Understanding ALL the Therapeutic Options for Acute Lymphoblastic Leukemia ALL, acute lymphoblastic leukemia. This activity is supported by an educational grant from Shire. Friday Satellite Symposium preceding the 58th ASH Annual Meeting.

Pediatric-Inspired Therapeutic Approaches for Young Adults and Adults With ALL Dan Douer, MD Division of Hematology Keck School of Medicine Los Angeles, California ALL, acute lymphoblastic leukemia.

About These Slides Please feel free to use, update, and share some or all of these slides in your noncommercial presentations to colleagues or patients When using our slides, please retain the source attribution: These slides may not be published, posted online, or used in commercial presentations without permission. Please contact permissions@clinicaloptions.com for details Slide credit: clinicaloptions.com Disclaimer: The materials published on the Clinical Care Options Web site reflect the views of the authors of the CCO material, not those of Clinical Care Options, LLC, the CME providers, or the companies providing educational grants. The materials may discuss uses and dosages for therapeutic products that have not been approved by the United States Food and Drug Administration. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or using any therapies described in these materials.

Faculty Program Director: Hagop M. Kantarjian, MD Chairman, Department of Leukemia Professor of Medicine The University of Texas M. D. Anderson Cancer Center Houston, Texas Anthony Stein, MD Professor of Hematology Division of Hematopoietic Stem Cell Transplantation Department of Hematology City of Hope Duarte, California Dan Douer, MD Division of Hematology Keck School of Medicine Los Angeles, California Renier J. Brentjens, MD Associate Professor, Department of Medicine Weill Medical College of Cornell University Associate Professor Department of Pharmacology Weill Cornell Graduate School of Medical Sciences Associate Attending Memorial Sloan Kettering Cancer Center New York, New York This slide lists the faculty who were involved in the production of these slides.

Faculty Disclosures Renier J. Brentjens, MD, has disclosed that he has a royalty relationship with, receipt of intellectual property rights/patent holder relationship with, has ownership interest in, and has received consulting fees from Juno Therapeutics. Dan Douer, MD, has disclosed that he has received consulting fees from Amgen, Baxalta, Gilead Sciences, and Pfizer and fees for non-CME/CE services from Jazz Pharmaceuticals. Hagop M. Kantarjian, MD, has no real or apparent conflicts of interest to report. Anthony Stein, MD, has disclosed that he has received consulting fees and fees for non-CME/CE services from Amgen and funds for research support from Amgen and Pfizer. This slide lists the disclosure information of the faculty and staff involved in the development of these slides.

Agenda Adult ALL: Overview Therapeutic Approaches to Adult ALL Pediatric-Inspired Therapy Principal Elements Outcomes Asparagine Depletion and Dosing Prevention and Management of Adverse Events Monitoring for Asparaginase Levels and Silent Inactivation ALL, acute lymphoblastic leukemia.

Adult ALL: Overview ALL, acute lymphoblastic leukemia.

Estimated New ALL Cases in 2016: 6590[2] ALL: Age Distribution and Age-Based Differences in Therapeutic Approaches Care for ALL pts historically divided between 2 different clinical teams[1] No collaboration Different treatments Estimated New ALL Cases in 2016: 6590[2] 11.4% (≥ 65 yrs) 8.2% (55-64 yrs) 42.8% of ALL pts ≥ 20 yrs of age 7.2% (45-54 yrs) 57.2% (< 20 yrs) 5.8% (35-44 yrs) ALL, acute lymphoblastic leukemia.   10.2% (20-34 yrs) 1. Sallan SE. Hematology Am Soc Hematol Educ Program. 2006;2006:128-132. 2. SEER Stat fact sheets: acute lymphocytic leukemia. Slide credit: clinicaloptions.com

High Rate of Intermediate Risk in Both Adult and Childhood ALL Ph+ 5% Poor 10% Good 8% Poor 32% Ph+ 25% Good 47% ALL, acute lymphoblastic leukemia; Ph+, Philadelphia chromosome positive. Intermediate 60% Intermediate 43% Adults Children Slide credit: clinicaloptions.com

Case: Maria 25-yr-old female who presented with shortness of breath Found to have large mediastinal mass and pleural effusion Labs: WBC 50,000 cells/μL (50% blasts); anemia; thrombocytopenia, bone marrow infiltration by 60% blasts Immunophenotyping negative for MPO and B-cell markers; positive for TdT, CD2, CD7, CD8, CD34 Moderately obese (BMI 31); otherwise no significant PMH BMI, body mass index; MPO, myeloperoxidase; PMH, past medical history; TdT, terminal deoxynucleotidyl transferase; WBC, white blood cell.

Case: Maria Maria was treated with a “pediatric-inspired” regimen with pegaspargase 2000 IU/m2 on Day 16 Day 28 bone marrow showed a CR that was MRD negative (by flow) and chest CT was normal After pegaspargase dosing, her bilirubin started to rise, peaking at 26 mg/dL on Day 34 from start of treatment No clinical symptoms of liver disease Bilirubin gradually dropped to 1.5 mg/dL by Day 45 MRD, minimal residual disease.

