Session 3 Changing paradigms in indolent NHL

1. Session 3Changing paradigmsin indolent NHL Chair: Kevin Imrie Toronto-Sunnybrook Regional Cancer CenterToronto, Canada

2. Stanford survival curve

3. Outline Optimising response to MabThera monotherapy in the first-line setting Eva Kimby MabThera plus CHOP or fludarabine: an update on two phase II trials Myron Czuczman Immunochemotherapy in untreated and relapsed indolent NHL Wolfgang Hiddemann Extended MabThera therapy to prolong remission Michele Ghielmini MabThera in Waldenstr�m�s macroglobulinaemia Steven Treon Future directions in the treatment of indolent NHL Finbarr Cotter Case study and panel discussion Kevin Imrie

4. Optimising response to MabThera monotherapy in the first-line setting Eva Kimby Karolinska Institute, Huddinge University Hospital Stockholm, Sweden

5. Indolent lymphoma:a heterogenous disease

6. Indolent B-cell lymphoma No established curative therapy?

7. Rituximab monotherapy in follicular lymphoma

8. Enhancing efficacy of MabThera Dose and number of infusions Early treatment, low tumour burden Maintenance Combinations chemotherapy/ other mAbs cytokines (IFN, G-CSF, IL-2, IL-12)

9. MabThera in untreated follicular lymphoma patients with a low tumour burden MabThera (375mg/m2 x 4 weeks); 49 evaluable patients ORR 73% (day 50) CR 20%, CRu 6%, PR 47% bcl-2 gene rearrangement by PCR:negative 57% blood, 31% marrow

10. MabThera for previously untreated follicular lymphoma: TTP With 12+ months of follow-up, the median TTP had not been reached.18 During the first year of follow-up, 10 responders and 5 patients with stable disease progressed. With 12+ months of follow-up, the median TTP had not been reached.18 During the first year of follow-up, 10 responders and 5 patients with stable disease progressed.

11. MabThera as first-line therapy for asymptomatic follicular lymphoma Advanced stage follicular grade 1 (n=37) MabThera (375mg/m2x 4 weeks): 32 evaluable patients ORR 72% CR 36%

12. Enhancing efficacy of MabThera Extended numberof infusions Combination with interferon-? (IFN)

13. Rationale for combining MabTheraand IFN in indolent lymphoma Both agents have clinical anti-tumour effect Different toxicity profile Different mechanism of action

14. Biological effects of IFN-? Modulation of monocyte/macrophage and natural killer cell function Upregulation of cell surface antigens on lymphocytes Recruitment of immune effector cells to the tumour

15. Rituximab as a single agent and in combination with interferon-?2a as treatment of untreated and first relapse follicular or other low-grade lymphomas. A randomized phase II study E Kimby, C Geisler, H Hagberg, H Holte, T Lehtinen, C Sundstr�m, on behalf of the Nordic Lymphoma Group

16. Nordic MabThera study: protocol

17. Nordic MabThera study: objectives Primary objective CR plus PR Secondary objectives molecular response duration of clinical and molecular response safety

18. Inclusion criteria Indolent lymphoma (CD20+) Untreated or first relapse (<6 monthschlorambucil/steroids or local radiotherapy) Stage II�IV Age 18�75 years Performance status WHO 0�2 Symptomatic, requiring treatment

19. Patient demographics 127 patients (126 intent-to-treat):September 1998�November 1999 Median age 54.1 years (range 26�75)

20. Pathology review

21. Response after cycle 1

22. Response

23. Response rates after cycle 2 (n=69*)

24. Late response (after week 16, cycle 2) MabThera alone: 7 patients showed late CR total 15 CR (42%) MabThera + IFN: 7 patients showed late CR total 23 CR (70%)

