Myelodysplastic Syndromes

Transcription

1 IPSS cytogenetic subgroups good intermediate poor p(gray-test) = Bone marrow blast count <5% 5-1% 11-2% 21-3% p(gray-test) <.1 Months Months 4/23/218 Myelodysplastic Syndromes Guillermo Garcia-Manero MD Professor of Medicine Chief, Section of MDS Deputy Chair for Translational Research Department of Leukemia MD Anderson Cancer Center Houston, TX 1/218 Objectives Basic concepts in MDS Molecular alterations Concept of clonal hematopoiesis Innate immune alterations in MDS Prognostic models Basic concepts therapy of MDS Investigational therapies Concept of HMA failure Diagnosis of MDS is based on morphology Cause of death in MDS Courtesy of Dr. Carlos Bueso-Ramos Dayyani et al. Cause of death in lower risk MDS. Cancer 21;116: Cytogenetic alterations are common in MDS Haase et al. Blood 27;11: Haase, D. et al. Blood 27;11: Cumulative survival Cumulative survival Blasts versus Cytogenetics in the Prognosis of MDS good intermediate poor A IPSS cytogenetic subgroup p (log-rank) < Months Bone marrow blast count <5% 5-1% 11-2% 21-3% p (log-rank) <.1 C Months Cumulative incidence function for AML Cumulative incidence function for AML (Schanz et al., JCO, 211) B D Category Poor (IPSS) Complex (non 5/7) Complex (5/7) Blasts (21-3%) OS (months) OS (HR) Figure 1 A-D Overall survival and cumulative risk of AML-transformation in IPSS cytogenetic and FAB bone marrow blast count subgroups (univariate analysis; pts. treated with supportive care exclusively) 1

2 4/23/218 Cytogenetic Scoring System in MDS (Schanz et al., JCO, 211) Molecular genetic landscape RUNX1 2% poor prognosis MDS-EV1 n/a ~5% cases over-expressed TP53 1% poor prognosis, therapy related MDS RAS 15% potential treatment targets in downstream pathway members JAK2 5% most often seen in RARS-T potential treatment with JAK2 inhibitors TET % seen in various myeloid malignancies potential link to DNA methylation and treatment with hypomethylating agents ASXL % potential treatment targets in histone modifying enzymes and ATRA EZH2 6% seen in various myeloid and solid tumor malignancies potential treatment targets in histone modifying enzyme Other less frequent: IDH2, Flt-3 Identification of RPS14 as the del5q gene UPD chromosome 7 in MDS RNA interference (RNAi) to interrogate 41 genes in the 5q-deleted region Introduction of 3-5 unique lentivirally expressed short hairpin RNAs targeting each of the 41 genes into normal CD34 + human progenitor cells Knock-down of RPS14 block of erythroid differentiation Forced expression of RPS14 cdna in BM cells of patients with 5q-syndrome phenotype rescue Haploinsufficiency of RPS14 block in processing of preribosomal RNA and formation of 4S ribosome units; analogous to Diamond Blackfan Anemia Ebert. Nature. 28;451:335-9 Heinrichs and Look, Leukemia 29;23:165 Mutation Frequency Point Mutations in MDS Associations With Clinical Features Independent Predictors of Overall Survival Somatic mutations in 18 genes were identified. 51% of samples had at least one mutation including 5 of cases with a normal karyotype. Bejar et al. NEJM 211 2