Therapeutic Approaches to Adult ALL ALL, acute lymphoblastic leukemia.

Adult ALL: No Standard Chemotherapy Approach Fundamentally different regimens without common basic principles (except maintenance and CNS prophylaxis)[1] No comparative trials between regimens or individual drugs The role of HSCT is unclear[2] ALL, acute lymphoblastic leukemia; CNS, central nervous system; HSCT, hematopoietic stem cell transplantation. 1. NCCN. Clinical Practice Guidelines In Oncology (NCCN Guidelines) for Acute Lymphoblastic Leukemia. V2.2016. 2. Rowe JM. Biol Blood Marrow Transplant. 2011;17:S76-S83. Slide credit: clinicaloptions.com

Comparison Between the 2 Main Adult Regimens Characteristic Asparaginase-Based BFM Models Hyper-CVAD Origin Modified from pediatrics[1] Pediatric Burkitt leukemia[2] Structure Complex Each cycle has different drugs and schedule[3] Simple A to B[1] Asparaginase Yes (much less than children)[1] None or limited*[1] Myelosuppression Limited[4] Common[2] Key toxicity Asparaginase related[4] Long cytopenias[5] BFM, Berlin-Frankfurt-Münster; Hyper-CVAD, hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone. *Could include late 2 doses of pegaspargase 2500 U/m2 on Day 1 for Mos 9 and 12. 1. NCCN. Clinical Practice Guidelines In Oncology (NCCN Guidelines) for Acute Lymphoblastic Leukemia. V2.2016. 2. Garcia-Manero G, et al. Hematol Oncol Clin North Am. 2000;14:1381-1396. 3. Larson RA, et al. Blood. 1995;85:2025-2037. 4. Patel B, et al. Leukemia. 2016;[Epub ahead of print]. 5. Gill S, et al. Ann Hematol. 2008;87:727-734. Slide credit: clinicaloptions.com

BFM Models and MDACC Trials: Outcomes in Adult ALL Pts Regimen N Median Age Treatment CR, % DFS, % GMALL 05/93[1] 1163 35 BFM, HD-Ara-C, HD-MTX 87 CALGB 8811[2] 198 32 BFM, ↑ Cy, ↑ ASP 85 36 CALGB 19802[3] 163 41 BFM, ↑ Cy, ↑ DNR 78 MRC/ECOG-UKALLXII/E2993[4] 1913 15-64 BFM + HD-MTX ± SCT 90 39* Hyper-CVAD[5] 288 40 Cy, DEX, ADR, VCR HD-MTX + HD-Ara-C 92 38 ALL, acute lymphoblastic leukemia; ADR, adriamycin; ASP, asparaginase; BFM, Berlin-Frankfurt-Münster; CALGB, Cancer and Leukemia Group B; ECOG, Eastern Cooperative Oncology Group; Cy, cyclophosphamide; DEX, dexamethasone; DNR, daunorubicin; GMALL, German Multicenter Study Group for Adult Acute Lymphoblastic Leukemia; HD-Ara-C, high dose cytarabine; HD-MTX, high dose methotrexate; Hyper-CVAD, hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone; MDACC, M. D. Anderson Cancer Center; MRC, Medical Research Council; SCT, stem cell transplantation. *5-yr OS. 1. Gökbuget N, et al. Blood. 2001;98:802a. 2. Larson RA, et al. Blood.1995;85:2025-2037. 3. Larson RA, et al. Ann Hematol. 2004;83(Suppl 1):S127-S128. 4. Goldstone AH, et al. Blood. 2008;111:1827-1833. 5. Kantarjian H, et al. Cancer. 2004;101:2788-2801. Slide credit: clinicaloptions.com

Pediatric-Inspired Therapy

Principles of Pediatric Treatment Approaches 7-8 drugs[1] with less intense myelosuppressive agents Prolonged postremission asparaginase (asparagine depletion)[2] BFM, COG models—not sustained[3] DFCI model—sustained (no asparaginase-free intervals)[4] Delayed reinduction[2] Early CNS prophylaxis during induction[5] Allogeneic HSCT used only for very high risk pts[6] (eg, t[4:11]) BFM, Berlin-Frankfurt-Münster; CNS, central nervous system; COG, Children’s Oncology Group; DFCI, Dana-Farber Cancer Institute; HSCT, hematopoietic stem cell transplantation. 1. NCCN. Clinical Practice Guidelines In Oncology (NCCN Guidelines) for Acute Lymphoblastic Leukemia. V2.2016. 2. Seibel NL. Hematology Am Soc Hematol Educ Program. 2008;2008:374-380. 3. Gaynon PS, et al. Leukemia. 2010;24:285-297. 4. Moghrabi A, et al. Blood. 2007;109:896-904. 5. Cooper SL, et al. Pediatr Clin North Am. 2015;62:61-73. 6. Pulsipher MA, et al. Biol Blood Marrow Transplant. 2011;17:S137-S148. Slide credit: clinicaloptions.com

