Published Ahead of Print on January 12, 2017, as doi:10.3324/haematol.2016.153957. Copyright 2017 Ferrata Storti Foundation. Long-term relapse-free survival in a phase 2 study of blinatumomab for the treatment of patients with minimal residual disease in B-lineage acute lymphoblastic leukemia by Nicola Gökbuget, Gerhard Zugmaier, Matthias Klinger, Peter Kufer, Matthias Stelljes, Andreas Viardot, Heinz A. Horst, Svenja Neumann, Monika Brüggemann, Oliver G. Ottmann, Thomas Burmeister, Dorothea Wessiepe, Max S. Topp, and Ralf Bargou Haematologica 2017 [Epub ahead of print] Citation: Gökbuget N, Zugmaier G, Klinger M, Kufer P, Stelljes M, Viardot A, Horst HA, Neumann S, Brüggemann M, Ottmann OG, Burmeister T, Wessiepe D, Topp MS, and Bargou R. Long-term relapse-free survival in a phase 2 study of blinatumomab for the treatment of patients with minimal residual disease in B-lineage acute lymphoblastic leukemia. Haematologica. 2017; 102:xxx doi:10.3324/haematol.2016.153957 Publisher's Disclaimer. E-publishing ahead of print is increasingly important for the rapid dissemination of science. Haematologica is, therefore, E-publishing PDF files of an early version of manuscripts that have completed a regular peer review and have been accepted for publication. E-publishing of this PDF file has been approved by the authors. After having E-published Ahead of Print, manuscripts will then undergo technical and English editing, typesetting, proof correction and be presented for the authors' final approval; the final version of the manuscript will then appear in print on a regular issue of the journal. All legal disclaimers that apply to the journal also pertain to this production process.
Long-term relapse-free survival in a phase 2 study of blinatumomab for the treatment of patients with minimal residual disease in B-lineage acute lymphoblastic leukemia Nicola Gökbuget, 1 * Gerhard Zugmaier, 2 * Matthias Klinger, 2 Peter Kufer, 2 Matthias Stelljes, 3 Andreas Viardot, 4 Heinz A. Horst, 5 Svenja Neumann, 5 Monika Brüggemann, 5 Oliver G. Ottmann, 6 Thomas Burmeister, 7 Dorothea Wessiepe, 8 Max S. Topp, 9 ** and Ralf Bargou 10 ** *Shared responsibility for lead authorship, **shared responsibility for senior authorship 1 Center of Internal Medicine, Goethe University, Frankfurt, Germany 2 Amgen Research (Munich) GmbH, Munich, Germany 3 Medical Department A, University Münster, Münster, Germany 4 Department for Internal Medicine III, University Ulm, Ulm, Germany 5 Medical Department II, Christian-Albrechts University, Kiel, Germany 6 Department of Haematology, Cardiff University, Cardiff, UK 7 Department for Hematology and Oncology and Tumor Immunology, Charité- Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany 8 Metronomia Clinical Research GmbH, München, Germany 9 Department of Internal Medicine II, Universitätsklinikum Würzburg, Würzburg, Germany 10 Comprehensive Cancer Center Mainfranken, Universitätsklinikum Würzburg, Würzburg, Germany Running head: Blinatumomab in ALL and MRD: long-term remission Correspondence: Gerhard Zugmaier, Amgen Research (Munich) GmbH, Staffelseestrasse 2, 81477 Munich, Germany; e-mail: gerhardz@amgen.com. Page 1 of 12
