Presente e futuro degli anticorpi bispecifici. Renato Bassan UOC Ematologia, Osp. Dell Angelo e SS. Giovanni e Paolo, Mestre - Venezia

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1 Presente e futuro degli anticorpi bispecifici Renato Bassan UOC Ematologia, Osp. Dell Angelo e SS. Giovanni e Paolo, Mestre - Venezia

2 Quiteanoldstory Immunocompetence and cancer NEGATIVE B/T-cell deficiency in leukemia Cancer/lymphoma in HIV+ POSITIVE GVHD/GVL effects in allogeneic SCT

3 GVL alongwithgvhd Blinatumomab, a bispecific product CAR T cells TODAY: new cell therapy recruiting/modifying T-cells

4 A bispecificantibody (BsAb) Is an antibody with mixed specificity Creating a dangerous liason(not involving MHC) between a ready-to-kill T-cell(or anything else) a (neoplastic) target The link is immuno-mediated We need functional T cells! BiTE Bispecifc T-cell engager

5 BsAbzoo first antigen binding site second antigen binding site THE MAKING OF BISPECIFIC ANTIBODIES Brinkmann U, Kontermann RE MABS 2017;9: accessory molecules/ linkers & combinations of individual domains (>100 formats)

6 Bi-or multi-specificconstructs

7 Velasquez MP et al, Blood 2018;131:30-38

8 FunctionalanatomyofBiAb s

9 BiTE Yuraszeck T et al, Clin Pharmacol Ther 2017

10 Yuraszeck T et al, Clin Pharmacol Ther 2017 The story so far

11 ClinicalapplicationsofBsAb s Oncology Other Solid cancers (most sites/conditions) Blood cancers CNS disorders (TfR and BACE1 BiAb s) Plaque psoriasis (COVA322), psoriasis (ALX- 0761) Osteoarthritis (ABT981) SLE(AMG 570) Adapted from Trivedi A et al, Clin Transl Sci 2017;10:

12 A reviewofrecenttrialsin hem-onc Velasquez MP et al, Blood 2018;131:30-38

13

14 Blinatumomabin B-lymphoma

15 First evidencein B-celllymphoma BM pre after Blinatumomab d15 Liver w4 BargouR etal, Science2008

16 Othermalignancies(butALL)

17 Blinatumomabstory FDA EMA AIFA FDA (? EMA) Yuraszeck T et al, Clin Pharmacol Ther 2017

18 The ALL file

19 Progress in Ph-ALL (notenough) ITALY: NILG trials 09/00 10/07 GERMANY: GMALL trials FRANCE: GRAALL trials Log-rank test P= year OS: 55% 5-year OS: 36% (N 163) medianage41years(range18 67) (N 304) medianage35years(range16 67) A common language: pediatric-based chemotherapy and MRD/risk-oriented allotransplantation strategy BassanR et al, ASH 2016; HoelzerD, 2010; DombretH, EHA 2014

20 Progress in Ph+ ALL (not enough) Overall Survival (proportion) NILG (BassanR etal, JCO 2011) Imatinib/CHT IM+ (n=59) IM (n=35) % 0.25 P=0.009 Pre-imatinib 23% Time (years) GIMEMA (Chiaretti S etal, Haematologica 2016) Dasatinib monotherapy followed by CHT MDACC (Ravandi F et al, Cancer 2015) GRAALL (Chalandon Y et al, Blood 2015) Dasatinib/Hyper-CVAD Imatinib/Hyper-CVAD vs Imatinib/VCR-Dexa

21 Relapsed/refractory (R/R) BCP-ALL Poor prognosis among adults with R/R acute lymphoblastic leukemia treated with standard of care (SOC) chemotherapy Prognostic factors for a better outcome: Younger age and lower WBC at primary diagnosis Longer duration of first remission Salvage 1 versus salvage 2-3 Allogeneic HSCT after salvage More recent period primary (diagnosis from 2005 onward) N= 1,706 Ph-negative R/R ALL CompleteRemissionRate (95% CI) Median OS, months (95% CI) No Prior Salvage (S1) One Prior Salvage (S2) Two or More Prior Salvages (S3) 40% (37% 44%) 21% (16% 26%) 11% (6% 18%) 5.8 ( ) 3.4 ( ) 2.9 ( ) Gökbuget N, Dombret H, Ribera JM et al. Haematologica. 2016;101(12):