L-Asparaginase Mechanism of Action Diet synthesis in liver ALL tumor cell Asparagine circulating in blood Asparagine Asparagine synthetase Asparaginase ALL, acute lymphoblastic leukemia. Aspartic acid Glutamine Glutamic acid Slide credit: clinicaloptions.com

Asparaginase in Newly Diagnosed ALL: Pediatric vs Adult Regimens Pediatric regimens Typically incorporate asparaginase with other drugs in induction and postremission therapies[1] Use supported by randomized trials[2] Adult regimens Limited use of asparaginase due to AEs observed in early adult trials[3] Reluctance among treating physicians No randomized trials AE, adverse events; ALL, acute lymphoblastic leukemia. 1. Seibel NL. Hematology Am Soc Hematol Educ Program. 2008;2008:374-380. 2. NCI Childhood Acute Lymphoblastic Leukemia Treatment (PDQ®). Slide credit: clinicaloptions.com

RCTs of E coli Asparaginase Addition to Frontline Pediatric ALL POG 8704: 7 drugs T-cell ALL[1] DFCI 77-01: 8 drugs Non–T-cell ALL[2-4] No asparaginase P < .001 100 80 60 40 20 2 4 6 8 Continuous CR (%) Yrs 20% 38% 100 80 60 20% Survival (%) 40 46% 20 P = .04 ALL, acute lymphoblastic leukemia; DFCI, Dana-Farber Cancer Institute; POG, Pediatric Oncology Group; RCT, randomized clinical trial. 2 4 6 8 10 12 14 16 18 20 Yrs Consolidation ± 25,000 IU/m2 E coli asparaginase weekly x 30 1. Amylon MD, et al. Leukemia. 1999;13:335-342. 2. Sallan SE, et al. Cancer Res. 1983;43:5601-5607. (Updated courtesy of Dr. DeAngelo. 3. Salzer WL, et al. Leukemia. 2010;24:355-370. 4. Salzer WL, et al. Ann N Y Acad Sci. 2014;1329:81-92. Slide credit: clinicaloptions.com

Liposomal daunorubicin (150 mg/m2) Anthracycline Intensification (+ Hi-DAC) Confers No Added Benefit in Adult ALL Pts Study Drug Escalation CR, % 5-Yr OS, % CALGB 10802 BFM[1] Daunorubicin (80 mg/m2) 81 39 MDACC Hyper-CVAD[2] Liposomal daunorubicin (150 mg/m2) NR 44 MSKCC ALL-2 “AML-like”[3] Mitoxantrone (80 mg/m2) 83 33 ALL, acute lymphoblastic leukemia; AML, acute myeloid leukemia; BFM, Berlin-Frankfurt-Münster; CALGB, Cancer and Leukemia Group B; Hi-DAC, high-dose intermittent ARA-C; Hyper-CVAD, hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone; MDACC, MD Anderson Cancer Center; MSKCC, Memorial Sloan Kettering Cancer Center; NR, not reported. 1. Stock W, et al. Cancer. 2013;119:90-98. 2. Thomas D, et al. Cancer. 2010;116:4580-4589. 3. Lamanna N, et al. Cancer. 2013;119:1186-1194. Slide credit: clinicaloptions.com

“AML-Like” Myelosuppression: Is Prolonged and Profound Marrow Aplasia Necessary in AML? No added benefit from anthracycline dose intensification[1-3] Steroids + vincristine = CR 50% 3 out of 4 or 5 drugs used in BFM inductions are nonmyelosuppressive: asparaginase, prednisone, vincristine[1,4-7] Long, low-dose maintenance Pediatric regimens typically use nonmyelosuppressive drugs[10] ALL, acute lymphoblastic leukemia; AML, acute myeloid leukemia; BFM, Berlin-Frankfurt-Münster. 1. Stock W, et al. Cancer. 2013;119:90-98. 2. Thomas D, et al. Cancer. 2010;116:4580-4589. 3. Lamanna N, et al. Cancer. 2013;119:1186-1194. 4. Stock W, et al. Leuk Lymphoma. 2011;52:2237-2253. 5. Teuffel O, et al. Leukemia. 2011;25:1232-1238. 6. Egbelakin A, et al. Pediatr Blood Cancer. 2011;56:361-367. 7. Shaw PJ, et al. Med Pediatr Oncol. 1995;24:18-22. 8. Gökbuget N, et al. Hematology Am Soc Hematol Educ Program. 2006;2006:133-141. 9. Kung FH, et al. Cancer. 1978;41:428-434. 10. Ribera JM, et al. Mediterr J Hematol Infect Dis. 2014;6:e2014052. Slide credit: clinicaloptions.com

