Hairy Cell Leukemia Foundation and The Royal Marsden NHS Foundation Trust THE GENETIC CAUSE OF HAIRY CELL LEUKAEMIA (HCL) AND ITS THERAPEUTIC TARGETING ENRICO TIACCI, M.D. Institute of Hematology, University of Perugia – Italy (Director: Prof. B. Falini) PATIENT SEMINAR London - September 20, 2014

Perugia: Etruscan Arch

Perugia: Town Hall and Fountain

Perugia: University Medical Center

MUTATION OF THE BRAF GENE IN ALMOST ALL PATIENTS WITH HCL* HAIRY CELL *Tiacci et al., BRAF mutations in Hairy Cell Leukiemia New England Journal of Medicine 2011

MUTATION OF THE BRAF GENE IN ALMOST ALL PATIENTS WITH HCL* Signal from the environment HAIRY CELL Receptor Cell surface RAS V600E BRAF VEMURAFENIB pMEK pERK survival proliferation transformation *Tiacci et al., BRAF mutations in Hairy Cell Leukiemia New England Journal of Medicine 2011

VEMURAFENIB First drug inhibitor of BRAF Orally available Already approved for BRAF-mutated melanoma - Not toxic to the bone marrow Overall responses in about 50% of cases (<5% complete responses) Median duration: ~7 months

VEMURAFENIB VEMURAFENIB IN HCL Highly active against patients’ hairy cells in the laboratory First drug inhibitor of BRAF Orally available Already approved for BRAF-mutated melanoma - Not toxic to the bone marrow Overall responses in about 50% of cases (<5% complete responses) Median duration: ~7 months

Effect of Vemurafenib on HCL cells Hairy cell Vemurafenib

Effect of Vemurafenib on HCL cells Hairy cell Trimming of hairy cells Vemurafenib Cell death

MUTATION OF THE BRAF GENE IN ALMOST ALL PATIENTS WITH HCL* HAIRY CELL VEMURAFENIB survival proliferation transformation “hairiness” *Tiacci et al., BRAF mutations in Hairy Cell Leukemia New England Journal of Medicine 2011

VEMURAFENIB VEMURAFENIB IN HCL Highly active against patients’ hairy cells in the laboratory First drug inhibitor of BRAF Orally available Already approved for BRAF-mutated melanoma - Not toxic to the bone marrow Overall responses in about 50% of cases (<5% complete responses) Median duration: ~7 months

VEMURAFENIB VEMURAFENIB IN HCL Highly active against patients’ hairy cells in the laboratory About 40% of HCL patients treated with purine analogues (cladribine or pentostatin) will relapse within 5-10 years, a problem especially for younger patients First drug inhibitor of BRAF Orally available Already approved for BRAF-mutated melanoma - Not toxic to the bone marrow Overall responses in about 50% of cases (<5% complete responses) Median duration: ~7 months

VEMURAFENIB VEMURAFENIB IN HCL Highly active against patients’ hairy cells in the laboratory About 40% of HCL patients treated with purine analogues (cladribine or pentostatin) will relapse within 5-10 years, a problem especially for younger patients Progressive decrease of response rate and duration after each successive course of purine analogue First drug inhibitor of BRAF Orally available Already approved for BRAF-mutated melanoma - Not toxic to the bone marrow Overall responses in about 50% of cases (<5% complete responses) Median duration: ~7 months

VEMURAFENIB VEMURAFENIB IN HCL Highly active against patients’ hairy cells in the laboratory About 40% of HCL patients treated with purine analogues (cladribine or pentostatin) will relapse within 5-10 years, a problem especially for younger patients Progressive decrease of response rate and duration after each successive course of purine analogue Bone marrow toxicity and immune suppression after multiple courses of chemotherapy First drug inhibitor of BRAF Orally available Already approved for BRAF-mutated melanoma - Not toxic to the bone marrow Overall responses in about 50% of cases (<5% complete responses) Median duration: ~7 months