22 Refractory/relapsed(R/R) ALL R/RPh-B-precursorALL (INTERNATIONAL REFERENCE ANALYSIS; N=1706) Goekbuget N et al, Haematologica 2016

23 Innovationsin R/RBCP ALL Experimental arms INO-VATE Phase 3 Inotuzumab ozogamicin (INO) CD22 TOWER Phase 3 Blinatumomab CD19 ELIANA Phase 2 Tisagenlecleucel CD19 Patients, N Median age 47 years 37 years 11 years(3-23) Age 55 years, N (%) 43 (39%) 67 (25%) 0 (0%) Overt ALL, % 100% 100% 100% (at screening) Ph+ ALL, N (%) 14 (13%) 0 (0%) NA First salvage, N (%) 73 (67%) 114 (42%) NA Prior allo-hsct, N (%) 17 (16%) 94 (35%) 46 (61%) Kantarjian HM, DeAngelo DJ, Stelljes M, et al, N Engl J Med. 2016;375: Kantarjian HM, Stein A, Gökbuget N, et al, N Engl J Med. 2017;376: Maude SL, LaetschTW, BuechnerJ et al, N EnglJ Med. 2018;378:

24 Blinatumomab Improved Overall Survival in Patients With Relapsed or Refractory Philadelphia Negative B- cell Precursor Acute Lymphoblastic LeukaemiaIn a Randomised, Open-label Phase 3 Study (TOWER) Max S. Topp *, 1 Anthony Stein, 2 Nicola Gökbuget, 3 Adele K. Fielding, 4 Andre C. Schuh, 5 Josep Maria Ribera Santasusana, 6 Andrew Wei, 7 Hervé Dombret, 8 Robin Foà, 9 Renato Bassan, 10 Onder Arslan, 11 Miguel A. Sanz, 12 Julie Bergeron, 13 FatihDemirkan, 14 EwaLech-Maranda, 15 Alessandro Rambaldi, 16 Xavier Thomas, 17 Alex Fleishman, 18 Dirk Nagorsen, 18 Christopher Holland, 19 Zachary Zimmerman, 18 HagopKantarjian 20 1 Würzburg, Germany, 2 Duarte CA, USA, 3 Frankfurt am Main, Germany, 4 London, United Kingdom, 5 Toronto ON, Canada, 6 Badalona, Spain, 7 Melbourne, Australia, 8 Paris, France, 9 Roma, Italy 10 Venezia, Italy, 11 Ankara, Turkey, 12 Valencia, Spain, 13 Montreal QC, Canada, 14 Izmir, Turkey, 15 Warszawa, Poland, 16 Bergamo, Italy, 17 Pierre-Benite, France, 18 Thousand Oaks CA, USA 19 Washington, DC, USA 20 HoustonTX, USA EHA 2016 (late breaking abstract); final report by Kantarajian H et al, NEJM 2017

25 TOWER TOWER Study A Phase 3, Randomised, Open Label Study Investigating the Efficacy of the BiTE Antibody Blinatumomab Versus Standard of Care Chemotherapy in Adult Subjects With Relapsed/Refractory B-precursor Acute Lymphoblastic Leukaemia Primary Objective Evaluate the effect of blinatumomab on overall survival (OS) compared with standard of care (SOC) chemotherapy

26 Key Eligibility Criteria Inclusion Age 18 years R/R Philadelphia-negative (Ph ) pre-b ALL: - refractory to intensive combination chemotherapy (initial or salvage) - untreated first relapse (remission <12 months) - untreated second or greater relapse - relapse at any time after allohsct > 5% blasts in bone marrow ECOG 2 Exclusion Clinically relevant CNS pathology AutoHSCT prior 6 weeks or allohsct prior 12 weeks Active GvHD (grade 2-4) or GvHD treatment prior 2 weeks

