CUII I WIN

Highlightsfrom EH/

10 Anni di Highlights

Alessandro M. Vannucchi CRIMM- Center of Research and Innovation of MPN

Azienda Ospedaliera Universitaria Careggi University of Florence, Italy

CUII I WIN

Highlightsfrom EH/ Figure 1: MPN timeline: critical research and clinical data

William Dameshek uses the term

"myeloproliferative''

Heuck describes PMF and Vaquei PV

Bergamo trial of hydroxycarbamlde

In ET H i Description of JAK2V617K

Approval of ruRolltlnlb for PV

PV5G studies vnth hydroxycarbamlde, busulfan,

pipobroman venesection, chlorambucil, 32P are reported

_I_

RIC-alloSCT for Myelofibrosis

reported

Description of CALR mutations

~r 1879

Hemorrhagic thrombo-cythemla or ET, Epstein & Goedel

T 2016

ECIAP study aspirin In PV PT-1 study

hydroxycarbamlde vs anagrellde In ET

PVSG studies Initiated and first diagnostic

criteria

First use of Interferon (Unkesch) and anagrellde

ISIIversteln)

Trials with JAK inhibitors begin

CYTOPV study confirms target PCV

Approva I of ruxolltlnlb for MF

AM Vannucchi, C Harrison, unpublished, 2

CUII I WIN

Highlightsfrom EH/ Figure 1: MPN timeline: critical research and clinical data

William Dameshek uses the term

"myeloproliferative''

Heuck describes PMF and Vaquei PV

Bergamo trial of hydroxycarbamlde

In ET til

PV5G studies vnth hydroxytarbamlde, busulfan,

pipobroman venesection, chlorambucil, 3ZP are reported

_I_

RIC-alloSCT for Myelofibrosis

reported

™r 1879

Hemorrhagic thrombo-cythemla or ET, Epstein & Goedel

ECIAP study asplr PT-1 study

hydroxycarbaml anagrellde In

Description of JAK2V617K

Approval of ruxolltlnlb for PV

o o

Description of CALR mutations

PVSG studies Initiated and first diagnostic

criteria

First use of Interferon (Llnkesch) and anagrellde

(Sllversteln)

AM Vannucchi, C Harrison, unpublished, 2

l U11 I WIN

Biologia molecolare delle MPN Highlightsfrom EH/

JAK2 Chr 9p24.1

FERM

MPL Chrl p34.2 ■ F b n

type II

CALR Chr 19 pl3.13

535 547 | V617F

SH2 JH2 exl2 JH1 (kinase)

li

in S505N S515N

I I

wsxw

TM JM ! 1

* 591 626 631

491 513 518

—I Q- CO N P

r m L Q mi

(typel mutation) 1 II Q- CO N p c 5-bp Insertion 1

1 (type2 mutation) 1 II ■ II mutant specific

Nonmutant CALR I II II

52-bp Deletion

sequence

l U11 I WIN

Biologia molecolare delle MPN Highlightsfrom EH/

Pre- 5o, PMF 6%

10%

12% 67%

N= 286

Type 2-like 39% Type -| _|ike

57%

Essential thrombocythemia

Type 2-like 15%

Type 1-like 83%

Primary myelofibrosis

Overt- 14%

PMF 6% 4%

18%

►

N= 390

58%

JAK2V617F B

JAK2 Exl 2 CALR

Typel CALR Type2

MPZ.W515 Triple

Negativ

Pietra D et al, Leukemia 201 ( 30:431-8;

PV, ET: Database of CRIMM; Florence; PMF: Database AGIMM, Guglielmelli Petal, Blood 2017; 129:3227-36.

l U11 I WIN

Biologia molecolare delle MPN Highlightsfrom EH/ Gene N= ASXL1 EZH2

SRSF2

IDH1/2

TET2

LNK/SH3B3

ZRSR2

SF3B1

SETBP1

DNMT3A

CSF3R

NRAS

CBL

U2AF1

RUNX1

TP53

133 12%

0 3%

2%

22%

2%

5%

3%

2%

2%

3%

0

1%

0 2% 1%

183 11%

3%

2%

1%

16%

0

3%

5%

2%

6% 3%

1%

1%

1% 2% 2%

Pre-PMF 27S 18%

4%

9%

3%

24%

5%

0

5%

0

4%

9% 4%

7%

3%

3% 4%

Overt MF

17%

3% 4%

8%

4%

4%

9%

4% 6%

1% 3%

Vannucchi AM etal, Leukemia 2013; 27:1861-9. TefferiAet al, BoodAdv 2016; 1:21-30; TefferiAetal, Blood Adv 2016; 1:105-111; Guglielmelli Pet al, Blood; 2017:129:3227-3