3 4/23/218 Mutation Frequency and Distribution Genomics of MDS TP53 7.5% TET2 2.5% ASXL1 14. RUNX1 8.7% NRAS/KRAS/BRAF 5.% CBL 2.3% JAK2 3.% EZH2 6. IDH1/IDH2 3. ETV6 2.7% NPM1 1.8% Karyotype 5q- alone -7/7q- alone or +1 abnormality +8 alone -2q alone Complex Normal and Y alone Other Unknown Bernd Boidol & Bennett Caughey Papaemmanuil et al Blood 213;122: Somatic Mutations in MDS Are Associated with Clinical Features and Predict Prognosis Independent of the IPSS-R Analysis of Combined Datasets from the International Working Group for MDS-Molecular Prognosis Committee Rafael Bejar, MD, PhD Elli Papaemmanuil, PhD Torsten Haferlach, MD Seishi Ogawa, MD, PhD Guillermo Garcia-Manero, MD Jaroslaw P. Maciejewski, MD, PhD Mikkael A. Sekeres, MD, MS Matthew J. Walter, MD Timothy A. Graubert, MD Mario Cazzola, MD Luca Malcovati, MD Pierre Fenaux, MD, PhD Eva Hellstrom-Lindberg, MD, PhD Wolfgang Kern, MD Jacqueline Boultwood, PhD Andrea Pellagatti, PhD Bejar et al. ASH 215 abstract 97 David Bowen, MD, PhD Sudhir Tauro, PhD Michael J Groves, PhD Paresh Vyas, MD, PhD Lynn Quek, MD Aziz Nazha, MD Felicitas Thol, MD Michael Heuser, MD Lee-Yung Shih, MD Yasunobu Nagata, MD, PhD Yusuke Okuno, MD, PhD Eric Padron, MD David Sallman, MD Rami S. Komrokji, MD Alan F. List, MD Detlef Haase, MD, PhD Julie Schanz, MD Valeria Santini, MD Michaela Fontenay, MD, PhD Peter J Campbell, MD, PhD Heinz Tüchler Kristen Stevenson, MS Donna S Neuberg, ScD Peter Greenberg, MD Benjamin L Ebert, MD, PhD On behalf of the IWG for MDS investigators Overall Survival by Mutation Number 17 genes sequenced in 1996 patients with OS data ASXL1 CBL DNMT3A ETV6 EZH2 IDH1 IDH2 JAK2 KRAS NPM1 NRAS RUNX1 SRSF2 TET2 TP53 U2AF1 SF3B1 O v e ra ll S u rv iv a l (% ) N u m b e r o f M u ta te d G e n e s Y e a r s (n = ) 1 (n = ) 2 (n = 4 6 ) 3 (n = 2 1 ) 4 (n = ) 5 /6 /7 (n = 2 2 ) S F 3 B 1 o n ly (n = 2 7 ) Mutation Frequency 26%.5% Mutated Genes and Clinical Phenotypes Gene % Mut FAB WHO IPSS-R Blast% Plts Sex Age ANC Hgb OS TP ASXL1 21 SRSF2 15 U2AF1 8.9 NRAS 3.6 RUNX1 1 STAG2 5.6 IDH2 3.4 KRAS 2.3 NPM1 1.5 BCOR 4.7 TET2 26 ZRSR2 6.4 EZH2 5.9 CBL 4.4 RAD PTPN GATA2 1.3 NF1 4.5 ETV6 2.6 PRPF8 2.4 FLT3.9 IDH1 2.3 PHF6 2.9 GNAS.9 WT1 1.2 ATRX 2.1 U2AF2 1 SMC3 1.3 KIT 1.1 MPL 1.8 DNMT3A 12 JAK2 3.6 SF3B1 22 p-value adverse < <.1 p-value favorable Clonal Progression from Myelodysplastic Syndrome (MDS) to Secondary Acute Myeloid Leukemia (saml). Walter MJ et al. N Engl J Med 212;366:

4 4/23/218 Flt3 alterations in MDS Effect of acquisition of Flt3 or Ras mutations in MDS Probability of Transformation-free Survival Non-FLT3/RAS FLT3/RAS Time (Months) Daver et al. AJH 213 Koichi Takahashi Cytogenetic acquisition in MDS t(3;18)(p21q21.3) t(6;9) t(2;9)(p14p21) del 13q12q22 del17q22q24 del14q22q31 del 3q21q27 del12p11p13 del9q12q22 Del 1p34.1p36.2 Y del alone Jabbour. ASH 211 abstract 382 5p del alone Complex abn exclud 7 abn 7% Tri 21 Add 19p13.3 Other abn 5% Add 18q23 chr 7 abn alone 7% Tri 13 alone Tri 14 or Add 14q32 alone chr 7 abn + other abn 13% Tri X alone XXYY Tri 8 alone 13% Tri 11 alone Tri Y alone Tri 9 alone Tri 8 + Tri 5 Effect of cytogenetic acquisition in MDS Probability of Overall Survival Non-CA CA Time (Months) Jabbour. ASH 211 abstract 382 Hypothesis #5: identification of drivers of transformation A) Early identification patients at risk Diploid Intervention Somatic Mutations in Normal Individuals Diploid Abnormal B) LR MDS 11 months ACA 8 months AML Diploid Early identification patients at risk Abnormal Abnormal Abnormal Intervention Diploid LR MDS 6 months ACA 7 months AML Jaiswal S et al. N Engl J Med 214;371:

5 Cumulative incidence of t-mns (%) 4/23/218 Clonal Hematopoiesis and Atherosclerosis Can we predict development of therapy related MDS? José J. Fuster et al. Science 217;355: Published by AAAS Wong et al. Nature. 215; 518(754): Clonal hematopoiesis increases the risk of therapy-related myeloid neoplasms Abstract #38 Koichi Takahashi 1,2, Feng Wang 2, Hagop Kantarjian 1, Denaha Doss 3, Kanhav Khanna 3, Erika Thompson 3, Keyur Patel 4, Sattva Neelapu 5, Curtis Gumbs 2, Carlos Bueso-Ramos 4, Courtney D DiNardo 1, Simona Colla 1, Farhad Ravandi 1, Song Xingzhi, Jianhua Zhang 2,7, Xifeng Wu 6, Felipe Samaniego 5, Guillermo Garcia- Manero 1, and P Andrew Futreal 2 Department of 1 Leukemia, 2 Genomic Medicine, 3 Genetics, 4 Hematopathology, 5 Lymphoma and Myeloma, and 6 Epidemiology, MD Anderson Cancer Center, Houston, TX Takahashi et al. Lancet Oncology 216 Padron et al. Lancet Oncology t-mn cases 14 t-mns patients with paired samples Primary cancer (e.g. Lung cancer) PB Chemotherapy/XRT x years 32 gene molecular barcode seq (Haloplex HS, Agilent) Detectable in PB? t-mns B M 295 gene capture seq Driver mutations Clonal hematopoiesis increases risk of t-mns Practical use of NGS in MDS CI of t-mn at 1 years: 29% (95% CI: 8-53%) vs. % (95% CI: -%) Number at risk (censored) No clonal hematopoiesis Clonal hematopoiesis No clonal hematopoiesis Clonal hematopoiesis P =.9 PPV = 26.7% (95%CI: %) Time (years) NPV = 98.3% (95%CI: 9.9%- 99.9%) 59 () 5 (5) 38 (7) 16 (17) 15 () 11 (1) 9 () 4 (2) Gene CHIP/CCUS (DNMT3A, TET2,ASXL1,JAK2,SF3B1,P53, PPMD1) P53 Flt-3 IDH-2 IDH-1 NPM1 RAS 3 mutations Implication Observation Increased risk of T-MN Favor HMA Poor outcome allosct At HMA failure Consider IDH2 inhibitor Consider clinical trial Consider ARA-C based therapy At HMA failure Consider clinical trial Poor prognosis 5

6 Relative Expression 4/23/218 Overexpression of Other Innate Immunity Like Signaling Components in MDS BM CD34+ (non-chip-seq identified) TLR2 Stimulation Activates Histone Demethylase JMJD3 CHIP-Seq gene products Toll like receptors (TLR) TLR2/ TLR1 TLR2/ TLR6 Genes examined in MDS BM CD34+ cells TLR1, 2, 3, 4, 6, 7, 8, 9, MYD88, IL-8 expression level in primary MDS BM CD34+ cells MYD fold NF-kB I-kB p5 p65 IL8 receptor IL fold 5.5 fold 138 fold De Santa F et al Cell 27 JMJD3 is Overexpressed in MDS CD34+ Cells 5 2 fold IL8 TLR1 TLR2 TLR6 MYD88 IL-8 MDS bone marrow CD34+ Genes showing potential prognostic value TLR1 and MYD88 expression levels negatively associate with overall survival (OS) in MDS patients Innate Immunity Genes & Patient Response to Epigenetic Targeting Drugs Immune Dysregulation in MDS SAHA/ AZA MDS TLR6 D D5 D21 D28 Resistance Sensitive N=7 N=11 FPR2 D D5 D21 D28 Resistance Sensitive C5AR D D5 D21 D28 Resistance Sensitive TYROBP D D5 D21 D28 Resistance Sensitive FPR1 D D5 D21 D28 Resistance Sensitive Yang H et al Immunosuppression CTL Th17 Tregs DC Macrophage Adaptive Immune Responses B Cells NK Selective Leukemic Clone Growth Tumor Immune Evasion Mechanisms: 1. Inhibitory B7 expression by tumor, APC and stroma cells. 2. APC 3. Treg. Hematopoietic hierarchy MYELOID PROGENITOR COMPARTMENT Lin - ckit + sca1 - CD34 + CD16/32 - Lin - CD34 + CD38 + CD45RA - CD123 + CMP Lin - ckit + sca1 + CD34 - CD135 - LT-HSC Lin - CD34 + CD38 - CD45RA - CD9 + MPP MEP GMP Lin - ckit + sca1 - CD34 - CD16/32 - Lin- ckit + sca1 - Lin - CD34 + CD38 + CD45RA - CD123 - CD34 + CD16/32 + ST-HSC Lin - ckit + sca1 + CD34 + CD135 - HSC COMPARTMENT Lin - CD34 + CD38 + CD45RA + CD123 + Lin - ckit + sca1 + CD34 + CD135 + Lin - CD34 + CD38 - CD45RA - CD9 - Lin - ckit + sca1 + CD34 + CD135 bright MLP Lin - CD34 + CD38 - CD45RA + CD9 - CLP LYMPHOID PROGENITOR COMPARTMENT Prognostic models IPSS WPSS Global MDACC model MDACC lower risk model Impact of comorbidities New revised IPSS ERYTHROCYTES PLATELETS GRANULOCYTES MONOCYTES PRO T-CELL PRO B-CELL Modified from Iwasaki H et al. Immunity 27 6

