1. Contributions to TSC1 & 2 Gene Variation Databases TSC1 N=820 entries TSC2 N*=2064 entries Published data 73% Unpublished data Total = 27% Published data 75% Unpublished data Total = ~25% [Parents] [Single Queries] 18% 6% 3% 17% 4% 3% 0.5% 0.05% Database curators: Dr Rosemary Ekong and Prof Sue Povey

2. A phase II trial of the mTOR inhibitor sirolimus in patients with TSC or sporadic LAM (TESSTAL trial) Julian Sampson, Institute of Medical Genetics, Cardiff, UK See Davies DM et al. Clin Cancer Res 2011; 17:4071-4081

3. TRIALLOCATIONN PRIMARY OUTCOMEDRUGPHASE 1Cincinnati25AMLsirolimusII 2Cincinnati25SEGAeverolimusII 3UK/Switz (MC)16AMLsirolimusII 4Cincinnati30AMLeverolimusII 5USA (MC)36AMLsirolimusII 6International99AMLeverolimusIII 7International99SEGAeverolimusIII Current and Completed Clinical Trials of mTOR inhibition in TSC 10 Boston/Cincinnati 20 Neurocognition everolimus II 8 Barcelona 18 AML sirolimus II 9 Cincinnati/Houston 20 Seizures everolimus II 11 Cincinnati 99* LAM everolimus II

4. TESSTAL: Design Non-randomised, Open label Multicentre (Brighton, Cardiff, Nottingham, Zurich) Primary outcome = angiomyolipoma size Oct 2005 – Sept 2009 Fleming’s single stage design P1 0.1, P2 0.4, α 0.05, β 0.1 (N ≥ 15) Sample size: 16 recruited Intention to treat

5. Treatment Oral sirolimus as liquid, once daily for 2 years Dose adjusted to obtain: - Starting drug level 3-6 ng/ml - Escalation to 6-10 ng/ml at 2 months (first MRI on treatment) unless all target AML reduced by ≥ 10% (4 of 16 patients) Sirolimus levels lower than in previous trial (Bissler et al.)

6. Major Inclusion Criteria TSC (Roach criteria, 1998) or LAM (CT/Bx) 1 or more AML of ≥ 2cm 18 – 65 yrs of age GFR ≥ 40 mL/min Major Exclusion Criteria IQ < 70 AML bleed last 12 months AML embolization last 6 months Continuous O 2 requirement Proteinuria >1g/day Pregnancy/intention Breast-feeding Change in AED in last 3 months

7. Assessments: Primary Outcome AML size by serial MRI scan Un-enhanced transaxial scans, 1.5 Tesla systems Scans at baseline, 2, 6,12, 24 months Up to 5 target AMLs per kidney Sum Longest Diameters (SLD) RECIST criteria i.e. response is ≥ 30% reduction in SLD and no new lesions

8. Assessments: Secondary Outcomes Pulmonary Function FEV 1, FVC, DL CO at baseline,4, 6, 12, 24 months Expressed as % predicted values Neurocognition IQ for inclusion by NART Immediate recall memory - AIMBP Immediate recognition memory - CANTAB Executive function - CANTAB

9. 3 were not enrolled 2 were ineligible 1 declined to participate 19 patients with tuberous sclerosis or lymphangiomeiomatosis (LAM) screened SIROLIMUS THERAPY, 16 started 10 had angiomyolipomas measured at 24 months 11 had neurocognitive assessment at 12 months 13 had neurocognitive assessment at 4 months 15 had angiomyolipomas measured at 2 months 13 had angiomyolipomas measured at 6 months* 12 had angipomyolipomas measured at 12 months 9 with LAM had pulmonary function assessed at baseline 8 had pulmonary function assessed at 4 months 6 had pulmonary function assessed at 6 months # 6 had pulmonary function assessed at 12 months # 5 had pulmonary function assessed at 24 months 16 had angiomyolipomas measured at baseline 14 had neurocognitive assessment at baseline 16 patients enrolled 6 had LAM only 3 had tuberous sclerosis and LAM 7 had tuberous sclerosis only 1 withdrew 1 died 1 withdrew

10. 3 were not enrolled 2 were ineligible 1 declined to participate 19 patients with tuberous sclerosis or lymphangiomeiomatosis (LAM) screened SIROLIMUS THERAPY, 16 started 10 had angiomyolipomas measured at 24 months 11 had neurocognitive assessment at 12 months 13 had neurocognitive assessment at 4 months 15 had angiomyolipomas measured at 2 months 13 had angiomyolipomas measured at 6 months* 12 had angipomyolipomas measured at 12 months 9 with LAM had pulmonary function assessed at baseline 8 had pulmonary function assessed at 4 months 6 had pulmonary function assessed at 6 months # 6 had pulmonary function assessed at 12 months # 5 had pulmonary function assessed at 24 months 16 had angiomyolipomas measured at baseline 14 had neurocognitive assessment at baseline 16 patients enrolled 6 had LAM only 3 had tuberous sclerosis and LAM 7 had tuberous sclerosis only 1 withdrew 1 died 1 withdrew

