May 29 - June 2, 2015 Leukemia Stem Cell Phenotypes Correlate With Cytogenetic Risk Factors and Outcomes CCO Independent Conference Highlights of the 2015 ASCO Annual Meeting* *CCO is an independent medical education company that provides state-of-the-art medical information to healthcare professionals through conference coverage and other educational programs. This program is supported by educational grants from AstraZeneca, Bayer, Bristol-Myers Squibb, Celgene Corporation, Genentech, Incyte, and Novartis.

clinicaloptions.com/oncology Leukemia Stem Cell Phenotypes Correlate With Outcomes Distinct Clinical Issues in Acute Myeloid Leukemia  Remission in AML is not always associated with cure  Current cytogenetic markers not prognostic for individuals in a given risk group –Cytogenetic results often take > 1 wk to obtain  Leukemic stem cells may be resistant to conventional chemotherapy and may be cause of relapse Gerber JM, et al. ASCO Abstract Gerber JM, et al. Blood. 2012;119:

clinicaloptions.com/oncology Leukemia Stem Cell Phenotypes Correlate With Outcomes Poor Prognostic Phenotype: CD34+CD38- ALDH int  ALDH identifies CD34+CD38- stem cells in AML –Cells with CD34+CD38- ALDH int phenotype are 96% leukemic by FISH  Resistant to induction therapy –Total leukemic burden decreased by 1.0 log 10 cells vs 2.5 logs for bulk leukemic cells  Pts with persistent CD34+CD38- ALDH int cells relapse –6/7 in pt sample with persistent CD34+CD38- ALDH int ultimately relapsed despite no overt relapse at follow-up –In same sample, 9/9 without ALDH int cells remained in remission with follow-up of 688 days Gerber JM, et al. ASCO Abstract Gerber JM, et al. Blood. 2012;119:

clinicaloptions.com/oncology Leukemia Stem Cell Phenotypes Correlate With Outcomes 2 Additional Leukemic Stem Cell Phenotypes Identified in AML Pts  CD34- stem cells [1] –Low CD34 expression associated with NPM1 mutation [2]  CD34+CD38- ALDH high stem cells –Primitive phenotype  Each AML pt has only 1 type of stem cell  Current study evaluated AML leukemic stem cell phenotypes and response to chemotherapy regimens with respect to long-term outcomes [3] 1. van der Pol MA, et al. Hematologica. 2003;88: Taussig DC, et al. Blood. 2010;115: Gerber JM, et al. ASCO Abstract 7000.

clinicaloptions.com/oncology Leukemia Stem Cell Phenotypes Correlate With Outcomes Leukemia Stem Cell Phenotypes: Study Design  Multicenter, randomized phase II trial [1,2] to determine correlation of stem cell phenotype with response to chemotherapy  Primary endpoint: CR Pts with AML (N = 165) Flavopiridol 50 mg/m 2 IV Days Ara-C 2 g/m 2 IV over 72 hrs, Days Mitoxantrone 40 mg/m² IV Day 9 Ara-C 100 mg/m 2 IV Days Daunorubicin* 90 mg/m² IV Days 1-3 † *Idarubicin 12 mg/m 2 if daunorubicin not available. † Followed by Ara-C 100 mg/m 2 IV Days daunorubicin* 45 mg/m² IV Days 1-2 if residual leukemia after 14 days. 2:1 randomization; stratified by < or ≥ 50 yrs of age, secondary AML, WBC < or ≥ 50,000/mm³ 1. Gerber JM, et al. ASCO Abstract ClinicalTrials.gov. NCT

clinicaloptions.com/oncology Leukemia Stem Cell Phenotypes Correlate With Outcomes Clinical Characteristics Characteristics Treated Pts (n = 98) Median age, yrs (range)60 (29-70) Male, n (%)50 (51%) WBC > 50,000/cm 3, n (%)9 (9) Cytogenetics, n (%)  Adverse  Complex  Monosomal 41 (42) 29 (30) 23 (23) FLT3-ITD mutation, n (%)9 (9) NPM1 mutation, n (%)22 (22) Secondary AML, n (%)39 (40) Treatment-related AML, n (%)10 (10) European LeukemiaNet characteristics, n (%)  Favorable  Intermediate-1  Intermediate-2  Adverse 12 (12) 30 (31) 18 (18) 38 (39) Treatment group, n (%)  FLAM  (70) 29 (30) CR, n (%)63 (64) Gerber JM, et al. ASCO Abstract 7000.

clinicaloptions.com/oncology Leukemia Stem Cell Phenotypes Correlate With Outcomes AML Stem Cell Phenotype Correlates With Cytogenetic and Molecular Risk Factors  All correlations highly significant, P <.001 (Fisher’s exact and Mantel-Haenszel tests were used to analyze differences) Phenotypes and Risk Factors Characteristic, n (%) CD34- (n = 22) CD34+CD38- ALDH int (n = 43) CD34+CD38- ALDH high (n = 33) NPM1 mutations14 (64)*6 (14)2 (6) † Poor cytogenetic risk factors and/or FLT3- ITD 4 (18) ‡ 15 (35)28 (85) § *Sole abnormality, n = 11. † +FLT3-ITD or complex karyotype. ‡ 9% with ELN poor phenotype; 11q23, n = 2. § 73% with ELN poor phenotype; 55% with earlier myelodysplastic syndrome or myeloproliferative neoplasm. Gerber JM, et al. ASCO Abstract 7000.

clinicaloptions.com/oncology Leukemia Stem Cell Phenotypes Correlate With Outcomes Stem Cell Phenotype Correlates With Clinical Outcomes  All correlations highly significant Phenotypes and Outcomes Outcome CD34- (n = 22) CD34+CD38- ALDH int (n = 43) CD34+CD38- ALDH high (n = 33) CR, %86*67*45 * EFS, mos  EFS at 2 yrs, %  HR (95% CI) ( )* Ref* ( )* Overall survival, mo  OS at 2 yrs, %  HR (95% CI) † Not reached Ref ( ) † ( ) † *P <.01 † P =.02 Gerber JM, et al. ASCO Abstract 7000.

clinicaloptions.com/oncology Leukemia Stem Cell Phenotypes Correlate With Outcomes Leukemia-Free Survival, Stem Cell Phenotype, and Bone Marrow Transplant  In CD34+CD38-ALDH high pts without bone marrow transplant (n = 7), no pt had leukemia-free survival at 2 yrs (P =.03) Gerber JM, et al. ASCO Abstract Reprinted with permission No BMT, CD34 Neg (N = 13) No BMT, ALDH Int (N = 13) BMT, CD34 Neg (N = 6) BMT, ALDH Int (N = 16) BMT, ALDH High (N = 8) Days from Remission Leukemia-Free Survival Probability

clinicaloptions.com/oncology Leukemia Stem Cell Phenotypes Correlate With Outcomes Leukemia Stem Cell Phenotypes: Investigator Conclusions  In AML, 3 distinct leukemia stem cell phenotypes that correlate with cytogenetic or molecular abnormalities and outcomes –CD34-: most favorable –Particularly in those with NPM1 –CD34+CD38-ALDH int : intermediate (most common) –CD34+CD38-ALDH high : poorest outcome –High percentage refractory cases –No leukemia-free survival at 2 yrs without allogeneic BMT Gerber JM, et al. ASCO Abstract 7000.

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