7 Proportion of patients Proportion of patients 4/23/ : Survival by # Blasts Revised IPSS Prognostic variable Cytogenetics Very good Good Intermediate Poor Very poor BM blast, % < 2 > - <5% 5%-1% > 1% Hemoglobin > < 1 < 8 Platelets > < 1 < 5 ANC >.8 <.8 Greenberg et al. Blood 212;12: Proposed treatment algorithm for patients with MDS Low-risk (IPSS low, INT-1) (BM blasts < 1%) Any age Iron chelation Growth factors (Epo + G-CSF) MTI (5-AZA/decitabine) Lenalidomide (5q-) Immunemodulation Clinical trial Failure/ Progression Allo SCT MDS Age < 6 Intensive chemotherapy High-risk (IPSS INT-2, high) (BM blasts > 1%) MTI (5-AZA/decitabine) Clinical trial Age 6 MTI (5-AZA/decitabine Clinical trial Intensive chemotherapy 1 1 Consider in younger patients with diploid cytogenetics 2 Consider earlier in younger patients Atallah. Cancer Inv. 28;26:28-16 Natural history of MDS after incorporation of HMAs Prodrome ICUS, CHIP LR-MDS Untreated HMA? lenalidomide HMA failure? HMA lower risk failure survival: months HMA higher risk failure survival: 4-6 months HR-MDS Untreated HMA AML-like SCT HMA failure AML-like?? Jabbour. Cancer 215; Jabbour. Cancer 21; Steensma Blood 215. AML MDS-4: randomized phase III of lenalidomide in lower risk del5q MDS Efficacy PBO LEN 5 LEN 1 RBC-TI 26 weeks (N,%) 3 (6) 19 (41) 23 (56) IWG-TI (N, %) 4 (8) 23 (5) 25 (61) Median t to response (weeks).3 (.3-24) 3.3 ( ) 4.3 ( ) Median Hgb CCGR+PCGR 8 (17) 17 (41) Progression to AML: LEN 5 6%, LEN 1 1%, PBO Time to AML: 9.3, 5.9 and 3.1 months G3-4 neutropenia in LEN 5 7, LEN 1 75%, PBO 15% Discontinuation in LEN 5 16%, LEN 1 9% and PBO 5% Fenaux. Blood 29:114:39 (abstract 944) Results: AML-Free Survival by CyR in Patients With Isolated del(5q) and del(5q) + 1 Additional Abnormality Isolated del(5q) (n = 13) del(5q) + 1 additional abnormality (n = 32) CyR Responder Non-responder Log-rank P =.42.2 Median AML-free survival, months (95% CI) Major + Minor 59.9 (43.2 NR) Non-responder 36.7 ( ) Time to AML or death (months).2 Median AML-free survival, months (95% CI) Major + Minor 58.1 (34.8 NR) Non-responder 3.7 ( ) Time to AML or death (months) For the risk of AML transformation or death, CyR was associated with a 41% reduction (95% CI.38.92; P =.19) in patients with isolated del(5q) and a 58% reduction (95% CI ; P =.56) in patients with del(5q) + 1 additional abnormality, compared with no CyR CyR Responder Non-responder Log-rank P =.259 Sekeres MA, et al. ASH 213; abstract 39. 7