Retrospective Comparison in Adolescents and Young Adults Pre-2008: Pediatric vs Adult Protocols Study Age Range, Yrs N EFS,* % P Value Pediatric Protocol Adult Protocol United States[1] 16-20 321 63 34 < .0001 France[2] 15-20 177 67 41 The Netherlands[3] 15-18 91 69 .0001 Sweden[4] 59 74 39 < .01 United Kingdom[5] 15-17 128 65 49 .01 Italy[6] 14-17 242 83 55 NR EFS, event-free survival; NR, not reported. *7-yr EFS for US study; 5-yr EFS for France, The Netherlands, Sweden, and UK studies; 2-yr EFS for Italy study. 1. Stock W, et al. Blood. 2008;112:1646-1654. 2. Boissel N, et al. J Clin Oncol. 2003;21:774-780. 3. de Bont JM, et al. Leukemia. 2004;18:2032-2035. 4. Hallböök H, et al. Cancer. 2006;107:1551-1561. 5. Ramanujachar R, et al. Pediatr Blood Cancer. 2007;48:254-261. 6. Testi AM, et al. Blood. 2004;104:1954a. Slide credit: clinicaloptions.com

Treatments for ALL: Pediatric vs AYA vs Adult Pts 39 15-21 60-65+ ? Employing a different treatment 9 8 6 4 2 Rate per 100,000 20% 46% < 1 7 5 3 1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-59 70-74 75-59 80-84 85+ Pediatricians Adult Oncology Specialists ALL, acute lymphoblastic leukemia; AYA, adolescents and young adults. Age at Diagnosis (Yrs) Slide credit: clinicaloptions.com Katz AJ, et al. Cancer Causes Control. 2015;11:1627-1642.

Excluded from analysis Pediatric or Pediatric-Inspired Regimens in Prospective Adult ALL Trials 2007-2014 Regimen Study N Ph+ Age Upper Limit, Yrs OS,* % Pediatric DFCI[1] 110 Yes (21/110) 50 75 CALGB 10403[2] 296 No 39 78 Pediatric inspired PETHEMA[3] 81 NR 30 69 GRAALL-2003[4] 225 45 60 64 47 USC[5] 40 Excluded from analysis 57 58 ALL, acute lymphoblastic leukemia; CALGB, Cancer and Leukemia Group B; DFCI, Dana-Farber Cancer Institute; GRAALL, Group for Research on Adult Acute Lymphoblastic Leukemia; NR, not reported; PETHEMA, Programa Español de Tratamientos en Hematología; Ph+, Philadelphia chromosome positive; USC, University of Southern California. *3-yr estimated OS for DFCI, 2-yr OS for CALGB 10403, 6-yr OS for PETHEMA, 3.5-yr OS for GRAALL-2003, and 7-yr OS for USC. 1. DeAngelo DJ, et al. ASH 2015. Abstract 80. 2. Stock W, et al. ASH 2014. Abstract 796. 3. Ribera JM, et al. J Clin Oncol. 2008;26:1843-1849. 4. Huguet F, et al. J Clin Oncol. 2009; 27:911-918. 5. Douer D, et al. J Clin Oncol. 2014;32:905-911. Slide credit: clinicaloptions.com

Asparaginase Dose, IU/m2 Multiple Cycles of Asparaginase in Pediatric/Pediatric-Inspired Regimens: Adult ALL Trials 2007-2014 Regimen Study Asparaginase Form Asparaginase Dose, IU/m2 Pediatric DFCI[1] Pegaspargase 2500 Q2W or 2000 Q3W x 8-15 doses CALGB 10403[2] Pegaspargase[3] 2500 x 7 cycles Pediatric inspired PETHEMA[4] E coli 10,000 x 3 cycles 20,000 Q4W x 12 mos GRAALL-2003[5] 10,000 x 9 cycles USC[6] 2000 x 6 cycles ALL, acute lymphoblastic leukemia; CALGB, Cancer and Leukemia Group B; DFCI, Dana-Farber Cancer Institute; GRAALL, Group for Research on Adult Acute Lymphoblastic Leukemia; PETHEMA, Programa Español de Tratamientos en Hematología; USC, University of Southern California. 1. DeAngelo DJ, et al. ASH 2015. Abstract 80. 2. Stock W, et al. ASH 2014. Abstract 796. 3. Larsen EC, et al. J Clin Oncol. 2016;34:2380-2388. 4. Ribera JM, et al. J Clin Oncol. 2008;26:1843-1849. 5. Huguet F, et al. J Clin Oncol. 2009;27:911-918. 6. Douer D, et al. J Clin Oncol. 2014;32:905-911. Slide credit: clinicaloptions.com