27 Randomisationand Dosing Randomisation 2 : 1 (Blinatumomab : SOC) Stratified by age, prior salvage, and prior allohsct Induction (2 cycles) if 5% blasts Consolidation (3 cycles) if 5% blasts Maintenance (up to 12 months) Follow-up Blinatumomab* Continuous infusion 4 wk on, 2 wk off; 9 µg/day for 7 days, then 28 µg/day wk 2-4 Continuous infusion 4 wk on, 8 wk off; 28 µg/day *Dexamethasone was given pre-dose to prevent cytokine release syndrome SOC Chemotherapy Investigator Choice: FLAG ± anthracycline; HiDAC-based; high-dose MTX-based; or clofarabine-based

28 Proportion of Patients (with upper 95% CI) HaematologicResponsein Induction 60% 50% 40% 30% 20% 10% 0% (p < 0.001) 44% 25% Blinatumomab (N = 271) SOC (N = 134) (p < 0.001) 34% 16% 9% 1% 4% 4% Overall response Complete remission CRh CRi Overall response 45% Hazard ratio for event-free survival (EFS): 0.55 (0.43, 0.71); p < (p = 0.007) 30% (N=267) (N=109)

29 Molecular Remission Among Responders 60% 50% 40% Blinatumomab SOC 30% 20% 10% 0% 74/97 (76%) 16/33 (48%) 57/74 (77%) 11/21 (52%) Overall response Complete remission Molecular remission was defined as <10-4 blasts in the first 12 weeks

30 Survival Probability Overall Survival (Intent-to-Treat) Median OS (95% CI): Blinatumomab, 7.7 months (5.6, 9.6) SOC, 4.0 months (2.9, 5.3) Stratified log-rank p = Hazard ratio: 0.71 (0.55, 0.93) 0.0 Number of Subjects at Risk: 1: : Months At 76% of events, the stratified log-rank test surpassed the O Brien-Fleming boundary (p < ) to stop the study for benefit

31 Overall Survival Censoring for AlloHSCT Survival Probability AlloHSCT post-baseline n (%) (95% CI) Median OS (95% CI): Blinatumomab, 6.9 months (5.3, 8.8) SOC, 3.9 months (2.8, 4.9) Stratified log-rank p = Hazard ratio: 0.66 (0.50, 0.88) Number of Subjects at Risk: 1: 271 2: Months Blinatumomab (N = 271) SOC (N = 134) 65 (24%) (19%, 30%) 32 (24%) (17%, 32%)

32 Overall Survival by Subgroup Subgroup Events/Subjects Blinatumomab SOC Age <35 years 68/123 (55.3) 34/60 (56.7) 35 years 96/148 (64.9) 53/74 (71.6) Prior salvage therapy S0 53/114 (46.5) 39/65 (60.0) S1 61/91 (67.0) 32/43 (74.4) S2+ 50/66 (75.8) 16/26 (61.5) Prior allohsct Yes 58/94 (61.7) 26/46 (56.5) No 106/177 (59.9) 61/88 (69.3) Baseline bone marrow blasts <50% 31/69 (44.9) 16/30 (53.3) 50% 132/201 (65.7) 71/104 (68.3) Unknown 1/1 (100.0) 0/0 (0.0) Overall 164/271 (60.5) 87/134 (64.9) Hazard Ratio (95% CI) 0.70 (0.46, 1.06) 0.77 (0.55, 1.08) 0.60 (0.39, 0.91) 0.59 (0.38, 0.91) 1.13 (0.64, 1.99) 0.81 (0.51, 1.29) 0.70 (0.51, 0.96) 0.66 (0.36, 1.20) 0.78 (0.58, 1.04) NE* (NE, NE) 0.71 (0.55, 0.93) *NE = Not estimable Blinatumomab Better SOC Better