CUI1 IV-HN

Biologia molecolare delle MPN Highlightsfrom EH/

clinical practice guidelines

Philadelphia chromosome-negative chronic myeloproliferative neoplasms: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

Vannucchi AM et al, Ann Oncol 2015; 26: v85-v9<

1 VS CUIIIVJIN

Biologia molecolare delle MPN Highlightsfrom EH/ High Molecular Risk Prognostic Category

harboring >1 mutation in any one of ASXL1, EZH2, SRSF2, IDH1/2

Overall Survival Blast Transformation

• A HMR status is associated with reduced OS and increased risk of blast transformation ir PMF patients independent of IPSS/DIPPS-plus

Vannucchi AM, et al. Leukemia. 2013;27:186

Influence of the Number of Mutations on OS and LFS in PMF

HMR mutations

Time (years)

Transformation to AML Number of mutations

100-

— 0 75- 1 — 2 50-

— 3-4 25-

0-

log rank p=0.0003

Years "io"

Number of mutations — 0 1

— 2 — 3-4

Guglielmelli P, et al. Leukemia. 2014; 28: 1804-1810. Lundberg P et al. Blood 2014;123:2220-2

l U11 I WIN

Biologia molecolare delle MPN Highlightsfrom EH/

Prognostically Relevant Non-Driver Gene Mutations in PV and ET

PV= 133 Mayo, 215 Florence 27-gene panel ET= 183 Mayo, 174 Florence PMF= 182 Mayo

Tefferi A. et al. Blood Adv 2016:1:21-30

1 VS CUIIIVJIN

Biologia molecolare delle MPN Highlightsfrom EH/ MYSEC (MYelofibrosis SECondarv to PV and ET)-PMF a Molecular-Enriched Prognostic Model • Includes 685 patients, 397 with PET-MF and 384 with PPV-M

Co variate HR (95% Cl) P value Points

Age at MF dx* 1.07 (1.05-1.09) <.0001 0.15

Hb <11 g/dL 2.3 (1.6-3.3 <.0001 2

Pit <150xl09/L 1.7 (1.2-2.5) .006 1

PB blasts >3% 2.9 (1.8-4.8 <.0001 2

CALR wt 2.6 (1.2-5.3) .001 2

Const, symptoms 1.5 (1.0-2.0) .03 1

* continuous, 0.15 point/year

• Of the HMR mutations, only SRSF2 mutations were significant for reduced OS in PET-MF.

Passamonti F et al. Leukemia 2017, in press; Rotunno G et al, AJH, 2016;91:6(

l U11 I WIN

Biologia molecolare delle MPN Highlightsfrom EH/ Clonal Hematopoiesis of Indetermined Potential

CL 3

o o cn JC u

■ <9

s ■ 3 < a o S 5= CO

o

6

5 - 4

-3-

Genes ■ ASXU U DNMT3A U GNAS U JAK2 U SF3B1 TET2 Total

2 ■

1 ■

T-r

<40 40-49 (o = 214) (n = 341)

.j 1 i i

50-59 60-69 (0 = 707) (0 = 767)

T

70-79 (0 = 475)

II 80-89

(o = 132) Age (years)

• Clonal hematopoiesis is increasingly common with aging (10% of persons older than 65 vs 1 % of <50y).

Thorsten Klampfl et al. Blood 2011;118:167-176; Xie M et al. Not Med. 2014 ;20(12):1472-8; Jaiswal S et al. N Engl JI 2014 Dec 25;371(26):2488-98; Genovese G et al. N Eng! J Med. 2014 25;371(26):2477-8; Jaiswal S et al, NEJM,:

l U11 I WIN

Biologia molecolare delle MPN Highlightsfrom EH/

Association with the risk of Hematologic Cancers and Coronary Heart Disease/Early Ml

A Hematologic Cancer Events/No. at Risk Hazard Ratio (95% Cl) P Value

No mutation (referent) 11/3208 JHS 10/2326 MEC 1/882

Mutation 5/134 <0.001 JHS 3/83 -■- 7.1 (2.0-25) 0.002 MEC 2/51 -*-I 36 (4.9-270) <0.001 Mutation, VAF ^0.10 5/57 M 49 (21-120) <0.001

