1. 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.

2. 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 2105. Abstract 7000. Gerber JM, et al. Blood. 2012;119:3571-3577.

3. 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 2105. Abstract 7000. Gerber JM, et al. Blood. 2012;119:3571-3577.

4. 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;88:983-993. 2. Taussig DC, et al. Blood. 2010;115:1976- 1984. 3. Gerber JM, et al. ASCO 2105. Abstract 7000.

5. 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 1-3 + Ara-C 2 g/m 2 IV over 72 hrs, Days 6-8 + Mitoxantrone 40 mg/m² IV Day 9 Ara-C 100 mg/m 2 IV Days 1-7 + 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 1-5 + 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 2105. Abstract 7000. 2. ClinicalTrials.gov. NCT01349972.

6. 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  7 + 3 69 (70) 29 (30) CR, n (%)63 (64) Gerber JM, et al. ASCO 2105. Abstract 7000.

7. 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 2105. Abstract 7000.

8. 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) 13 46 0.58 (0.3-3.1)* 11.3 26 Ref* 2.2 0 2.15 (1.2-3.9)* Overall survival, mo  OS at 2 yrs, %  HR (95% CI) † Not reached 76 0.53 18.7 38 Ref (13.1-35.8) † 9.4 34 1.3 (6.28-35.8) † *P <.01 † P =.02 Gerber JM, et al. ASCO 2105. Abstract 7000.

9. 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 2105. Abstract 7000. Reprinted with permission. 1.0 0.8 0.6 0.4 0.2 0 020040060080010001200 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

10. 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 2105. Abstract 7000.

11. Go Online for More CCO Coverage of ASCO 2015! Short slidesets of all the key data Additional CME-certified analyses with expert faculty commentary on all the key studies in:  Gastrointestinal cancers  Genitourinary cancer  Hematologic malignancies  Immunotherapy  Lung cancer clinicaloptions.com/oncology