Consolidation Dosing, IU/m2 Number of Cycles With Asparaginase in Newly Diagnosed Adult ALL, 1988-2000 Protocol Asparaginase Form Induction Dosing, IU/m2 Consolidation Dosing, IU/m2 Doses/Cycle Cycles Pre-1988[1,2] E coli 5000-6000 x 9-14 d None CALGB 8811[3] and 19802[4] 6000 x 6 6000 x 4 (BIW) 2 CALGB 9511[5] Pegaspargase 2000 x 2 1 MRC/ECOG UKALLXII/E2993[6] 10,000 x 14 d 10,000 x 3 UCSF 8707[7] 6000 x 14 d 12,000 x 6 (TIW) ALL, acute lymphoblastic leukemia; CALGB, Cancer and Leukemia Group B; ECOG, Eastern Cooperative Oncology Group; MRC, Medical Research Council; UCSF, University of California, San Francisco. 1. Hoelzer D, et al. Blood. 1988;71:123-31. 2. Annino L, et al. Blood. 2002;99:863-871. 3. Larson RA, et al. Blood. 1995;85:2025-2037. 4. Stock W, et al. Cancer. 2013;119:90-98. 5. Wetzler M, et al. Blood. 2007;109:4164-4167. 6. Rowe JM, et al. Blood. 2005;106:3760-3767. 7. Linker C, et al. J Clin Oncol. 2002;20:2464-2471. Slide credit: clinicaloptions.com

Pegaspargase (2000 IU/m2 IV x 6 doses) in adults with ALL USC Trial: Modification of Augmented CCG Pediatric BFM Protocol in Adult ALL Pegaspargase (2000 IU/m2 IV x 6 doses) in adults with ALL x 2 X Delayed Reinduction 1 Induction 1 Induction 2 Consolidation 1 Consolidation 2 X DNR VCR PRED Peg-Asp IT-MTX Cyclo VCR PRED Peg-Asp Ara-C 6MP IT-MTX HD-MTX VCR Peg-Asp PRED IT-MTX ARA-C VM 26 DNR VCR Peg-Asp Cyclo DEX Ara-C 6-TG IT-MTX Maintenance therapy continues for 2 yrs 6MP, 6-mercaptopurine; 6-TG, 6-thioguanine; ALL, acute lymphocytic leukemia; ARA-C, cytarabine; BFM, Berlin-Frankfurt-Münster; CCG, Children’s Cancer Group; Cyclo, cyclophosphamide; DEX, dexamethasone; DNR, daunorubicin; HD-MTX, high dose methotrexate; IT-MTX, intrathecal methotrexate; Peg-Asp, pegylated asparaginase; PRED, prednisone; USC, University of Southern California; VCR, vincristine; VM 26, teniposide. Slide credit: clinicaloptions.com Douer D, et al. J Clin Oncol. 2014;32:905-911.

Asparagine Depletion and Dosing

Pegaspargase PK/PD in Adults PK/PD assessed after 1 dose 2000 IU/m2 IV in adults with newly diagnosed ALL (N = 25) Serum asparagine depletion after 14 days: 100% of pts 21 days: 82% of pts 28 days: 44% of pts T½ = 7.0 days (95% CI: 6.0-7.9) 1 Pegaspargase Serum Conc (IU/mL) 0.1 0.01 7 14 21 23 35 ALL, acute lymphoblastic leukemia; Conc, concentration; PK/PD, pharmacokinetic/pharmacodynamics; T½, half-life. Days Slide credit: clinicaloptions.com Douer D, et al. Blood. 2007;109:2744-2750.

Prevention and Management of Adverse Events

DFCI ALL Consortium Trial in Pts Aged 18-50 Yrs: Peg-Asp Adverse Events Toxicity of Peg-Asp (2500 IU/m2 Q2W x 15) assessed with CTCAEv4.0 criteria AEs (Grade 3-5), % Total (N = 65) Dosing Period Induction (n = 65) Cons I (n = 52) CNS (n = 38) Cons II (n = 34) Cont (n = 54) Febrile neutropenia 46 23 29 5 21 Pancreatitis 1 AST 15 10 9 7 ALT 52 17 8 14 Bilirubin 36 16 6 2 Thrombosis 12 3 27 CNS hemorrhage Hypersensitivity 4 Osteonecrosis AE, adverse event; ALL, acute lymphoblastic leukemia; ALT, alanine transaminase; AST, aspartate transaminase; CNS, central nervous system; Cons I, consolidation I; Cons II, consolidation II; CTCv4.0, Common Terminology Criteria for Adverse Events version 4.0; Peg-Asp, pegylated asparaginase. Slide credit: clinicaloptions.com DeAngelo DJ, et al. ASH 2015. Abstract 80.

Hyperbilirubinemia (Grade 3/4), % GMALL Study in Pts Aged 15-55 Yrs: Hyperbilirubinemia During Induction Only Pt Subgroup Hyperbilirubinemia (Grade 3/4), % P Value Peg-Asp dose (IU/m2) 1000 (n = 764) 2000 (n = 382) 10 16 .004 Age Younger than 45 yrs 45 yrs or older 11 17 .005 BMI < 30 ≥ 30 12 18 .04 BMI, body mass index; GMALL, German Multicenter Study Group for Adult Acute Lymphoblastic Leukemia; Peg-Asp, pegylated asparaginase. Slide credit: clinicaloptions.com Goekbuget N, et al. ASH 2010. Abstract 494.

