1. Update on Iron Toxicity in Myelodysplastic Syndromes: I. Myelodysplastic Syndromes Update Aristoteles Giagounidis, MD, PhD Department of Haematology and Oncology St. Johannes Hospital Duisburg, Germany

2. Cumulative Survival of 1806 Untreated Patients with Primary MDS (Düsseldorf MDS Registry, 1970–2003) Years Graphic courtesy of Dr. U. Germing. 2 0 0.6 0.4 0.2 0.0 0.8 1.0 46810 12 141618 20 Cumulative Survival

3. Score Prognostic Variable 00.51.01.52.0 BM blasts (%)<55–10––11–2021–30 KaryotypeGood a Intermediate b Poor c –– Cytopaenia d 0/12/3–– a Good: normal, -Y, del(5q), del(20q); b Intermediate: other abnormalities not seen in “good” or “poor”; c Poor: complex (≥3 abnormalities) or chromosome 7 anomalies; d Haemoglobin <10 g/dL, absolute neutrophil count <1.5  10 9 /L, platelet count < 100  10 9 /L. International Prognostic Scoring System (IPSS) Graphic on top: with permission from Greenberg P, et al. Blood. 1997;89:2079-2088.Score Risk Subgroup Median Survival (Y) 0Low5.7 0.5–1.0Intermediate-13.5 1.5–2.0Intermediate-21.2 ≥2.5High0.4

4. Prognosis of MDS according to the IPSS Survival (%) Low Int-1 Int-2 High SurvivalAML evolution 0 10 20 30 40 50 60 70 80 90 100 0123456789101112131415161718 Time (years) 0 10 20 30 40 50 60 70 80 90 100 0123456789101112131415161718 AML Evolution (%) Time (years) Low Int-1 Int-2 High With permission from Greenberg P, et al. Blood. 1997;89:2079-2088.

5. Score Parameter0123 WHO categoryRA, RARS, 5q–RCMD, RCMD-RSRAEB-1RAEB-2 KaryotypeGood a Intermediate b Poor c –– TransfusionYesRegular–– a Good: normal, -Y, del(5q), del(20q); b Intermediate: other abnormalities not seen in “good” or “poor”; c Poor: complex (≥3 abnormalities) or chromosome 7 anomalies; d median survival. With permission from Malcovati L, et al. Blood. 2005;106:abstract 788. WHO Classification-Based Prognostic Scoring System (WPSS)Score Risk Subgroup Survival, Italian Cohort (m) Survival, German Cohort (m) 0Very low103141 1Low7266 2Intermediate4048 3–4High2126 5–6Very high129

6. Survival and Risk of Leukaemic Progression According to WPSS at Diagnosis With permission from Malcovati L, et al. J Clin Oncol. 2007;25:3503-3510. Overall Survival (P <.001) Risk of AML Evolution (P <.001) Abbreviation: AML, acute myeloid leukaemia.

7. ComorbidityScore Cardiac disease2 Moderate-to-severe hepatic disease 1 Severe pulmonary disease 1 Renal disease1 Solid tumour1 Total Score Risk 2-Y Risk of Nonleukaemic Death 0Low24 1–2Inter- mediate 42 >2High61 MDS-Specific Comorbidity Index To predict the impact of extra-haematologic comorbidities on survival of patients with MDS Left graphic: with permission from Della Porta MG, et al. Blood. 2008;112:abstract 2677.

8. MDS Therapeutic Options Best supportive care, including iron chelation Haematopoietic growth factors Immunosuppressive therapy Differentiation agents Farnesyltransferase inhibitors Thalidomide/lenalidomide Arsenic trioxide Low-dose chemotherapy Epigenetic treatment Intensive chemotherapy Allogeneic stem cell transplantation ´ Low Risk High Risk Prognosis

9. 1 unit PRC 200–250 mg 1–2 mg Daily Losses Iron Imbalance in Chronically Transfused Patients

10. 2 units/month Iron Accumulation Due to Transfusion Therapy Serum ferritin ~1000 μg/L Moderate transfusion requirement Normal body iron: 3–4 g No physiologic mechanism to excrete excess of iron 24 units/year ≥ 5 g iron/year Gattermann N. Hematol Oncol Clin North Am. 2005;19(suppl 1):13-17.