8 Percent of Pts 4/23/218 5-azacitidine: alternative dosing Phase II, prospective, multicenter, randomized, open-label, 3-arm trial Hematologic Improvement Screening Cycle 1-6 AZA mg/m 2 SC Day -21 to -1 Initial Randomization Lyons R. JCO 29;11: AZA mg/m 2 SC AZA 5 75 mg/m 2 SC Repeat cycle every 28 days Maintenance Randomization AZA 5 75 mg/m 2 SC q 28 or 42 days Erythroid Major Platelet Major Neutrophil Major Any HI* *Pts counted only once for best response in an improvement category Minor improvement at top of HI columns A Randomized Phase II Study of Low-Dose Decitabine versus Azacitidine in Patients with Low- or Intermediate-1-Risk Myelodysplastic Syndromes: A Report on Behalf of the MDS Clinical Research Consortium Jabbour E 1, Short N 1, Huang X 1, Maiti A 1, Kadia T 1, Daver N 1, Borthakur G 1, DiNardo C 1, Pemmaraju N 1, Sasaki K 1, Estrov Z 1, Verstovsek S 1, Ravandi F 1, Alvarado Y 1, Sekeres M 2, Komrokji R 3, Steensma D 4, DeZern A 5, Roboz G 6, Kadia T 1, Borthakur G 1, DiNardo C 1, Miller D 1, Dong X 1, Kantarjian H 1, Garcia-Manero G 1 (Blood 217) 1 The University of Texas MD Anderson Cancer Center, Houston, TX; 2 Cleveland Clinic, Cleveland, OH; 3 Moffitt Cancer Center, Tampa, FL; 4 Dana-Farber Cancer Institute, Boston, MA; 5 Johns Hopkins University, Baltimore, MD; 6 Cornell Medical College, New York, NY DAC vs. AZA in LR-MDS. Treatment Bayesian adaptive randomization: DAC vs. AZA Regimens: DAC 2 mg/m 2 IV D1-3 every 4 weeks AZA 75 mg/m 2 IV/SC D1-3 every 4 weeks Response assessment by modified IWG 26 Between 11/212 and 2/216, 113 pts with LR- MDS treated: DAC, n=73 AZA, n=4 Median duration of follow-up = 2 months (range: 2-43 months) DAC vs. AZA in LR-MDS. Response (IWG) DAC vs. AZA in LR-MDS. OS Response DAC (N=7) n (%) AZA (N=39) n (%) P CR 26 (37) 14 (36).9 mcr 6 (9) 2 (5) HI 17 (24) 3 (8) ORR 49 (7) 19 (49).3 SD 18 (26) 17 (44) PD 3 (4) 3 (8) Median number of cycles: 9 (range: 1-41) 8

9 4/23/218 LR MDS post HMA Failure. Outcome n events mos A Decision Analysis of RIC Allogeneic HSCT for Older Patients with De-Novo MDS: Early Transplantation Offers Survival Benefit in Higher-Risk MDS CIBMTR Study #LK8-2 COI Disclosures per ASH Median follow-up: 16 (1-8) months Median TFS and OS: 15 and 17 months Jabbour et al; abstract #388 LK8-2-11_1.ppt Monte Carlo Low/int-1 IPSS Survival Estimates Test of Equality over Strata Proposed treatment algorithm for patients with MDS MDS RIC HSCT Test p Log-Rank <.1 Wilcoxon <.1-2Log(LR) <.1 Non-transplant Low-risk (IPSS low, INT-1) (BM blasts < 1%) Any age Iron chelation Growth factors (Epo + G-CSF) MTI (5-AZA/decitabine) Lenalidomide (5q-) Immunemodulation Clinical trial Failure/ Progression Age < 6 Intensive chemotherapy High-risk (IPSS INT-2, high) (BM blasts > 1%) MTI (5-AZA/decitabine) Clinical trial Age 6 MTI (5-AZA/decitabine Clinical trial Intensive chemotherapy 1 1 Consider in younger patients with diploid cytogenetics 2 Consider earlier in younger patients LK8-2-11_15.ppt Allo SCT Atallah. Cancer Inv. 28;26:28-16 Hypomethylators vs Intensive Chemo Rx in MDS with 1-3% Blasts 33 pts: 93 (28%) Rx with HMA and 237 (7) with chemo Rx Parameter HMA Intensive Chemo Rx MVA: worse survival with chemo Rx p value -% CR + CRp Median Rem. dur. (mos) %8-wk mortality median OS (mos) Nazha. Blood 122: abst 2788: 213 Decitabine vs. Intensive Chemotherapy Survival