33 Adverse Events (Regardless of Causality) Any AE, n (%) Any grade 3 AE Any grade 4 AE Any grade 5/fatal AE Grade 5 infection Grade 3 AE of interest, n (%) Neutropenia Infection Neurologic event Cytokine release syndrome Blinatumomab Treated (N=267) 263 (99) 98 (37) 82 (31) 51 (19) 30 (11) 101 (38) 91 (34) 25 (9) 13 (5) Events occurring up to 30 days after last dose of protocol-specified therapy, or before allohsct SOC Treated (N=109) 108 (99) 33 (30) 48 (44) 19 (17) 13 (12) 63 (58) 57 (52) 7 patients (5 blinatumomab, 2 SOC) who did not receive allohsct died during the study without documented relapse 9 (8) 0 (0)

34 Complete Molecular and Hematologic Response in Adult Patients With Relapsed/Refractory (R/R) Philadelphia Chromosome-Positive B- Precursor Acute Lymphoblastic Leukemia (ALL) Following Treatment With Blinatumomab: Results From a Phase 2 Single-Arm, Multicenter Study (ALCANTARA) Giovanni Martinelli, 1 Hervé Dombret, 2 Patrice Chevallier, 3 Oliver Ottmann, 4 Nicola Gökbuget, 5 Max S. Topp, 6 Adele K. Fielding, 7 Lulu Ren Sterling, 8 Jonathan Benjamin, 9 Anthony Stein 10 1 Institute of Hematology and Medical Oncology "L. e A. Seragnoli", Bologna, Italy; 2 University Paris Diderot, HôpitalSaint-Louis, Paris, France; 3 Hematology, CHU Nantes, Nantes, France; 4 Department of Haematology, Cardiff University, Cardiff, UK; 5 Department of Medicine II, Goethe University, Frankfurt, Germany; 6 Medizinische Klinikund PoliklinikII, UniversitätsklinikumWürzburg, Würzburg, Germany; 7 Department of Haematology, UCL, London, UK; 8 Amgen Inc., San Francisco, CA, USA; 9 Amgen Inc., Thousand Oaks, CA, USA; 10 Gehr Family Center for Leukemia Research, City of Hope, Duarte, CA, USA ASH 2015; finalreport bymartinelli G etal, J ClinOncol2017

35 Open-Label, Single-Arm, Multicenter Phase 2 Study in R/R Ph+ ALL Screening / Pre-phase Blinatumomab 9 to 28 µg/day* civ infusion 4 weeks on, 2 weeks off Up to 2 cycles Primary endpoint assessment * Only cycle 1, days 1 to 7: 9 µg/day Blinatumomab 28 µg/day civ infusion 4 weeks on, 2 weeks off Up to 3 cycles Consolidation 30-day Safety Follow-up Follow-up (up to 18 months) Study Endpoints Primary CR/CRhduring the first 2 cycles Key Secondary Minimal residual disease response by PCR of BCR-ABL during the first 2 cycles CR, CRh, and duration Relapse-free survival Overall survival HSCT realization Incidence of adverse events and antibody formation CR, complete remission; CRh, complete remission with partial hematological recovery of peripheral blood counts (platelets > 50,000/µL and ANC > 500/µL); civ, continuous intravenous; HSCT, hematopoietic stem cell transplantation

36 Eligibility Key Inclusion Criteria Adults ( 18 years) with Ph+ B-precursor ALL - Relapsed or refractory to at least one 2+ generation TKI or - Intolerant to 2+ generation TKI and intolerant/refractory to imatinib > 5% bone marrow blasts ECOG performance status 2 Key Exclusion Criteria Allogeneic HSCT within 12 weeks prior to start of blinatumomab Ac]ve acute or ac]ve chronic (grade 2 4) GvHD, or systemic treatment for GvHDwithin 2 weeks before treatment start History or presence of clinically relevant CNS pathology (epilepsy, seizure, paresis, aphasia, stroke, severe brain injuries, dementia, Parkinson s disease, cerebellar disease, organic brain syndrome, psychosis) CNS, central nervous system; ECOG, Eastern Cooperative Oncology Group; GvHD, graft-versus-host disease