Word count: Manuscript (up to 1,500 words) 1,500 words Tables/figures (up to 3) 3 References (up to 15) 9 Supplemental material 1 supplemental figure Acknowledgments This study was funded by Amgen Inc. The authors would like to thank Jonathan Latham, PharmD (PharmaScribe, LLC), whose work was funded by Amgen Inc., and Beate D. Quednau, PhD (Amgen Inc.), for assistance in the preparation of this manuscript. Disclosures This work was funded by Amgen Inc. Disclosures for individual authors are as follows. NG: Speaker and advisory board honoraria from Amgen and Pfizer. Research support from Amgen. GZ: Employee of Amgen (Research) Munich GmbH and shareholder in Amgen Inc. MK: Employee of Amgen (Research) Munich GmbH and shareholder in Amgen Inc. Inventor on patents related to blinatumomab. PK: Employee of Amgen (Research) Munich GmbH and shareholder in Amgen Inc. Inventor on patents related to blinatumomab. Recipient of royalties on blinatumomab product sales. AV: Amgen (Honoraria, Advisory Board); Janssen (Honoraria, Advisory Board); Gilead (Advisory Board); Roche (Honoraria); BMS (Advisory Board); Pfizer (Honoraria). MST: Amgen (honoraria, consulting, research funding, and travel expenses). RB: Fees from Amgen, Novartis, Astra Zeneca, and GEMoaB, and a patent for blinatumomab with royalties paid. MS, HH, NS, MB, OO, TB, DW: None Page 2 of 12
In adults with acute lymphoblastic leukemia (ALL), chemotherapy advances have improved hematologic response rates to greater than 80% and relapse to <50%. Leukemic cells not detected by conventional morphologic methods may persist or reappear after chemotherapy as minimal residual disease (MRD), defined as at least 10-4 (0.01%) leukemic cells by quantitative polymerase chain reaction. Patients aged 15 to 55 years with MRD after consolidation have a 5- year relapse-free survival (RFS) rate of 25%, compared with 67% among those without MRD. 1 Allogeneic hematopoietic stem cell transplantation (allohsct) in patients with MRD improves 5- year RFS to 44% (versus 11% without allohsct), but fewer than 50% of patients with MRD receive allohsct, often because of rapidly occurring relapse. 1 Blinatumomab, a bispecific T-cell engager (BiTE ) antibody construct with dual specificity for CD19 and CD3, 2 demonstrated efficacy in 2 phase 2 studies for the treatment of relapsed or refractory B-lineage ALL, with response rates of 43% to 69% and median RFS of 5.9 to 7.6 months. 3,4 A randomized phase 3 study showed significantly improved overall survival with blinatumomab compared with standard of care chemotherapy in adults with relapsed or refractory ALL. 5 The data summarized here represent the final analysis of 5-year RFS in a single-arm phase 2 study in adult patients with B-lineage ALL who had persistent MRD or MRD relapse after intensive chemotherapy. Full study methods were described previously. 6 Patients aged 18 years with B-lineage ALL in hematologic complete remission (CR) with quantifiable MRD of 10-4 after consolidation I of first-line therapy using GMALL protocols were enrolled between January 2008, and August 2009. Each patient received up to 4 cycles of initial treatment with blinatumomab and up to 3 additional cycles if hematologic relapse had not occurred. Each cycle included open-label blinatumomab 15 µg/m 2 /day by continuous intravenous infusion over 4 weeks, followed by a 2-week treatment-free interval. The primary endpoint was MRD response within the first 4 cycles, defined as BCR-ABL or MLL-AF4 below the detection limit or individual Page 3 of 12
rearrangements of immunoglobulin or T-cell receptor genes <10-4. An institutional review board or independent ethics committee approved the protocol for each study center. In the primary analysis, after all patients completed blinatumomab treatment, the rate of MRD response was 80% (16 of 20 evaluable patients) and all MRD responses occurred in the first cycle. 6 Patients completed follow-up visits for RFS assessment for up to 5 years. In the first follow-up analysis after a median follow-up of 33 months, 12 of 20 evaluable patients (60%) were still in remission. 