VEMURAFENIB VEMURAFENIB IN HCL Highly active against patients’ hairy cells in the laboratory About 40% of HCL patients treated with purine analogues (cladribine or pentostatin) will relapse within 5-10 years, a problem especially for younger patients Progressive decrease of response rate and duration after each successive course of purine analogue Bone marrow toxicity and immune suppression after multiple courses of chemotherapy Rationale for using Vemurafenib in HCL patients with multiple relapses after, or refractory to, standard chemotherapy First drug inhibitor of BRAF Orally available Already approved for BRAF-mutated melanoma - Not toxic to the bone marrow Overall responses in about 50% of cases (<5% complete responses) Median duration: ~7 months

Sponsor: Institute of Hematology, Perugia HCL-PG01 CLINICAL TRIAL Sponsor: Institute of Hematology, Perugia 26 patients with refractory or pluri-relapsed HCL recruited and evaluable:

CR = Complete Remission Stop drug Vemurafenib 960 mg twice/day for 8 weeks 2 weeks off-drug no CR CR Vemurafenib 960 mg twice/day for 4 weeks Stop drug CR no CR Stop drug Vemurafenib 960 mg twice/day 4 weeks CR = Complete Remission Stop drug

Sponsor: Institute of Hematology, Perugia HCL-PG01 CLINICAL TRIAL Sponsor: Institute of Hematology, Perugia 26 patients with refractory or pluri-relapsed HCL recruited and evaluable:

Sponsor: Institute of Hematology, Perugia HCL-PG01 CLINICAL TRIAL Sponsor: Institute of Hematology, Perugia 26 patients with refractory or pluri-relapsed HCL recruited and evaluable: - Drug generally well tolerated

Sponsor: Institute of Hematology, Perugia HCL-PG01 CLINICAL TRIAL Sponsor: Institute of Hematology, Perugia 26 patients with refractory or pluri-relapsed HCL recruited and evaluable: - Drug generally well tolerated - Drug very active: 25/26 (96%) patients responded

Sponsor: Institute of Hematology, Perugia HCL-PG01 CLINICAL TRIAL Sponsor: Institute of Hematology, Perugia 26 patients with refractory or pluri-relapsed HCL recruited and evaluable: - Drug generally well tolerated - Drug very active: 25/26 (96%) patients responded - 9/26 (34.6%) complete responses

Sponsor: Institute of Hematology, Perugia HCL-PG01 CLINICAL TRIAL Sponsor: Institute of Hematology, Perugia 26 patients with refractory or pluri-relapsed HCL recruited and evaluable: - Drug generally well tolerated - Drug very active: 25/26 (96%) patients responded - 9/26 (34.6%) complete responses - 16/26 (61.4%) partial responses

Sponsor: Institute of Hematology, Perugia HCL-PG01 CLINICAL TRIAL Sponsor: Institute of Hematology, Perugia 26 patients with refractory or pluri-relapsed HCL recruited and evaluable: - Drug generally well tolerated - Drug very active: 25/26 (96%) patients responded - 9/26 (34.6%) complete responses normal blood counts in 6/9 pts. - 16/26 (61.4%) partial responses after 12 months

Sponsor: Institute of Hematology, Perugia HCL-PG01 CLINICAL TRIAL Sponsor: Institute of Hematology, Perugia 26 patients with refractory or pluri-relapsed HCL recruited and evaluable: - Drug generally well tolerated - Drug very active: 25/26 (96%) patients responded - 9/26 (34.6%) complete responses normal blood counts in 6/9 pts. - 16/26 (61.4%) partial responses normal blood counts in 5/16 pts. after 12 months after 12 months

Sponsor: Institute of Hematology, Perugia HCL-PG02 CLINICAL TRIAL Sponsor: Institute of Hematology, Perugia Cell surface “hairiness”

Sponsor: Institute of Hematology, Perugia HCL-PG03 CLINICAL TRIAL Sponsor: Institute of Hematology, Perugia Cell surface + YRITUXIMAB HCL cell “hairiness”