JHS 3/34 -■- 21 (5.7-80) <0.001 MEC 2/23 -m 90 (29-280) <0.001

|-1-■ I ■ I » M|-1......... 1 10 100

B c P=0.002 by Wilcoxon test

o.o-i- No Hematologic Hematologic

Cancer Cancer

A CHIP and Coronary Heart Disease No. of Participants with

Subgroup Coronary Heart Disease/ No. at Risk

Biol mage No mutation (reference) 94/326 Mutation 19/44 MDC

No mutation (reference) 299/607 Mutation 21/33

Fixed-effects meta-analysis 0.7

Hazard Ratio (95% Cl) P Vali

1.8 (1.1-2.9) 0.03

2.o (1.2-3.i) o.oo:

1.9 (1.4-2.7) <0.00!

L0 5 4.0

B CHIP and Early-Onset Myocardial Infarction

No. of Participants with Myocardial Infarction/ Subgroup No. at Risk Odds Ratio (95% Cl)

ATVB No mutation (reference) Mutation PROMIS No mutation (reference) Mutation Fixed-effects meta-analysis

P Vali

<o.oo:

<o.oo: <o.oo:

Jaiswal S et al. N Engl J Med 2014;371:2488-2498 Jaiswal S et al. N Engl J Med 2017;377:111

Criteri Diagnostici CUII IV-HN

Highlightsfrom EH/ PV ET Pre-PMF Maior criteria Maior criteria Maior criteria

1. Hb >16.5g/dL in men, or 16.0 1. Platelet count >450xl09/L 1. BM biopsy with Mk g/dL in women, or Hct >49% 2. BM biopsy with proliferation proliferation and atypia, w/o and 48%, or increased RCM mainly of the Mk lineage with reticulin fibrosis >G1; with incr. 2. BM biopsy with hyper- mature enlarged Mk with cellularity, granulocytic prolifer. cellularity with panmyelosis and hyperlobulated nuclei and often decreased erythr'iesis Mk proliferation with 3. Not meeting WHO criteria for 2. Not meeting WHO criteria for

pleomorphic Mks other myeloid neoplasms other myeloid neoplasms 3. Presence of JAK2MS17? or 4. Presence of JAK2MS17?, 3. Presence of JAK2MSYJ?, JAK2 exl2 mutation CALR or MPL mutation

CALR or MPL mutation, or in the absence of these mutations, presence of another clonal marker, or absence of minor reactive BM reticulin Minor criteria l.Anemia

Minor criteria Minor criteria 2.Leucocytosis >llxl09/L 1. Subnormal sEPO levels 1. Presence of a clonal marker, or

absence of evidence of reactive thrombocytosis

3.Palpable splenomegaly 4.Increased LDH

3 major or first 2 major + minor 4 major or first 3+ minor 3 major + >1 minor

Overt PMF Major criteria

1. BM biopsy with Mk proliferation and atypia with either reticulin fibrosis G2-3 and/or collagen 2. Not meeting WHO criteria for other myeloid neoplasms 4. Presence of JAK2MS11?, CALR or MPL mutation, or in the absence of these mutations, presence of anothei clonal marker, or absence of reactive myelofibrosis Minor criteria 1. Anemia 2. Leucocytosis >llxl09/L 3. Palpable splenomegaly 4.Increased LDH 5. Leukoerythroblastosis

3 major + >1 minor

In the absence of any of the 3 major clonal mutations, the search for the most frequent accompanying mutations (eg, ASXL1, EZH2, TET2, IDH1/IDH2, SRSF2, SF3B1) are of help in determining the clonal nature of the disease.

Arber DAetal, Blood 2016; 127:2391-4

Studi Clinici CUIIHU IN

Highlightsfrom EH/ 1JAK inhibitor (Company) MF PV/ET Note

phase, status

CEP701 (Cephalon) STOP

AZD1480 (AstraZeneca) STOP

XL019 (Exelixis) STOP

NS-018 (NS Pharma) 1 ?