11. Impact of Transfusion Dependency on Nontransplant Candidates With permission from Cazzola M, et al. N Engl J Med. 2005;352:536-538. Transfusion-independent Transfusion-dependent Survival Time (months) Cumulative Proportion Surviving 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 020406080100120140 N = 374 P =.005

12. RA, RARS, or 5q– (HR = 1.42, P <.001) RCMD or RCMD-RS (HR = 1.33, P =.07) With permission from Malcovati L, et al. Haematologica. 2006;91:1588-1590. Overall Survival of Transfusion-Dependent MDS Patients Based on Ferritin Level 180 Cumulative Proportion Surviving 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 020406080100120140160 Cumulative Proportion Surviving 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 020406080100120140160180 Survival Time (months) Serum ferritin (μg/L) 1000 1500 2000 2500 Serum ferritin (μg/L) 1000 1500 2000 2500 Abbreviations: RA, refractory anaemia; RARS, RA with ringed sideroblasts; RCMD, refractory cytopaenia with multilineage dysplasia; RS, ringed sideroblasts.

13. Independent Impact of Iron Overload and Transfusion Dependency on Survival and Leukemic Evolution in Patients with Myelodysplastic Syndrome Sanz G, Nomdedeu B, Such E, Bernal T, Belkaid M, Ardanaz MT, Marco V, Pedro C, Ramos F, del Cañizo C, Luño E, Cobo F, Carbonell F, Gomez V, Muñoz JA, Amigo ML, Bailen A, Bonanad B, Tormo M, Andreu R, Arrizabalaga B, Arilla MJ, Bueno J, Requena MJ, Bargay J, Sanchez J, Senent L, Arenillas L, de Paz R, Xicoy B, Duarte R, Cervera J. (Spanish Registry of MDS) 50th Annual Meeting of the American Society of Hematology San Francisco, California 8 December 2008

14. Overall Survival in Patients with MDS by RBC Transfusion Dependency 0.0 0.2 0.4 0.6 0.8 1.0 0510152025 Years from diagnosis No RBC Transfusion Dependency RBC Transfusion Dependency P <.0001 With permission from Sanz G, et al. 50th Annual American Society of Hematology Meeting; December 6-9, 2008. Abstract 640. N = 2241 Probability of Survival

15. 0.0 0.2 0.4 0.6 0.8 1.0 0510152025 Years from Diagnosis No RBC Transfusion Dependency RBC Transfusion Dependency P <.0001 With permission from Sanz G, et al. 50th Annual American Society of Hematology Meeting; December 6-9, 2008. Abstract 640. N = 2241 Leukaemia-Free Survival in Patients with MDS by RBC Transfusion Dependency Probability of Survival

16. Prognostic Impact of Development of Iron Overload is Independent of WPSS Score Overall Survival Leukaemia-Free Survival Variable a HR P-value Iron overload4.34<.001 WPSS1.60<.001 Variable a HR P-value WPSS2.24<.001 Iron overload2.13<.001 a Multivariate analyses, including WPSS and development of iron overload (time-dependent) (n = 580). Cases with less than 3 serum ferritin measurements were excluded. With permission from Sanz G, et al. 50th Annual American Society of Hematology Meeting; December 6-9, 2008. Abstract 640.