7 The final analysis reported here was conducted after the last patient completed the last study visit, with median follow-up of 50.8 months. Ten patients (50%) were still in remission 5 years after the start of blinatumomab treatment. Per study protocol, patients could receive allohsct any time after the first cycle of blinatumomab treatment. Nine patients proceeded to allohsct: 7 with and 2 without MRD responses. Kaplan-Meier analyses of RFS for all 20 patients, with or without censoring for allohsct, are provided in Figure 1A. Overall, 5 of 9 patients with allohsct and 5 of 11 patients without allohsct after blinatumomab remained in continuous CR 5 years after starting blinatumomab treatment. Patient characteristics by allohsct use are provided in Online Supplementary Table S1. Serum immunoglobulin levels were available at baseline and end of follow-up for 6 patients (Online Supplementary Table S2). 8 Kaplan-Meier analyses of RFS for 15 patients with Philadelphia chromosome (Ph)-negative ALL are provided in Figure 1B. Four of 6 patients with Ph-negative ALL who did not receive allohsct or any other subsequent therapy were in hematologic remission 5 years after starting blinatumomab treatment. Patient characteristics at baseline are summarized for patients with and without documented RFS 5 years in Table 1. Nineteen of 20 patients were treated in first hematologic CR (CR1). Five patients had Ph-positive ALL (BCR-ABL translocations) and 2 had MLL-AF4 translocations. Page 4 of 12
All 10 patients with RFS 5 years had molecular failure. Among 10 patients with RFS <5 years, 5 had molecular relapse and 5 had molecular failure. In an interim follow-up analysis from the confirmatory phase 2 BLAST study of blinatumomab in 116 patients with MRD-positive ALL, patients in CR1 had significantly higher rates of RFS at 18 months than patients with CR2 or higher. 9 Kaplan-Meier analyses of RFS for 15 patients with molecular failure in CR1 in the study reported herein are provided in Figure 1C. Only 1 patient was treated in second CR (CR2), so it was not possible to compare outcomes between patients in CR1 and CR2. Data from both studies indicate that blinatumomab may have a curative potential in patients with MRD-positive ALL in CR1. In this study, efficient T-cell activation and expansion was observed in 19 of 20 patients, irrespective of MRD status after blinatumomab treatment, 10 and T-cell expansion was similar between patients with or without RFS 5 years (Online Supplementary Figure S1). Patients with and without RFS 5 years showed comparable serum concentrations of cytokines during the first week of cycle 1 (data not shown). Although there was a visual trend towards increased T- cell expansion with higher MRD level, no correlation was identified (R 2 = 0.048) in this small patient population (Online Supplementary Figure S2). In another phase 2 study of patients with relapsed or refractory B-lineage ALL who received blinatumomab, patients with overall survival (OS) 30 months and MRD response had a markedly increased T-cell expansion, compared with patients who had OS <30 months and persistent MRD. 11 Patients with relapsed or refractory disease have a larger activation matrix (i.e., tumor load) for T cells, possibly leading to more pronounced T-cell expansion in patients with long-term OS. Importantly, the present study did not require a lower initial dose of blinatumomab in cycle 1, potentially overcoming limitations in efficient T-cell activation with stepwise dosing. Detailed data for each of the 20 patients are provided in Table 2. Seven of 10 patients with RFS 5 years achieved MRD response during blinatumomab treatment that was ongoing at the time Page 5 of 12