11. 3 were not enrolled 2 were ineligible 1 declined to participate 19 patients with tuberous sclerosis or lymphangiomeiomatosis (LAM) screened SIROLIMUS THERAPY, 16 started 10 had angiomyolipomas measured at 24 months 11 had neurocognitive assessment at 12 months 13 had neurocognitive assessment at 4 months 15 had angiomyolipomas measured at 2 months 13 had angiomyolipomas measured at 6 months* 12 had angipomyolipomas measured at 12 months 9 with LAM had pulmonary function assessed at baseline 8 had pulmonary function assessed at 4 months 6 had pulmonary function assessed at 6 months # 6 had pulmonary function assessed at 12 months # 5 had pulmonary function assessed at 24 months 16 had angiomyolipomas measured at baseline 14 had neurocognitive assessment at baseline 16 patients enrolled 6 had LAM only 3 had tuberous sclerosis and LAM 7 had tuberous sclerosis only 1 withdrew 1 died 1 withdrew

12. 3 were not enrolled 2 were ineligible 1 declined to participate 19 patients with tuberous sclerosis or lymphangiomeiomatosis (LAM) screened SIROLIMUS THERAPY, 16 started 10 had angiomyolipomas measured at 24 months 11 had neurocognitive assessment at 12 months 13 had neurocognitive assessment at 4 months 15 had angiomyolipomas measured at 2 months 13 had angiomyolipomas measured at 6 months* 12 had angipomyolipomas measured at 12 months 9 with LAM had pulmonary function assessed at baseline 8 had pulmonary function assessed at 4 months 6 had pulmonary function assessed at 6 months # 6 had pulmonary function assessed at 12 months # 5 had pulmonary function assessed at 24 months 16 had angiomyolipomas measured at baseline 14 had neurocognitive assessment at baseline 16 patients enrolled 6 had LAM only 3 had tuberous sclerosis and LAM 7 had tuberous sclerosis only 1 withdrew 1 died 1 withdrew

13. Angiomyolipoma Response sum of longest diameters Reduction AML burden in all patients 8/16 patients respond by RECIST criteria 8/10 in per-protocol group 25% diameter reduction ≡ 60% in volume (for spherical lesions)

14. Angiomyolipoma Response: Percent Reduction in Sum of Longest Diameters 2 months6 months12 months24 months LAM110ND13Deceased LAM26314250 LAM314 41 LAM4882338 LAM54Withdrew LAM637Withdrew TSC1 (L)28 3028 TSC2 (L)1327 Withdrew TSC3914Withdrew TSC422Withdrew TSC51632 34 TSC6ND52926 TSC722233028 TSC8 (L)34241817 TSC916111821 TSC10261417

15. AML Response 41 / 48 AMLs smaller at last measurement than baseline 2 unchanged 5 larger: TSC3 - 1 of 5 AMLs increased by 1mm. Others shrank by 20-30% TSC4 - 4 of 9 AMLs grew (by up to 30%) while 5 shrank (by up to 25%) Most shrinkage in first year – mean LD of AMLs measured at 0,12 and 24 months were 2.92, 2.19 and 2.11cm respectively

16. Lung Function in Patients with LAM Mean rate of decline in FEV1 = 49 ml/yr over 12/12 (N=7) = 76 ml/yr over 24/12 (N = 5)

17. TSC* N S-LAM N IQ (SD) 105 (+/-15) 8 107 (+/-12) 6 Deficits on Tests (< 5 th Percentile) At Baseline 9/88 (10.2%) 8 2/63 (3.2%) 6 At 4 months 6/88 (6.8%) 8 1/45 (2.2%) 5 At 12 months 7/77 (9.1%) 7 0/44 (0%) 5 IQ and Neurocognitive Deficits * No patient with TSC had seizures in the year prior to or during the study

18. Immediate Recall Memory TSC mean change + 2 S-LAM +1.6 Immediate Recognition Memory TSC mean change -1.625 S-LAM - 0.6 Executive Function TSC mean change + 1.5 S-LAM + 3.0 Neurocognitive Tests: Summary Scores by Domain

19. Adverse Events Reported in all patients. Majority CTCAE grade 1 or 2 All patients had some time off therapy (days to months) Drug discontinued in 2 patients because of toxicity (peripheral oedema, proteinuria) One death (deemed unrelated to treatment) Frequent AEs: Respiratory infections, 5/16 – all LAM 3 serious and possibly sirolimus-related Mouth ulcers, 6/16 Proteinuria, 5/16

20. Summary Sirolimus therapy (3-10ng/ml) reduced size of most AMLs in patients with TSC or S-LAM AML burden reduced in all patients Most shrinkage in first year of therapy Response sustained at 2 years Side effects acceptable to most patients – but care in LAM Neurocognitive function – similar changes in TSC and S-LAM patients Lung function in LAM – little change, decline slowed ?

21. Acknowledgements TESSTAL team: D Mark Davies, Petrus de Vries, Simon Johnson, Deborah McCartney, Jane Cox, Andreas Serra, Peter Watson, Christopher Howe, Tim Doyle, Kate Pointon, Justin cross, Anne Tattersfield, Chris Kingswood. J Bissler, D Franz, D Kruger, F McCormack (Cincinnati) A Hunt TSA, James Tudor Trust, Wyeth (Pfizer)

22. TRON: UK Trial of Everolimus for neurocognitive problems in TSC

23. TRON Randomized control (2:1) trial, single UK centre Recruitment target 48 Age 16 - 60 yrs IQ ≥ 60 and deficit (-2 SD or more) in a 1º outcome measure 6 months treatment, blood levels 3-10ng/ml Determine effect sizes on recall memory and executive function in TSC Secondary outcomes: seizures, QOL, wider aspects of neurocognition, safety Protocol developed with Novartis and TSA (GB) Recruitment planned to open end 2011