Grade 3/4 Hyperbilirubinemia by Pegaspargase Dose Study Median Age, Yrs (Range) Grade 3/4 Hyperbilirubinemia by Pegaspargase Dose, % 2500 IU/m2 2000 IU/m2 1000 IU/m2 CALGB 10403[1] 24 (16-39) 23 USC II*[2] 32 (18-57) 31 DFCI*[3] 32 (18-50) 36 7 UKALL (induction)*[4] 46 (25-65) ALL, acute lymphoblastic leukemia; CALGB, Cancer and Leukemia Group B; DFCI, Dana-Farber Cancer Institute; USC, University of Southern California. *Adequate enzymatic activity measured and detected for ≥ 14 days. 1. Advani AS, et al. ASH 2013. Abstract 3903. 2. Douer D, et al. J Clin Oncol. 2014;32:905-911. 3. DeAngelo DJ, et al. ASH 2015. Abstract 80. 4. Patel B, et al. Leukemia. 2016;[Epub ahead of print]. Slide credit: clinicaloptions.com

USC Trial: Duration of Grade 3/4 Liver Toxicity With Pegaspargase Phase II trial of adult pts (N = 57) receiving pediatric regimen with 6 doses Peg-Asp (2000 IU/m2) Toxicities assessed with NCI CTCAE v3.0 criteria Parameter Toxicity Hyperbilirubinemia Transaminitis Median time to event per dose, days (range) To grade 3/4 AE To recovery* 13 (9-33) 34 (13-63) 20 (2-58) 38 (6-83) Pts delayed for next cycle, n (doses) 10 (12) 11 (23) AE, adverse event; CTCAE v3.0, Common Terminology Criteria for Adverse Events version 3.0; NCI, National Cancer Institute; Peg-Asp, pegylated asparaginase; USC, University of Southern California. *Recovery defined as grade 1 hyperbilirubinemia, grade 2 transaminitis. Slide credit: clinicaloptions.com Burke PW, et al. ASH 2013. Abstract 2671.

Pegaspargase-Associated Grade 3/4 Liver Toxicity: Conclusions Most common toxicity with Peg-Asp treatment but rarely becomes clinical liver disease[1] Mostly occurs after first dose[1] Long but reversible Very often no recurrence after subsequent doses (no need to discontinue) Risk associated with dose, greater age,[2] and BMI[3] Synchronization with other drugs Impact of delaying chemotherapy? BMI, body mass index; Peg-Asp, pegylated asparaginase. 1. Burke PW, et al. ASH 2013. Abstract 2671. 2. Aldoss I, et al. ASH 2013. Abstract 3915. 3. Goekbuget N, et al. ASH 2010. Abstract 494. Slide credit: clinicaloptions.com

Toxicity Prevention and Management Adult dose ≤ 2000 IU/m2, no cap (consider 1000 IU/m2 for high BMI) Clinical hypersensitivity: switch to Erwinia asparaginase[1] Hypersensitivity prevention: hydrocortisone premedication[1] Avoid asparaginase activity during profound and prolonged neutropenia[2] Pt education to report early symptoms related to Asp Thrombosis prevention: minimize cryoprecipitate[1] Thrombosis treatment with anticoagulant[1]: LMWH or oral factor Xa inhibitor (apixaban) Liver toxicity—continue[1,3] Discontinue only for clinical pancreatitis[1,3] Asp, asparaginase; BMI, body mass index; LMWH, low molecular weight heparin 1. Stock W, et al. Leuk Lymphoma. 2011;52:2237-2253. 2. Ylikangas P, et al. Ther Drug Monit. 2002;24:502-506. 3. NCCN. Clinical Practice Guidelines In Oncology (NCCN Guidelines) for Acute Lymphoblastic Leukemia. V2.2016. Slide credit: clinicaloptions.com

Reasons for Not Completing all 6 Doses of Pegaspargase Event Pegaspargase toxicity Pancreatitis, allergy, DVT 19% Induction failure Death in consolidation Relapse in consolidation 18% HSCT in CR1 Withdrew consent Total 28 (55%) CR1, first CR; DVT, deep venous thrombosis; HSCT, hematopoietic stem cell transplantation. Slide credit: clinicaloptions.com Douer D, et al. J Clin Oncol. 2014;32:905-911.

Synchronization of Pegaspargase and Daunorubicin: Induction Phase I DNR 60 mg/m2 ANC > 500 VCR 1.4 mg/m2 IT-MTX Day 16 PRED 60 mg/m2 Peg-Asp IV 2000 IU/m2 ANC, absolute neutrophil counts; DNR, daunorubicin; IT-MTX, intrathecal methotrexate; Peg-Asp, pegylated asparaginase; PRED, prednisone; VCR, vincristine. Days 1 8 15 22 29 Slide credit: clinicaloptions.com Douer D, et al. Blood. 2007;109:2744-2750.

Induction Outcomes: Efficacy and Safety USC I and II Trial Parameter Observation CR, % (N = 76)[1-2] 4-wk CR, % (n = 73) 96 Median TTR, days (range)[2] To ANC > 500/µL* To platelets > 50,000/µL* 17 (14-33) 17 (12-35) Early death, %[1-2] 1.3 *Observed in 83% of pts by Day 21. ANC, absolute neutrophil counts; TTR, time to recovery. Slide credit: clinicaloptions.com 1. Douer D, et al. Blood. 2007;19:2744. 2. Douer D, et al. J Clin Oncol. 2014;32:905-911.