of the final MRD assessment. The other 3 patients with RFS 5 years did not achieve MRD response during blinatumomab treatment, but all 3 had low MRD levels at baseline (<1.5x10-3 ). One had Ph-positive ALL, did not undergo allohsct, and had increasing MRD that was controlled by administration of the tyrosine kinase inhibitor dasatinib during and after blinatumomab treatment. The other 2 had low MRD that was maintained during blinatumomab treatment (1 with Ph-negative ALL and 1 with Ph-positive ALL who also received the tyrosine kinase inhibitor imatinib), and both received allohsct after blinatumomab. Overall, 5 patients had Ph-positive ALL, of whom 2 were in remission at final analysis (1 with and 1 without allohsct). Among 10 patients who did not have documented RFS 5 years, 6 had hematologic relapse (2 CD19 -, 2 CD19 +, and 2 with unknown CD19 status), 2 had extramedullary relapse (both CD19 + ), and 1 withdrew consent (censored in RFS analysis) while still in remission (previously reported at 2.6 months 7 ; subsequent documentation showed the patient withdrew consent at 1.4 months). One patient who received allohsct died of graft-versus-host disease, sepsis, and multiorgan failure while in remission 19.1 months after blinatumomab treatment started. The 6 hematologic relapses occurred 3.2, 5.1, 12.4, 31.0, 44.3, and 50.8 months, respectively, after blinatumomab treatment started. The patient with hematologic relapse at 50.8 months had an initial MRD response to blinatumomab but experienced MRD relapse during follow-up. After MRD relapse, the patient received 1 cycle of blinatumomab retreatment, then allohsct. The patient did not achieve another MRD response before extramedullary relapses in the brain and testis 4.2 and 6.5 months after blinatumomab retreatment. Adverse events during the primary study and interim follow-up analysis were described previously. 6,7 Two new grade 3 or 4 adverse events were reported in this final analysis. Investigators did not consider either event to be related to blinatumomab treatment. One patient with RFS of 12.4 months had grade 3 pulmonary hemorrhage during follow-up that resolved the Page 6 of 12
following day. One patient had recurrence of breast cancer as metastatic disease during followup that the investigator reported as an adverse event. Most patients with molecular failure or molecular relapse of ALL experience hematologic relapse within 5 years after chemotherapy. In this final analysis of a phase 2 study, half of the patients with B-precursor ALL and MRD who received blinatumomab achieved long-term remission through 5 years of follow-up, further supporting the results of the study s primary analysis and interim follow-up analysis (Online Supplementary Figure S3). 6,7 Among 9 transplanted patients, 1 transplant-related death due to graft-versus-host disease was reported. To our knowledge, this was the first study conducted with an immunotherapy for ALL that focused on patients with MRD-positive disease. Long-term RFS included patients with Ph-positive or MLL-AF4 positive disease, but the sample sizes were small. In conclusion, patients with MRD-positive ALL can achieve long-term RFS after blinatumomab treatment with or without subsequent allohsct. These findings warrant further investigation of early administration of blinatumomab in adults with ALL, hematologic remission, and MRD to prevent relapse, instead of later administration at the time of hematologic relapse. Page 7 of 12