BMS-911543 (BMS) I/II ? LY2784544 (Lilly) II 1 STOP

Momelotinib (Gilead) III, lst/2nd line COMPLETE --->

Pacritinib (CTI) III, lst/2nd line COMPLETE, on Hold-->re-test

Fedratinib (Sanofi) III, lst/2nd line l/ll STOP

Ruxolitinib (Incyte/Novartis) 111(2) II (ET,PV) III (PV) MF & PV 2nd line APPROVED

Studi Clinici l U11 I WIN

Highlightsfrom EH/

COMFORT I

Patients with MF (N = 309)

Randomized 1:1 <

Ruxolitinib 15 mg BID or

20 mg BID

Placebo BID

_II COMFORT II

Patients with MF (N = 219)

Randomized / 2:1 \

Ruxolitinib 15 mg BID or

20 mg BID

Best available therapy (BAT)

Primary Endpoint • Number of subjects achieving >35% reduction in spleen volume* from baseline to week 24 Secondary Endpoint • Proportion of patients with >50% reduction in Total Symptom Score (mod. MFSAF v2.0 electronic diary)

Primary Endpoint • Number of subjects achieving > 355 reduction in spleen volume* from baseline to week 48 Secondar/Exploratorv endpoints • Changes in functioning and sympto

Ruxolitinib MTD: 25 mg twice daily or 100 mg once daily with thrombocytopenia as DLT

* As measured by MRI/CT scan Verstovsek S et al. NEJM 2012; 366:799-807; Harrison C et al. NEJM 2012; 366:787

Studi Clinici I VS CUII IvIN

Highlightsfrom EHP

Resistance to or intolerance of HU (modified ELN criteria) Phlebotomy requirement Nonpalpable spleen

Prerandomization (day -35)

Hct, 40%-45%

RESPONSE: Spleen >5 cm

ECOG PS < 2

Ruxolitinib 10 mg bid

n = 74

Extended treatment phase H > Week 26

Crossover to ruxolitinib

>|-^Week 26

n = 75 Week 28 (pr imary analysis)

Week 80 _

RESPONSE: Week 32

Final analysis

• Ruxolitinib-randomized patients had their doses individually titrated for efficacy and safety (to a maximum of 25 mg bid) • Investigator-selected BAT as monotherapy included HU (at a tolerated dose if the patient were likely to receive benefit), interferon (IFN)/peg-IFN, anagrelide, pipobroman, immunomodulatory drugs, or observation • All patients received low-dose aspirin unless medically contraindicated

bid, twice daily; VannucchiAM et al, NEJM2015; 372:426; Passamonti F et al, Lancet Oncol 2017; 18:88-'

Studi Clinici l U11 I WIN

Highlightsfrom EH/ Target Hematocrit for Optimal Management of PV: Results of the CYTO-PV Stud

n HCT HCT <45% 45-50% HR P

N = 182 N=183 (95%CI)

Primary Endpoint (CV death, MI, stroke, PAT, DVT, PE, TIA, abdominal thrombosis)

5 (2.8%)

18 (9.8%)

3.91 (1.45- 10.53)

0.005

IR % person/year 1.1 4.4

Total CV events (Primary plus superficial vein thrombosis)

8 (4.4%)

20 (10.9%)

2.69 (1.19- 6.12)

0.012

IR % person/year 1.9 5.0

Marchioli R, et al. NEJM. 2013; 368:22-

Studi Clinici l U11 I WIN

Highlightsfrom EH/ Symptoms burden in MPN

Significant symptom heterogeneity exists within each MPN subtype, sometimes independent c disease features or prognosis, i.e. symptoms are prominent even in low-risk MPN populations.

100%

■ ET(N=874)

■ PV(N=729)

MF (N=486)

■ MPN Total (N=2089)

10

> Q> LD

E o -t-> Q.

E IS)

c fD

ET(N=874)

PV(N=729)

MF (N=486)

MPN Total (N=2089)

(/I VI

o u =■ 3 £ 00 CO

2- Q; 15 Z c o

2 c o

w 0 H

CUD £

c '<5

k. 01 >

VI VI

£ > v IE Q. 01

*-» «c bp ai

% E Qi Ml i

8 E E o o ■O o -Q .52

U ■ C

TO L 0 c 01

? v> £

u OJ c o CO

u_ £ bp *5

5

5 o.