37 Patient Characteristics n / N* Male 24 / 45 53% Median age (range), years 55 (23 78) Age group 18to < 55 years 55to < 65 years 65 years Cytogenetics and molecular analyses Philadelphia + other cytogenetic abnormalities ABL kinase domain mutations T315I mutation Prior relapses 0 (primary refractory) / / / / / / 37 3 / / / 45 4 / 45 Prior allogeneic HSCT 20 / 45 44% Prior tyrosine kinase inhibitors Imatinib Dasatinib Nilotinib Ponatinib Bone marrow blasts (central review) < 50% 50% * Number of patients with evaluable data HSCT, hematopoietic stem cell transplantation 45 / / /45 16 / / /45 34 / 45 49% 24% 27% 58% 46% 27% 7% 56% 29% 9% 100% 56% 87% 36% 51% 24% 76%

38 Response During First Two Cycles n / N 95% CI Primary endpoint CR/CRh T315l mutation 2 prior 2+ generation TKI Prior ponatinib treatment Age 18 to < 55 years Age 55 years Secondary endpoints Best response CR CRh CRi(not qualifying for CRh) 16 / 45 4 / / 27 8 / 23 8 / 22 8 / / 45 2 / 45 2/ 45 36% 40% 41% 35% 36% 35% 31% 4% 4% Complete MRD response* 14/ 16 88% HSCT after blinatumomab-induced remission 100-day post-transplant mortality rate 4 / 16 1 / 4 25% 25% 4 87 *Among CR/CRhresponders only;includes all four CR/CRhpatients with the T315I mutation. Complete MRD response = no detectable PCR amplification of Ig or TCR genes in central lab with a sensitivity of 10-5 CR, complete remission; CRh, complete remission with partial hematological recovery of peripheral blood counts; CRi, complete response incomplete; MRD, minimal residual disease

39 Overall Survival 1.0 Survival Probability Patients at Risk Study Month NE, not estimable Median follow-up: 8.8 months

40 Relapse-Free Survival Survival Probability Patients at Risk Study Month NE, not estimable Median follow-up: 8.8 months

41 MRD: whatmeanswhat MRD Leukemicmass (no. of cells) MRD correspondence Log scale % , , , , , , , , , BASELINE Microscopic threshold forcr (5%) Flow cytometry(0,1-0,01%) RQ-PCR (0,1-0,01%) ddpcr/ NGS (?) No man s land

42 MRD in BCP ALL Relapse-free survival(n=272) according to MRD level according to Allo-SCT YES (n=110)/no(n=162) N Goekbuget, R Foà, G Martinelli, A Rambaldi, R Bassan(manuscript) Mantel-Byaranalysis with allohsctas a time-dependent covariate attributed a patient to the nontransplantgroup until time of transplant (patients undergoing allohsctmust survive long enough to receive allohsct.the Simon-Makuchmethod was used to graphically display results from the Mantel-Byartest.

43 Abstract #680 Long-Term Outcomes After BlinatumomabTreatment: Follow-up of a Phase 2 Study in Patients With Minimal Residual Disease Positive B-cell Precursor Acute Lymphoblastic Leukemia Nicola Gökbuget, 1 Hervé Dombret, 2 Massimiliano Bonifacio, 3 Albrecht Reichle, 4 Carlos Graux, 5 Christoph Faul, 6 Helmut Diedrich, 7 Max S. Topp, 8 Monika Brüggemann, 9 Heinz A. Horst, 10 Julia Stieglmaier, 11 Hendrik Wessels, 11 Vincent Haddad, 12 Gerhard Zugmaier, 11 Dirk Nagorsen, 13 Ralf C. Bargou 14 ASH 2016; finalreport bygoekbugetn etal, Blood2018