References 1. Gökbuget N, Kneba M, Raff T, et al. Adult patients with acute lymphoblastic leukemia and molecular failure display a poor prognosis and are candidates for stem cell transplantation and targeted therapies. Blood. 2012;120(9):1868-1876. 2. Nagorsen D, Kufer P, Baeuerle PA, Bargou R. Blinatumomab: a historical perspective. Pharmacol Ther. 2012;136(3):334-342. 3. Topp MS, Gökbuget N, Zugmaier G, et al. Phase II trial of the anti-cd19 bispecific T cell-engager blinatumomab shows hematologic and molecular remissions in patients with relapsed or refractory B-precursor acute lymphoblastic leukemia. J Clin Oncol. 2014;32(36):4134-4140. 4. Topp MS, Gökbuget N, Stein AS, et al. Safety and activity of blinatumomab for adult patients with relapsed or refractory B-precursor acute lymphoblastic leukaemia: a multicentre, single-arm, phase 2 study. Lancet Oncol. 2015;16(1):57-66. 5. Topp MS, Stein A, Gökbuget N, et al. Blinatumomab improved overall survival in patients with relapsed or refractory Philadelphia negative B-cell precursor acute lymphoblastic leukemia in a randomized, open-label phase 3 study (TOWER). Haematologica. 2016;101(s1):Abstract S149. 6. Topp MS, Kufer P, Gökbuget N, et al. Targeted therapy with the T-cell-engaging antibody blinatumomab of chemotherapy-refractory minimal residual disease in B- lineage acute lymphoblastic leukemia patients results in high response rate and prolonged leukemia-free survival. J Clin Oncol. 2011;29(18):2493-2498. 7. Topp MS, Gökbuget N, Zugmaier G, et al. Long-term follow-up of hematologic relapsefree survival in a phase 2 study of blinatumomab in patients with MRD in B-lineage ALL. Blood. 2012;120(26):5185-5187. Page 8 of 12
8. Zugmaier G, Topp MS, Alekar S, et al. Long-term follow-up of serum immunoglobulin levels in blinatumomab-treated patients with minimal residual disease-positive B- precursor acute lymphoblastic leukemia. Blood Cancer J. 2014;4(9):244. 9. Gökbuget N, Dombret H, Bonifacio M, et al. Long-term outcomes after blinatumomab treatment: follow-up of a phase 2 study in patients (pts) with minimal residual disease (MRD) positive B-cell precursor acute lymphoblastic leukemia (ALL) [abstract]. Blood. 2015;126(23):680. 10. Klinger M, Brandl C, Zugmaier G, et al. Immunopharmacologic response of patients with B-lineage acute lymphoblastic leukemia to continuous infusion of T cell-engaging CD19/CD3-bispecific BiTE antibody blinatumomab. Blood. 2012;119(26):6226-6233. 11. Zugmaier G, Gökbuget N, Klinger M, et al. Long-term survival and T-cell kinetics in relapsed/refractory ALL patients who achieved MRD response after blinatumomab treatment. Blood. 2015;126(24):2578-2584. Page 9 of 12
Tables Table 1. Baseline characteristics and treatment outcome by duration of RFS Sex, n (%) RFS 5 years (n=10*) RFS <5 years (n=10**) Male 3 (30) 5 (50) Female 7 (70) 5 (50) Age, years, median (range) 48.5 (23-77) 54.5 (20-72) Prior consolidation II, n (%) 4 (40) 7 (70) Disease status, n (%) Molecular relapse in CR1 0 (0) 4 (40) Molecular relapse in CR2+ 0 (0) 1 (10) Molecular failure in CR1 10 (100) 5 (50) Molecular failure in CR2+ 0 (0) 0 (0) MRD status, n (%) MRD <10-3 3 (30) 1 (10) MRD 10-3 7 (70) 9 (90) Method for MRD evaluation, n (%)*** Ig/TCR rearrangements PCR 7 (70) 9 (90) BCR-ABL translocations PCR 2 (20) 3 (30) MLL-AF4 translocations PCR 1 (10) 1 (10) Number of blinatumomab cycles, median (range) 4 (1-7) 3.5 (2-5) Complete MRD response after 1 cycle, n (%) 7 (70) 9 (90) AlloHSCT after blinatumomab treatment, n (%) 5 (50) 4 (40) *Includes 1 patient who completed the study in remission, with RFS of 59.7 months (4.97 years). **One patient was censored after 43 days (1.4 months) because of withdrawal of consent. ***Patients could have both rearrangements and translocations. AlloHSCT: allogeneic hematopoietic stem cell transplantation; CR1: first hematologic complete remission; CR2+: second or greater hematologic CR; Ig: immunoglobulin; MRD: minimal residual disease; PCR: polymerase chain reaction; RFS: relapse-free survival; TCR: T-cell receptor. Page 10 of 12