S Ui

< *D u c o u

CUO Z

5

Geyer et al, Blood, 2014

Studi Clinici

PHYSICIANS

ET - Prevent vascular events -Slowor

delay condition Healthy blood

counts ■ Better QoL ^Symptom

improvement Reduction in spleen

size Reduce frequency of

phlebotomy

PV - Prevent vascular events

-Slowor delay condition

Healthy blood counts ■

Better QoL ^Symptom

improvement Hematocrit

<45% Reduce

phlebotomies Reduce

spleen size

MF — Prevent vascular

events

— Slow or delay condition

Healthy blood counts

— Better QoL

^Symptom improvement

Anemia treatment Reduce

blood transfusion Reduce

spleen size

CUIIIVJIN

Highlightsfrom EH/

PATIENTS

ET - Prevent vascular events

- Slow or delay condition Healthy

blood counts

- Better QoL

^Symptom improvement Reduction

in spleen size Reduce frequency of

phlebotomy

PV

MF

- Prevent vascular

events

- Slow or delay condition

Healthy blood counts

■ Better QoL

- Symptom improvement

Hematocrit <45% Reduce

phlebotomies Reduce

spleen size

— Prevent vascular

events

— Slow or delay

condition Healthy blood

counts

■ Better QoL ^Symptom

improvement Anemia

treatment Reduce

phlebotomies Reduce

spleen size

Mesa R et al, 2i

Prossimi 10 anni: wish list CUIIIVJIN

Highlightsfrom EH/

• Definire le forme Triplo-Negative • Sviluppare score molecolari piu performanti • Diagnosi multiparametrica (senza BOM?) • Parametri predittivi di evoluzione in sMF e LA • Terapie “eradicanti” (?) • Rischio di trombosi ancora elevato • Immunoterapia (?) • Controllo duraturo della patologia

Prossimi 10 anni l U11 I WIN

Highlightsfrom EH/ II Futuro negli Studi clinici nelle MPN — c o m e la

vedo?

Prossimi 10 anni l U11 I WIN

Highlightsfrom EH/ II Futuro negli Studi clinici nelle MPN — c o m e la

vedo?

"Dov'e che sono? Mi sembra di non stare in nessun posto. Ma se la morte e cosi, non e un bel lavoro. Sparito tutto: la gente, gli alberi, gli

uccellini per aria, il vino...Te cul”

AMARCORD, Federico Fellini (1973)

Report del gruppo di lavoro • F Silvestri Udine • L Pedrazzi Modena • C Gasparrini Campobasso • S Santini Prato • E Ruggeri Milano • L Cimarosto Belluno • F Ballerini Genova • 0 Racchi Genova • G Lo Scocco Firenze • R La Tagliata Roma • AM Vannucchi Firenze • A. Tondo Firenze-Meyer • G Musardo Faenza • E Raviolo Cuneo • F Faccinelli Perugia • T Petrucci Roma

Report del gruppo di lavoro • F Silvestri Udine • L Pedrazzi Modena • C Gasparrini Campobasso • S Santini Prato

• E Ruggeri Milano G TOdt f U11!!!!! • L Cimarosto Belluno • F Ballerini Genova • 0 Racchi Genova • G Lo Scocco Firenze • R La Tagliata Roma • AM Vannucchi Firenze • A. Tondo Firenze-Meyer • G Musardo Faenza • E Raviolo Cuneo • F Faccinelli Perugia • T Petrucci Roma

Cugina 73 anni

1- BOM: si per conoscenza scientifica 2- BOM: potrebbe essere non tanto ET o prePMF ma una PMF iniziale

3- Regole WHO: difensiva nostra?

4- Cambia trattamento ? NO 4-

prospettiva ?

OS and LFS in relation to diagnosis and IPSS risk categories in study patients population.

A

C 1.0 ■ „L„, Pre-PMF

0.8 ■ Overall survival O O 05 _i_i_

\ \ 1-1 LOW t INT2

0.2 ■ HIGH |

0.0 ■ 1 P<.0001 -i-i-i-i-i-r 0 5 10 15 20 25 30

Years

B

D

0 5 10 15 20 25 30

Years

Paola Guglielmelli et al. Blood 2017;129:3227-3236

©2017 by American Society of Hematology * blood

Diagnosi di Policitemia Vera:

Qunti sani giovani hanno un valore a livello WHO?

Come rendere cost-effective il percorso dx Iter

mutazionale Apnee notturne

Triple-negativity • Istopatologia: non differenze evidenti • Fenotipo clinico

• Permane incertezza ???

• Forte implicazione diagnostica nella MF

• Implicazioni di gestione nella ET

Albumina

•And so what?

•Critica interpretazione

•Utilizzazione terapeutica ??

•Si va verso score “oggettivi”

Interferone:

• Dati???

• Progressione??? • Non pud cambiare OGGI il nostro approccio terapeutico

Ruxolitinib:

• PV: quanti e quali pazienti? • MF: basse dosi? • Precoce • Discussione sulle inicazini in base alia classe di rischio

Timing del trapianto (Carella)