of treatment). i It is of key importance following trabectedin dosing guidelines in order to assure its appropriate safety profile. k Trabectedin is a treatment choice when looking for long-lasting tumor stabilization with good quality of life. However, prolonged complete responses can also be achieved with this agent. Take home messages

17. YON0914-732