17. Overall Survival in Patients with MDS by Serum Ferritin Level 0.0 0.2 0.4 0.6 0.8 1.0 05101520 Years from Diagnosis Ferritin <1000 ng/mL Ferritin  1000 ng/mL P <.0001 With permission from Sanz G, et al. 50th Annual American Society of Hematology Meeting; December 6-9, 2008. Abstract 640. N = 762 Probability

18. 0.0 0.2 0.4 0.6 0.8 1.0 05101520 Years from Diagnosis Ferritin <1000 ng/mL Ferritin  1000 ng/mL P <.0001 With permission from Sanz G, et al. 50th Annual American Society of Hematology Meeting; December 6-9, 2008. Abstract 640. N = 762 Leukaemia-Free Survival in Patients with MDS by Serum Ferritin Level Probability

19. Impact of Iron Chelation on Survival in MDS 40 mo (0.7–224) Not reached at 160 mo Median overall survival for Low or Int-1 IPSS (P <.03) “Although we were not able to demonstrate a decrease in organ dysfunction in patients receiving ICT for MDS, there was a significant improvement in overall survival” First data to document improvement in clinical outcome in patients with MDS receiving ICT 28 Serum ferritin ≥ 2000 μg/L 22 Clinical evidence of iron overload 18 DFO ICT therapy 10 No ICT Retrospective review of 178 patients (36 RA, 42 RARS, 28 RAEB, 16 RAEB-T or AML, 25 CMML, 31 other) Abbreviations: CMML, chronic myelomonocytic leukaemia; DFO, desferroxamine; ICT, iron chelation therapy; RAEB, refractory anaemia with excess blasts; RAEB-T, RAEB in transformation; RARS, RA with ringed sideroblasts. Leitch HA, et al. Blood. 2006;108:abstract 249. Graphic courtesy of Dr. N. Gattermann.

20. Survival Distribution Function 0.00 0.25 0.50 0.75 1.00 Time from Diagnosis to Death (months) 050100150200250 Iron chelation therapy No iron chelation therapy Median survival: 63 months (whole group); 115 months for chelated vs 51 months for nonchelated patients (P <.0001) Iron Chelation May Improve Survival in MDS Patients With permission from Rose C, et al. Blood. 2007;110:abstract 249.

21. Deferasirox in Patients with Transfusion- Dependent MDS EPIC Trial Design –1-year, multicenter, open-label, single-arm, trial –Deferasirox 10–30 mg/kg/d for 12 months –Primary efficacy endpoint was change in serum ferritin at 12 months Study population, N = 341 –Median age 68 years –Baseline serum ferritin 2730 ng/mL –Mean transfusion dependency duration 3.6 years –Mean blood received in previous year 116.4 mL/kg –Previous chelation 52% Drug-related adverse effects, all grades –Diarrhea 32%, nausea 13%, abdominal pain 15%, vomiting 8%, and rash 7% Conclusion: Significant reductions in serum ferritin levels over 1-year treatment with dose adjustments based on ferritin trends and safety markers Gattermann N, et al. Blood. 2008;112:abstract 633.

22. Serum Ferritin (ng/mL) Change in Serum Ferritin Levels with Deferasirox in MDS EPIC 1 and US03 2 Studies 1. Gattermann N, et al. Blood. 2008;112:abstract 633. 2. List AF, et al. Blood. 2007;110:abstract 1470.

23. Patients (n)53 34 28 19 13 Months from Baseline 0 0.4 0.6 0.8 1.0 Baseline6912 Labile Plasma Iron (  mol/L) 3 0.4 Threshold of Normal Labile Plasma Iron With permission from List AF, et al. Blood. 2007;110:abstract 1470. Deferasirox in Patients with MDS–Study US03 Change of Labile Plasma Iron Over 12 Months

24. 24 Elevated Pretransplant Serum Ferritin May Impact Prognosis of Haemopoietic Stem Cell Transplant (HSCT) in Patients with MDS In HSCT, iron overload may increase treatment- related mortality The hazard ratio for mortality associated with serum ferritin ≥2515 μg/L was 2.6 (P =.003) Serum ferritin is an independent prognostic marker in MDS patients undergoing HSCT Iron chelation therapy has a possible role in the pre- and posttransplant setting Armand P, et al. Blood. 2007;109:4586-4588.