10 Proportion Surviving Cumulative Probability 4/23/218 Overall Survival: Azacitidine vs CCR ITT Population Log-Rank p= months HR =.58 [95% CI:.43,.77] Deaths: AZA = 82, CCR = 113 Difference: 9.4 months 5.8% 24.4 months 26. AZA CCR Time (months) from Randomization Fenaux et al. Lancet Oncology 21 Hazard Ratio and 95% CI for Overall Survival ITT Subgroups Total - Event / N ITT 195 / 358 RAEB & RAEB-T: AGE / 24 AGE: < / / / 87 Male 134 / 251 Female 61 / 17 FAB: RAEB 95 / 27 RAEB-T 8 / 123 WHO: RAEB-1 15 / 31 RAEB-2 12 / 193 IPSS: INT-2 71 / 146 High 98 / 167 Cytogenetics: Good 8 / 167 Intermediate 38 / 76 Poor 67 / 1 Karyotype: -7/del (7q) 42 / 57 Cytopenias: /1 2 / 53 2/3 167 / 29 BM Blasts: 5% to < 11% 34 / 61 11% to < 21% 98 / % to < 31% 58 / 99 LDH: 24 U/I 97 / 28 > 24 U/I 94 / Favors Azacitidine Favors CCR Times to First Response with 5-azacitidine CCyR in MDS. OS by CyR Time 8 (cycles) Silverman et. al. ASH abstr 2526, 25 Time to First Response (CR, PR, HI [n=114[) Time From First Response to Best Response (CR, PR [n=36]) n events OS p= Median OS for patients with and without CCyR: 2 and 12 months (p=.1) Jabbour et al; abstract #281 TP53 mutation effect on HMA therapy in MDS Outcome in MDS post hypomethylating failure Takahashi et al. ASH 215 abstract #1663; Takahashi et al: Oncotarget, in press 1