Table 2. Individual baseline characteristics and outcomes, by duration of RFS Patient Age Baseline Characteristics MRD Response Ph MolF/ CR1/ Dose Duration Time to allohsct Duration No. Sex (y) Status MolR CR2+ MRD Incr. Response (mo.) (mo.) (mo.) 5 y Type of Event Relapse 1 F 42 Ph MolF CR1 10-3 No Yes 0.5* 1.4** No 2 F 62 Ph MolR CR1 10-3 No No 3.2 No Hematologic No 3 F 67 Ph+ MolF CR1 10-3 No Yes 3.3 4.2 No Extramedullary Yes 4 F 72 Ph+ MolR CR1 <10-3 No Yes 2.8 5.1 No Hematologic No 5 M 62 Ph MolF CR1 10-3 No Yes 5.6 6.5 No Extramedullary Yes 6 M 20 Ph MolR CR1 10-3 No Yes 1.4* 2.5 12.4 No Hematologic Unknown 7 M 47 Ph MolR CR2+ 10-3 No Yes 1.6* 2.8 19.1 No Death in remission 8 F 37 Ph MolF CR1 10-3 No Yes 1.4* 2.7 31.0 No Hematologic Unknown 9 M 69 Ph+ MolR CR1 10-3 No Yes 7.3 44.3 No Hematologic Yes 10 M 28 Ph MolF CR1 10-3 No Yes 14.4 18.7 50.8 No Hematologic Yes 11 F 31 Ph MolF CR1 <10-3 No Yes 0.5* 1.9 59.5* Yes 12 M 40 Ph+ MolF CR1 10-3 No No 3.1 61.9* Yes 13 F 63 Ph MolF CR1 10-3 No Yes 62.1* 62.9* Yes 14 F 34 Ph MolF CR1 <10-3 Yes No 5.6 63.4* Yes 15 F 68 Ph MolF CR1 10-3 No Yes 46.7* 63.8* Yes 16 F 77 Ph MolF CR1 10-3 No Yes 29.9* 64.3* Yes 17 F 23 Ph MolF CR1 10-3 No Yes 4.2* 5.8 64.4* Yes 18 F 57 Ph MolF CR1 10-3 No Yes 64.2* 65.0* Yes 19 M 31 Ph MolF CR1 10-3 Yes Yes 2.9* 4.4 65.8* Yes 20 M 65 Ph+ MolF CR1 <10-3 Yes No 70.1* Yes RFS CD19- Positive *Censored at the end of follow-up. **Patient was censored after 43 days (1.4 months) because of withdrawal of consent. : not applicable; allohsct: allogeneic hematopoietic stem cell transplantation; CD19 - : CD19-negative relapse; CD19 + : CD19-positive relapse; CR1: first hematologic complete remission; CR2+: second or greater hematologic CR; extramedullary: extramedullary relapse; F: female; hematologic: hematologic relapse; incr.: increased M: male; mo.: months; MolF: molecularly refractory; MolR: molecular relapse; MRD: minimal residual disease; No.: number; Ph : Philadelphia chromosome negative disease; Ph+: Philadelphia chromosome positive disease; RFS: relapse-free survival; y: year. Page 11 of 12
Figure Legend Figure 1. Kaplan-Meier analyses of hematologic relapse-free survival after blinatumomab therapy, with or without censoring at the date of allogeneic hematopoietic stem cell transplantation (allohsct). (A) All evaluable patients (N=20). (B) Patients with Philadelphia chromosome negative disease (N=15). (C) Patients with molecular failure in first hematologic remission (CR1; N=15). Page 12 of 12
Long-term relapse-free survival in a phase 2 study of blinatumomab for the treatment of patients with minimal residual disease in B-lineage acute lymphoblastic leukemia Nicola Gökbuget, Gerhard Zugmaier, Matthias Klinger, Peter Kufer, Matthias Stelljes, Andreas Viardot, Heinz A. Horst, Svenja Neumann, Monika Brüggemann, Oliver G. Ottmann, Thomas Burmeister, Dorothea Wessiepe, Max S. Topp, and Ralf Bargou SUPPLEMENTAL DATA Page 1 of 7
Online Supplementary Figure S1. CD3 + T-cell expansion during cycle 1 of blinatumomab treatment (study day 0 to 28) and during the subsequent 2-week treatment-free interval (study day 35). Evaluable patients (N=20) were grouped according to duration of relapse-free survival (RFS) (<5 versus 5 years; n=10 each). Data shown are median (interquartile range) cell values. For clarity, initial T-cell redistribution during the first week of cycle 1 is not shown. Page 2 of 7
Online Supplementary Figure S2. CD3 + T-cell expansion as baseline-adjusted area under the T-cell curve (AUC baseline) versus initial minimal residual disease (MRD) level. Page 3 of 7