25. Time from Transplantation (years) Overall Survival (%) P <.001 Serum ferritin 1st – 3rd quartile Serum ferritin highest quartile 0 20 40 60 80 100 012345678 Treatment-Related mortality (%) P =.005 Serum ferritin 1st – 3rd quartile Serum ferritin highest quartile 0 20 40 60 80 100 012345678 Time from Transplantation (years) DFS (%) P <.001 Serum ferritin 1st – 3rd quartile Serum ferritin highest quartile 0 20 40 60 80 100 012345678 Relapse (%) P =.7 Serum ferritin 1st – 3rd quartile Serum ferritin highest quartile 0 20 40 60 80 100 012345678 Outcomes According to Pretransplant Serum Ferritin Level in MDS Patients Undergoing HSCT Abbreviations: DFS, disease-free survival; HSCT, haemopoietic stem cell transplant. With permission from Armand P, et al. Blood. 2007;109:4586-4588.

26. Deferasirox Dosing by Transfusion Requirements and Therapeutic Goals Initial recommended dose 20 mg/kg/day For patients receiving pRBCs >14 mL/kg/month (~4 adult units) 30 mg/kg/day to reduce body iron For patients receiving pRBCs >7 mL/kg/month (~2 adult units) 10 mg/kg/day to maintain body iron Numerically half the dose of desferrioxamine For patients well managed on desferrioxamine Exjade. Summary of Product Characteristics. West Sussex, UK: Novartis Europharm Ltd; 2006.

27. Update on Iron Toxicity in Myelodysplastic Syndromes: II. Cardiac Iron Update Alberto Roghi, MD Professor Director, Cardiac Magnetic Resonance Unit Department of Cardiology A.De Gasperis Azienda Ospedaliera Niguarda Ca’Granda Milan, Italy

28. X With permission from Oudit GY, et al. J Mol Med. 2006;84:349-364. Non–transferrin-Bound Iron Transport by L-Type Ca2+ Channels in the Heart Abbreviations: Dcytb, duodenal cytochrome B; DMT1, dimetal transporter 1.

29. Longitudinal Heart and Liver Iron Time Courses in 38 Thlassaemia Major Patients With permission from Noetzli LJ, et al. Blood. 2008;112:2973-2978. Abbreviation: HIC, hepatic iron concentration.

30. Various Iron Loading States Graphic courtesy of Dr. A. Roghi.

31. Iron overload HypoxiaInfections Endocrinopathies OXIDATIVE STRESS Endothelial dysfunction Myocardial impairment Hypercoagulability Graphic courtesy of Dr. A. Roghi.

32. Relationship Between Iron Overload, Oxidative Stress, and Calcium Channels in Myocardial Cells With permission from Oudit GY, et al. J Mol Med. 2006;84:349-364. Abbreviations: NCX, sodium-calcium exchanger; ROS, reactive oxygen species; SR, sarcoplasmic reticulum; SERCA2a, sarcoplasmic reticulum Ca 2+ ATPase isoform 2.

33. Vasodilator Impairment of Aortic Ring by Iron Overload Response to Nitroglycerine Response to Acetylcholine With permission from Day SM, et al. Circulation. 2003;107:2601-2606. Iron n = 3 Control n = 2

34. Nonleukaemic Causes of Death and Relationship to Iron Overload 51% 31% 8% 2% Malcovati L, et al. J Clin Oncol. 2005;23:7594-7603. Death in low-risk myelodysplastic syndromes – cardiac failure is more common in transfused than nontransfused patients (P =.01) N = 467

35. With permission from Malcovati L, et al. J Clin Oncol. 2005;23:7594-7603. Abbreviation: HR, hazard ratio. Survival of Patients with Myelodysplastic Syndromes According to Transfusion Dependence

36. Iron Chelation Therapy May Improve Survival in Patients with MDS With permission from Rose C, et al. Blood. 2007;110:abstract 249.

37. Conclusions Chronic transfusion dependence in MDS may lead to significant iron overload and may contribute to increased morbidity and mortality Non–transferrin-bound iron causes oxidative stress and is deleterious to different organ systems, including liver and heart Both RBC transfusions and high ferritin levels independently worsen overall survival in patients with MDS Iron chelation with deferasirox consistently reduced serum ferritin levels and labile plasma iron levels in EPIC and US03 trials Effective iron chelation may improve overall survival in patients with low and intermediate-1 risk MDS

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