44 Open-label, Multicenter, Confirmatory Phase 2 Study in MRD-positive B-precursor ALL Inclusion -Exclusion Criteria Adult patients ( 18 years) with CD19+ B-precursor ALL in hematological CR (first or later) were eligible if they had: MRD, defined as a level of 10-3 (molecular failure or molecular relapse) in an assay with a minimum sensitivity of 10-4 ANC (neutrophils) 1,000/μL Platelets 50,000/μL Hemoglobin level 9 g/dl Exclusion criteria included: Circulating blasts or extra-medullary ALL involvement A history of CNS pathology, including CNS involvement by ALL Prior allo SCT Major differences compared to first blinatumomab study in MRDpositive ALL MRD level of 10-3 (half of the pts > 10-2 ) Inclusion of patients in second or later remission (one-third of the pts) MRD response evaluated after 1 cycle of treatment Prior chemotherapy (within 2 weeks) or radiotherapy (within 4 weeks)

45 Open-label, Multicenter, Confirmatory Phase 2 Study in MRD-positive B-precursor ALL Treatment Overview Patients ineligible for allo SCT Up to three additional cycles Cycle 1 Blinatumomab 15 µg/m 2 /day Primary endpoint assessment 2-year follow-up for efficacy Survival follow-up Blinatumomab was given by continuous IV infusion, 15 μg/m 2 /d x 28 days per cycle, for 4 weeks on/2 weeks off (one cycle) for a maximum of up to four cycles AlloSCT was offered for eligible patients at any time after cycle 1 A protocol amendment dated July, 2012, permitted restarting blinatumomab treatment at 5 μg/m 2 /day following treatment interruption due to a grade 3 neurologic adverse event Intrathecal prophylaxis was given during screening and in each treatment interval Patients eligible for allo SCT Up to three additional cycles AlloSCT when donor is available 100-day allosct-related mortality assessment

46 Open-label, Multicenter, Confirmatory Phase 2 Study in MRD-positive B-precursor ALL Primary endpoint Endpoints and MRD Evaluation Proportion of patients achieving a complete MRD response in the first cycle i.e. MRD negative (minimum sensitivity 10-4 ) Secondary endpoints (among others) Hematologic relapse-free survival among Ph- patients at 18 months after initiation of blinatumomab, censored at the time of SCT and post-blinatumomab chemotherapy MRD response: MRD below 10-4 Overall survival Time to hematologic relapse Incidence and severity of adverse events MRD Evaluation Patients enrolled based on PCR- or flow cytometry-based MRD level of 10-3 The reference lab confirmed MRD level and status at inclusion by quantitative PCR of individual clonal immunoglobulin (IG) and/or T-cell receptor (TR) gene rearrangements according to standardized methodology 1 MRD response was analyzed solely in the reference lab Reference: 1. Brüggemann M, et al. Leukemia 2010;24:

47 Overall Gender Female Male Open-label, Multicenter, Confirmatory Phase 2 Study in MRD-positive B-precursor ALL Age MRD Level at to to to <10 < ( ( Baseline 0.1% to < 1%) 1% to < 10%) -1 <1 ( 10% to < 1) Remission Status CR2/3 CR1 Treatment Interruptions During Cycle 1 No Yes Neurologic Events Grade 2 During Cycle 1 No Yes Complete MRD Response after Cycle 1 by Clinical Characteristics n/n 82/103 35/43 47/60 29/32 25/35 17/23 11/13 40/51 36/43 6/9 27/37 55/66 45/58 37/44 59/73 23/30 0 Primary Endpoint Efficacy Set % (95% Exact CI) 80 (71-87) 81 (67-92) 78 (66-88) 91 (75-98) 71 (54-85) 74 (52-90) 85 (55-98) 78 (65-89) 84 (69-93) 67 (30-93) 78 (60-90) 83 (72-91) 78 (65-87) 84 (70-93) 81 (70-89) 77 (58-90) Complete MRD Response Rate (95% CI) Complete MRD response (Primary endpoint FAS): 78%(88/113) Complete MRD response (Efficacy set): 80% (82/103) Complete MRD response: MRD neg with sensitivity of 10-4 (1:10.000)