UKALL14 Trial in Pts Aged 25-65 Yrs: Induction Toxicity Peg-Asp 1000 IU/m2 on Days 4, 18 Daunorubicin 60 mg/m2 on Days 3, 10, 17, 24 Parameter Pts (N = 91) Age > 40 yrs, % Age > 55 yrs, % 66 32 Death from induction toxicity, n/N (%) Hepatotoxicity + sepsis, n Hepatotoxicity + bowel ischemia or pancreatitis, n Neutropenic sepsis only, n Other causes, n 16/90 (18) 8 3 2 Protocol Amendment (n = 244) Pts aged > 40 yrs: Peg-Asp only on Day 18 Ph+ pts: no Peg-Asp All pts: daunorubicin dose reduced by 50% Post-amendment induction death rate: 2.5% Peg-Asp, pegylated asparaginase; Ph+, Philadelphia chromosome positive. Slide credit: clinicaloptions.com Patel B, et al. Leukemia. 2016;[Epub ahead of print].

Pediatric Regimens in Adults: Combinations With Newer Agents Ideal backbone chemotherapy is unknown Pegaspargase safely combined with: Anti-CD20 rituximab—GMALL 07/03[1,2] Blinatumomab—E1910[3] TKI (Ph+)[4] Inotuzumab? —synchronization GMALL, German Multicenter Study Group for Adult Acute Lymphoblastic Leukemia; Ph+, Philadelphia chromosome positive; TKI, tyrosine kinase inhibitor 1. Hoelzer DH, et al. EHA 2009. Abstract 0481. 2. Gökbuget N, et al. In: Acute Leukemias. 2008. 3. Clinicaltrials.gov. NCT02003222. 4. Lee KH, et al. Leukemia. 2005;19:1509-1516. Slide credit: clinicaloptions.com

Pediatric/Pediatric-Inspired Regimens in Adults: Conclusions Prospective multi-institutional studies consistently show longer survival compared with “historic” regimens that used much less or no asparaginase (eg, BFM, hyper-CVAD) 45% → 60%-70% Pts with negative MRD status on Day 28 appear to have very low relapse rate[1] Administration of multiple doses of asparaginase is tolerated[2] Standard of care for adults younger than 40 yrs of age[3] BFM, Berlin-Frankfurt-Münster; hyper-CVAD, hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone; MRD, minimal residual disease. 1. Stock W, et al. ASH 2014. Abstract 796. 2. Boissel N, et al. J Adolesc Young Adult Oncol. 2015;4:118-128. 3. NCCN. Clinical Practice Guidelines In Oncology (NCCN Guidelines) for Acute Lymphoblastic Leukemia. V2.2016. Slide credit: clinicaloptions.com

Pediatric Regimens in Adults: Problems and Challenges Upper age limit unclear but probably 50-55 yrs of age Asparaginase-related hepatotoxicity emerging as most common adverse event (observed less frequently in children) Asparaginase adverse events can be mitigated by adhering to toxicity management guidelines[1,2] Asparaginase dose/timing varies and may need to be adjusted with guidance from serum enzymatic activity assays Practical and compliance-related challenges in adults vs children Limited data from randomized trials 1. Stock W, et al. Leuk Lymphoma. 2011;52:2237-2253. 2. NCCN. Clinical Practice Guidelines In Oncology (NCCN Guidelines) for Acute Lymphoblastic Leukemia. V2.2016. Slide credit: clinicaloptions.com

Augmented BFM Regimen vs Hyper-CVAD in AYAs With Ph-Negative ALL 1.0 1.0 OS in All Pts OS in Pts ≤ 21 Yrs Retrospective study of newly diagnosed pts aged 12-40 yrs in single institution N = 106 0.8 0.8 0.6 0.6 Fraction Survival Fraction Survival 0.4 0.4 ABFM HCVAD Total 106 102 5-Yr OS, % 60 Fail 40 38 ABFM HCVAD Total 53 21 5-Yr OS, % 65 68 Fail 19 6 0.2 0.2 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 Yrs Yrs 1.0 1.0 CR Duration in All Pts OS in Pts > 21 Yrs 0.8 0.8 0.6 ABFM, augmented Berlin-Frankfurt-Münster; ALL, acute lymphoblastic leukemia; AYAs, adolescents and young adults; HCVAD, hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone; Hyper-CVAD, hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone; Ph, Philadelphia chromosome. 0.6 Fraction Survival Fraction Survival 0.4 0.4 ABFM HCVAD Total 99 100 5-Yr OS, % 53 55 Fail 39 ABFM HCVAD Total 53 81 5-Yr OS, % 57 58 Fail 21 32 0.2 0.2 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 Yrs Yrs Slide credit: clinicaloptions.com Rytting ME, et al. Am J Hematol. 2016;91:819-823.