Online Supplementary Figure S3. Key outcomes from each study analysis. allohsct: allogeneic hematopoietic stem cell transplantation; MRD: minimal residual disease; mo: months; RFS: relapse-free survival. *Number of evaluable patients. MRD response within the first 4 cycles was defined as BCR-ABL or MLL-AF4 below the detection limit or individual rearrangements of immunoglobulin or T-cell receptor genes <10-4 ; all MRD responses occurred in the first cycle of blinatumomab treatment. Primary Analysis (Topp et al 2011) 1 N = 20* Interim Follow-up (Topp et al 2012) 2 N = 20* Final Analysis N = 20* MRD response 16 (80%) 16 (80%) 16 (80%) allohsct after blinatumomab 8 (40%) 9 (45%) 9 (45%) Median follow-up 13.3 mo 32.9 mo 50.8 mo Alive and in remission 16 (80%) 12 (60%) 10 (50%) Median estimated RFS Not reached Not reached Not reached Page 4 of 7
Online Supplementary Table S1. Baseline characteristics and treatment outcome by allohsct after blinatumomab allohsct (n=9) No allohsct (n=11) Sex, n (%) Male 5 (56) 3 (27) Female 4 (44) 8 (73) Age, years, median (range) 31 (20-47) 65 (42-77) Prior consolidation II, n (%) 3 (33) 8 (73) Disease status, n (%) Molecular relapse in CR1 1 (11) 3 (27) Molecular relapse in CR2+ 1 (11) 0 (0) Molecular failure in CR1 7 (78) 8 (73) Molecular failure in CR2+ 0 (0) 0 (0) MRD status, n (%) MRD <10-3 2 (22) 2 (18) MRD 10-3 7 (78) 9 (82) Method for MRD evaluation, n (%)* Ig/TCR rearrangements 7 (78) 9 (82) BCR-ABL PCR translocations 1 (11) 4 (36) MLL-AF4 PCR translocations 1 (11) 1 (9) Number of blinatumomab cycles, median 2.0 4.0 Complete MRD response after 1 cycle, n (%) 7 (78) 9 (82) RFS, months, median (range) 59.5 (12.4-65.8) 44.3 (1.4-70.1) *Patients could have both rearrangements and translocations. allohsct: allogeneic hematopoietic stem cell transplantation; CR1: first hematologic complete remission; CR2+: second or greater hematologic CR; Ig: immunoglobulin; MRD: minimal residual disease; PCR: polymerase chain reaction; RFS: relapse-free survival; TCR: T-cell receptor. Page 5 of 7
Online Supplementary Table S2. Serum immunoglobulin levels of individual long-term survivors at screening and last follow-up (modified from Zugmaier et al, 2014) 3 Patient Ph Status Statistic IgA IgG IgM TKI After Blinatumomab 13 Ph Screening, mg/dl 217 629 66 None Last follow-up, mg/dl 13 250 49 % Change* 94% 60% 26% 15 Ph Screening, mg/dl 58 457 111 None Last follow-up, mg/dl 37 320 72 % Change* 36% 30% 35% 16 Ph Screening, mg/dl 132 830 103 None Last follow-up, mg/dl 58 801 100 % Change* 56% 3% 3% 18 Ph Screening, mg/dl 64 700 58 None Last follow-up, mg/dl 30 789 137 % Change* 53% +13% +136% 20 Ph + Screening, mg/dl 54 330 31 Imatinib, dasatinib Last follow-up, mg/dl 26 333 14 % Change* 52% +1% 55% 9 Ph+ Screening, mg/dl 178 696 38 Imatinib Last follow-up, mg/dl 63 487 36 % Change* 65% 30% 5% Reference range (70 400) (700 1600) (40 230) * The original publication 3 reported final percentages relative to the value at screening; the percent change shown here represents the change from screening to last follow-up. Screening refers to baseline. TKI: tyrosine kinase inhibitor. Page 6 of 7
REFERENCES 1. Topp MS, Kufer P, Gökbuget N, et al. Targeted therapy with the T-cell-engaging antibody blinatumomab of chemotherapy-refractory minimal residual disease in B- lineage acute lymphoblastic leukemia patients results in high response rate and prolonged leukemia-free survival. J Clin Oncol. 2011;29(18):2493-2498. 2. Topp MS, Gökbuget N, Zugmaier G, et al. Long-term follow-up of hematologic relapsefree survival in a phase 2 study of blinatumomab in patients with MRD in B-lineage ALL. Blood. 2012;120(26):5185-5187. 3. Zugmaier G, Topp MS, Alekar S, et al. Long-term follow-up of serum immunoglobulin levels in blinatumomab-treated patients with minimal residual disease-positive B- precursor acute lymphoblastic leukemia. Blood Cancer J. 2014;4(9):244. Page 7 of 7