48 Survival Probability Open-label, Multicenter, Confirmatory Phase 2 Study in MRD-positive B-precursor ALL Overall Survival by Complete MRD Response : 2: Philadelphia-negative patients in hematologic CR Study Month (Landmark Analysis Beginning at Study Day 45) P = 0.002* Number of Subjects at Risk: : MRD complete responder at cycle 1 (N = 85) Median 95% CI 38.9 (33.7, NR) 2: MRD incomplete responder at cycle 1 (N = 22) Median 95% CI 12.5 (3.2, NR) Complete MRD response (primary endpoint): MRD negative, no amplification in PCR (minimum sensitivity 10-4 ) NR = not reached. The landmark analysis by MRD response included patients with overall survival of 45 days *Log rank P value for association between OS and MRD response; causality not implied. Underlying baseline characteristics may also influence both outcomes.

49 Survival Probability Open-label, Multicenter, Confirmatory Phase 2 Study in MRD-positive B-precursor ALL Relapse-free Survival by Complete MRD Response : 2: Philadelphia-negative patients in hematologic CR Number of Subjects at Risk: Study Month (Landmark Analysis Beginning at Study Day 45) 1: MRD complete responder at cycle 1 (N = 85) Median 95% CI 23.6 ( 17.4, NR ) 2: MRD incomplete responder at cycle 1 (N = 15) Median 95% CI 5.7 ( 1.6, 13.6) P = 0.003* 100 patients with data on MRD response according to the PRIMARY EP EFFICACY SET Complete MRD response (primary endpoint): MRD negative, no amplification in PCR (minimum sensitivity 10-4 ) NR = not reached. The landmark analysis by MRD response included patients with overall survival of 45 days *Log rank P value for association between RFS and MRD response; causality not implied. Underlying baseline characteristics may also influence both outcomes.

50 Survival Probability : 2: Open-label, Multicenter, Confirmatory Phase 2 Study in MRD-positive B-precursor ALL Relapse-free Survival Philadelphia-negative patients in hematologic CR Median (95% CI) follow-up: 29.9 (24.2, 30.6) months The key secondary endpoint was met: 18-month Kaplan-Meier estimate of RFS = 54% (95% CI: 33%, 70%) exceeding the prespecified lower boundary of 28% Number of Subjects at Risk: NR = not reached. Study Month 1: Relapse-Free Survival censoring at allo SCT and post-blinatumomab chemotherapy (N = 110) Median 95% CI NR ( 6.3, NR) 2: Relapse-Free Survival not censoring at allo SCT and post-blinatumomab chemotherapy (N = 110) Median 95% CI 18.9 ( 12.3, 35.2) SCT in continuous CR: 67%

51 Blinatumomabin MRD+ Ph-negBCP-ALL Blinatumomab(#73) compared to historical SOC (#182) Patients in first CR with MRD 10-3 Kaplan Meier curve of RFS after propensity score adjustment using stabilized inverse probability of treatment weighting (IPTW) GökbugetN, Dombret H, GiebelS, et al (manuscript)

52 BlinatumomabforMRD+ALL A Viardot, R Bargou. Cancer Treat Rev 2018;65:87-95

53 Toward first line programs integrating new agents(biab s, others) with pediatric-type chemo(ph- ALL) and risk/mrd-oriented strategy Aimingto: BetterCR & mol CR rates More effective consolidation/lower relapse rate No SCT (when possible)/less TRM

54 ECOG 1910 Phase 3 study N= 360 patients with Ph-negBCP-ALL, aged 30 to 70y old 1:1 randomization Cycle 1 (Induction Phase 1) MRD Cycle 2 (Induction Phase 2) CR No CR Off Trial Blina Intensification Randomization MRD No blina MRD Blinatumomab Cycle #1 Blinatumomab Cycle #2 Allogeneic SCT MRD Consolidation Cycle 1 Consolidation Cycle 2Consolidation Cycle Blinatumomab 3 Cycle #3 MRD MRD Consolidation Cycle 1 Consolidation Cycle 2Consolidation Cycle 3 Consolidation Cycle 4 Allogeneic SCT MRD Consolidation Cycle 4 Blinatumomab Cycle #4 MRD Maintenance Therapy Courtesy of Mark Litzow