Hyper-CVAD (No Upper Age Limit) Not used by pediatricians Use should be validated in multi-institutional prospective clinical trials Outcomes of recent retrospective studies examining hyper-CVAD consistent with original reports[1,2] Hyper-CVAD associated with poor outcome in pts with T-cell ALL[3,4] Profound, long cytopenias[5] are probably unnecessary Toxicity prohibitive if used with long-acting Peg-Asp ALL, acute lymphoblastic leukemia; Hyper-CVAD, hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone; Peg-Asp, pegylated asparaginase; Ph+, Philadelphia chromosome positive. 1. Buyukasik Y, et al. Acta Haematol. 2013;130:199-205. 2. Morris K, et al. Leuk Lymphoma. 2011;52:85-91. 3. Kozlowski P, et al. Eur J Haematol. 2014;92:377-381. 4. Kota VK, et al. ASH 2015. Abstract 3762. 5. Gill S, et al. Ann Hematol. 2008;87:727-734. Slide credit: clinicaloptions.com

Monitoring for Hypersensitivity and Silent Inactivation

Parameters for Monitoring Asp Activity Serum asparagine[1,2] Lower level of quantitation can vary[3] Nadir serum asparaginase activity ≥ 0.1 IU/mL is mostly used as a correlate with asparagine depletion[3-5] Antiasparaginase antibodies[1-3] Asp, asparaginase. 1. Ahlke E, et al. Br J Haematol. 1997;96:675-681. 2. Boos J, et al. Eur J Cancer. 1996;32A:1544-1550. 3. Avramis VI, et al. Blood. 2002;99:1986-1994. 4. Riccardi R, et al. Cancer Res. 1981;41:4554-4558. 5. Appel IM, et al. Leukemia. 2008;22:1665-1679. Slide credit: clinicaloptions.com

Why Should We Consider Monitoring Asparaginase Activity? Asparaginase enzymatic inactivation Clinical allergic reaction Silent inactivation Reduce toxicity Hepatotoxicity (adults) Other dose-related toxicities? Relationship between Asp activity and overall outcome benefit Level Duration Sustainability Asp, asparaginase. Slide credit: clinicaloptions.com

Pegaspargase Serum Antibodies in Adults Prospective study in adult pts (N = 51) treated with Peg-Asp 2000 IU/m2 IV x 6 doses with premedication Samples collected before Peg-Asp dosing, same day, and weekly after dosing Parameter Pts Tested (n = 43) Doses (n = 61) Antibody detected, % 63 56 Asp activity < 0.2 IU/mL in pt tested, n (%) Pts with antibodies (n = 26) Pts without antibodies (n = 16) 2 (8) Asp, asparaginase; Peg-Asp, pegylated asparaginase. Slide credit: clinicaloptions.com Burke PW, et al. ASH 2014. Abstract 936.

DFCI Protocol 00-01: Fixed vs Individualized Dose of E coli Asparaginase Pediatric ALL pts achieving CR (N = 473) randomized to fixed vs individual dose of E coli asparaginase IM Q1W x 30 Fixed dose 25,000 IU/m2 Individualized dose starting at 12,500 IU/m2, adjusted per nadir serum asparaginase level Outcome Fixed Dose, % Individualized Dose, % P Value 5-yr EFS 82 90 .04 Switch to Erwinia or Peg-Asp Allergy Silent inactivation 22 20 NR 34 21 10 .01 EFS (max NSAA < 0.1 IU/mL) No switch Switch for silent inactivation (n = 19) 73 76 N/A 91 78 95 .058 ALL, acute lymphoblastic leukemia; Asp, asparaginase; DFCI, Dana-Farber Cancer Institute; EFS, event-free survival; N/A, not applicable; NSAA, nadir serum asparaginase level; Peg-Asp, pegylated asparaginase. Slide credit: clinicaloptions.com Vrooman LM, et al. J Clin Oncol. 2013;31:1202-1210.

Newly Developed Guidelines: Haematologica Van der Sluis, et al: “Consensus expert recommendations for identification and management of asparaginase hypersensitivity and silent inactivation”[1] Bleyer, et al: “Clinical application of asparaginase activity levels following treatment with pegaspargase”[2] Algorithm included for monitoring activity levels based on Percent dose administered Neutralizing antibody assessment Accelerated clearance assessment Serum asparaginase activity levels most reliable marker for efficacy Trough asparaginase activity levels ≥ 0.1 IU/mL safe target to ensure therapeutic benefit Antiasparaginase antibodies, asparagine measurements not indicated in clinic outside of clinical trials 1. van der Sluis IM, et al. Haematologica. 2016;101:279-285. 2. Bleyer A, et al. Pediatr Blood Cancer. 2015;62:1102-1105. Slide credit: clinicaloptions.com

Go Online for More CCO Coverage of Acute Lymphoblastic Leukemia! Additional downloadable slidesets from the live symposium Expert analyses with downloadable summary slidesets highlighting key data presented at ASH 2016 ClinicalThought commentaries on new developments in treating patients with ALL clinicaloptions.com/oncology