11 4/23/218 Monte Carlo Int-2/High IPSS Survival Estimates Non-transplant Test of Equality over Strata Test Log-Rank <.1 Wilcoxon <.1-2Log(LR) <.1 RIC HSCT p Successful Emulation of IV Decitabine Pharmacokinetics with an Oral Fixed-Dose Combination of the Oral Cytidine Deaminase Inhibitor (CDAi) E7727 with Oral Decitabine, in Subjects with Myelodysplastic Syndromes (MDS): Final Data of Phase 1 Study On Behalf of the ASTX727 Investigative Team Guillermo Garcia-Manero 1, Olatoyosi Odenike 2, Philip Amrein 3, David P Steensma 4, Amy DeZern 5, Laura C Michaelis 6, Stefan Faderl 7, Hagop Kantarjian 1, James N Lowder 8, Pietro Taverna 8, Aram Oganesian 8, Xiaoping Zhang 8, Mohammad Azab 8, and Michael R Savona 9. MD Anderson Cancer Center 1, University of Chicago 2, Massachusetts General Hospital 3, Dana-Farber Cancer Institute 4, Johns Hopkins University Hospital 5, Medical College of Wisconsin/Froedtert 6, Hackensack University Medical Center 7, Astex Pharmaceuticals 8, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center 9 LK8-2-11_16.ppt ASTX727 Phase 1 Results 5 Days total DAC AUC: Oral/IV ASTX727 Oral Dose (mg) 5-Days Total (AUC last ) % of AUC Cohort DAC 1 E7727 N Oral IV (Oral/IV) % % % % 1 DAC oral dose not adjusted by Weight or BSA 2 One significant outlier excluded from the PK analysis 3 Includes 13 patient dose expansion Cohort 4 Oral DAC (at 4 mg) exposure achieved primary objective and exceeded that of IV DAC at 2 mg/m2 (Oral/IV 14) Cohort 5 Oral DAC (at 3 mg) exposure was 85% of IV DAC at 2 mg/m2 Oral DAC dose of 35 mg in ASTX727 (Ongoing Phase 2) should achieve AUC of ~ 85-1 of IV DAC LR-MDS Early intervention in LR MDS (US North American MDS Consortium) Transfusion dependent Transfusion independent AZA x 3 days DAC X 3 days AZAX 5 days Observation NCT Funded Edward P Evans Foundation Cleveland Clinic: M. Sekeres; Dana Farber Cancer Center: D. Steensma; Johns Hopkins: A Dezern; MDAnderson: Garcia-Manero; Moffitt Cancer Center: R Komrokji; Weill-Cornell: G Roboz Ongoing trials of immune checkpoint blockade in acute myeloid leukemia. Type Therapy Primary Inclusion Clinicaltrials.gov Outcome Identifier Phase 1 Ipilimumab Acute GVHD Solid tumors, NCT6372 (23- Graft rejection lymphoma and 213) UCSD, DFCI, Autoimmune leukemia, including Scripps; reaction relapsed/refractory PI: Carrier AML following allo- SCT Phase 1 Ipilimumab Toxicity and New CMML or high NCT (212- immunologic risk MDS; AML with 216); response MRD+ by flow PI: B Smith Phase Ipilimumab or nivolumab Toxicity and MTD Relapsed leukemia, NCT (213-1/1b including AML, 216) lymphoma and MM PI: Matthew Davids after allo-sct Phase 2 Pidilizumab + DC vaccine Toxicity AML in CR prior to NCT19662 (21- cell collection for DC 216) generation PI: Rosenblatt/Avigan Phase 2 DC vaccine +/- nivolumab Safety, EFS Heme malignancy in NCT CR PI: Daver Phase 2 Azacytidine + nivolumab Response rate, Relapsed AML and NCT overall survival frontline elderly (>65 PI: Daver years) AML Phase 2 Idarubicin and cytarabine + nivolumab Event-free Induction in newly NCT survival diagnosed AML < 6 PI: Ravandi years Phase 2 Nivolumab Recurrence-Free AML in remission NCT Survival PI: Kadia Phase 2 Aza+durvalumab versus Aza alone ORR, PFS, OS Elderly HR-MDS NCT and AML Phase 1 Atezolizumab +/- vidaza Toxicity New MDS, MDS NCT25887 posthma FLT3 Inhibitors Under Development Preclinical Phase I Phase II Phase III VX-322 IMC-EB1 Sorafenib Midostaurin VX-398 KW-2449 MLN-518 CEP-71 MC-22 AP Quizartinib MC-26 CHIR-258 Crenolanib PLX3397 FLX925 Al-Atrash, Daver et al. Pharm Reviews,

12 4/23/218 Enasidenib (AG-221), a Potent Oral Inhibitor of Mutant Isocitrate Dehydrogenase 2 (IDH2) Enzyme, Induces Hematologic Responses in Patients with Myelodysplastic Syndromes (MDS) Eytan M. Stein, Amir T. Fathi, Courtney D. DiNardo, Daniel A. Pollyea, Ronan T. Swords, Gail J. Roboz, Robert Collins, Mikkael A. Sekeres, Richard M. Stone, Eyal Attar, Alessandra Tosolini, Qiang Xu, Michael Amatangelo, Ira Gupta, Robert D. Knight, Stéphane De Botton, Martin S. Tallman, and Hagop M. Kantarjian Venetoxclax (ABT-199)+DAC/AZA in AML 22 pts with new Dx AML, median age 74 (65-85) VEN 4-8 mg/d + DAC/AZA Therapy No Responses VEN + DAC 12 7CR, 1CRi, 1PR =75% VEN + AZA 1 3 CR, 3 CRi, 1 PR = 7% TOTAL 22 1 CR + 4 CRi Overall response16/22 =73% DiNardo. Blood 126 : abst 327; 215 SF3B1 mutations in MDS Conclusion and needs Increased role of genomic annotation in MDS New targets: CD33, CD123, Bcl-2, TGF-b, TLR, SF3B1,IDH, Flt-3, NPM1 Lower dose HMAs for lower risk MDS Potent oral forms of HMAs: CC-486, ASTX727 Second generation HMAs: SGI-11 Combinations: + PD1/PDL1 inhibitors 3 ongoing Phase III trials: CC-486, Rigosertib, ACE-536 Need: p53, RAS, transplant integration Papaemmanuil E et al. N Engl J Med 211;365: Thank you very much Guillermo Garcia-Manero ggarciam@mdanderson.org 12