55 GIMEMA LAL 2317 forph-cd19+ BCP ALL A. Induction/consolidation, Blinatumomab, MRD study and early SCT pre C1 C2 HD3 Blina C4 HD5 C6 Blina HD7 C8 H dd 1-28 dd 1-28 MRD TP1 primary endpoint TP2 TP3 esct, early allogeneic SCT (after Blinatumomab), for veryhr*or TP2 MRD 10-4 *WBC >100, highly adverse cytogenetics TP4 TP5 MRD risk model for riskoriented therapy B. Final MRD-oriented therapy MRD pos MRD neg SCT Maintenance Day 1 70 Week Treatment elements ADULT -TYPE (pre: CY/PDN; VCR, Dex, IDR) TRIPE IT Pegylated- ASP BLINATUMOMAB PEDIATRIC-TYPE (IDR-CY-DXM-6MP-AraC) PEDIATRIC-TYPE (HD MTX-AraC or HD MTX-ASP-6MP) with lineage-targetedmtx (B: 2.5 g/m 2 ) The number of patients required to evaluate an increase of MRD negativity from 60% (P0) to 75% (P1) is 85. Considering approx. 85% CR rate, 75% evaluable for MRD, expected loss of 10%, the total number of patients to enrol is149.

56 GIMEMA LAL 2116 for Ph+ ALL (D-ALBA) Steroid pretreatment Dasatinib + steroids Response evaluation (d85+) CHR + CMR CHR but no CMR No CHR Blinatumomab 28 µg for2 cycles (maximum 5 cycles) PRIMARY STUDY ENDPOINT CMR evaluation Dasatinib 6 months maintenance Post CMR treatment: dasatinib/blinatumomab(no SCT) possible; strict PCR monitoring CHR, complete haematological response; CMR, complete molecular response; PCR, polymerase chain reaction; SCT, stem cell transplantation. 56

57 Blinatumomab-ponatinib in Ph+ ALL (MDACC trial) Induction phase Consolidation phase: C2-C4 30 mg 15 mg in CMR wk 2 wk 4 wk 2 wk Maintenance phase 15 mg for 5 years Blinatumomab IT MTX, Ara-C Ponatinib 30 mg Ponatinib 15 mg Ara-C, cytarabine; MTX, methotrexate E Jabbour, personal communication (courtesy Ph. Rousselot) 57

58 Back tot-cells& othercriticalfactors T-cell related Defective number(few/no data) Defective function/inhibition Target related Loss/disruption of CD19 antigen expression Sanctuaries (CNS, testes, skin) Combined

59 T-cellsabout70% ofall lymphocytes Normallymphocytecount Most BCP ALL patientstlymphopenic? LessmarrowT-cellsin pts with >50% blast cells Post-blinatumomab increase to lower normal range 1 Klinger M etal, Blood2012; 2 Schub A etal, ASCO 2013

60 Blinatumomab-activatedT regs >8.5% predictsno response T reg activationleadigtoil-10 production with suppression of T-cell proliferation and CD8- mediated cell lysis DuellJ etal, Leukemia2017

61 Expressionofinhibitorymolecules(PD-1, PD-L1) mayalsoexplaininter-individualresponse 1,2 Increased PD-1 expression following blinatumomab in refractory case 1 Feucht J etal, Oncotarget2016; 2 Kohnke T etal, J HematolOncol2015; One PD-1+ blinatumomab-refractory patient responding to blinatumomab/pembrolizumab combination

62 CD19 antigenexpression CD19 neg relapsein 10-20% ofcases Clonalshift(CD19 neg subset) or othermolecular mechanism? Or both? disruptedmembrane export ofcd19 in 1 patient loss of CD81-dependent CD19 transport BraigF etal, Blood2017