25. Duration of response after cycle 2

26. Freedom from treatment (FFT)

27. Time to subsequent chemotherapy after two cycles (from randomisation)

28. Minimal residual disease bcl-2/IgH or clonal Ig-gene rearrangement tested by PCR CR patients only

29. Cycle 2: side effects Grade 3 thrombocytopenia: 2 Grade 4 neutropenia: 2 Grade 3 liver function: 1 All grade 3 and 4 side effects were in patients who received IFN

30. Nordic study: summary After one conventional cycle of MabThera,one additional cycle could improve responses Combination with IFN resulted in a greater improvement in response Bone marrow and blood PCR negativityshown during long-term follow-up Adverse events were mild to moderate

31. Phase III randomised trial:two cycles of MabThera � IFN-?in patients with CD20+ indolent lymphoma Nordic Indolent Lymphoma Group Eva Kimby, Stockholm Mads Hansen, Copenhagen Bj�rn �stenstad, Oslo

32. Nordic Lymphoma Group Investigators

33. MabThera plus CHOP or fludarabine: an update on two phase ll trials Myron Czuczman Roswell Park Cancer InstituteBuffalo, New York, USA

34. Rationale for MabThera plus chemotherapy: combination immunochemotherapy Single-agent efficacy Mechanisms of action are not cross-resistant Synergy between MabThera and chemotherapy1,2 Fludarabine inhibits complement inhibitory proteins3 Chemosensitisation associated with MabThera Non-overlapping toxicities No decrease in chemotherapy dose-intensity

35. �Concurrent� CHOP plus MabThera: treatment protocol

36. Concurrent CHOP plus MabThera: patient characteristics

37. Concurrent CHOP plus MabThera:DR and PFS The median DR and PFS have not been reached after 63.6+ and 65.1+ months of observation, respectively*

38. Concurrent CHOP plus MabThera:Kaplan-Meier analysis of PFS

39. Concurrent CHOP plus MabThera: prognostic factors The following prognostic factors for response were evaluated age sex race histology type stage at diagnosis WHO status at baseline

40. Concurrent CHOP plus MabThera:response by lesion size In only one category, lesion size, a significant difference existed in patients achieving a CR versus a PR

41. Concurrent CHOP plus MabThera:Kaplan-Meier analysis of PFS by response

42. Concurrent CHOP plus MabThera:bcl-2 studies by PCR Long-term bcl-2 PCR studies (+ pre-therapy) converted to negative in seven of eight patients one patient (nodal CR): PCR+ until relapse at 71 months three patients (all ongoing CR): PCR� 86+, 94+ and 100+ months four patients (two CR and two PD): PCR� then converted back to PCR+ two CR: ongoing at 95+ and 96+ months two PD: 29 months and 79 months In four patients converting back to PCR+: pre and post-treatmentbcl-2 is being analysed by nucleotide sequencing

43. Sequential CHOP followed by MabThera in newly diagnosed follicular NHL: protocol and patient characteristics

44. Sequential CHOP followed by MabThera in newly diagnosed follicular NHL: response MabThera after CHOP is well tolerated and providesadditional antitumour activity Current relapse pattern similar to CHOP alone Concurrent better than sequential MabThera

45. CHOP plus MabThera: conclusions Concurrent CHOP plus MabThera: 100% ORR and prolonged PFS Molecular PCR conversions seen CR patients: longer TTP Data suggests in-vivo synergy

46. Fludarabine Nucleotide analogue of Ara-A that inhibits DNA synthesis in sensitive cells Proven antitumour activity in CLL and relapsedlow-grade B-cell NHL Phase II first-line therapy trial in follicular NHL1 ORR = 65% (37% CR, 28% PR) in 49 assessable patients median number of cycles = 7 median relapse-free survival in responders = 15.6 months

47. MabThera plus fludarabine in indolent NHL: protocol

48. MabThera plus fludarabine: patient characteristics

49. MabThera plus fludarabine Protocol amendment After treating first 10 patients prophylactic Bactrim discontinued and protocol amended to allow fludarabine dose to be decreased by 40% for prolonged cytopenia; limited use of growth factor support Subsequent 30 patients taken off treatment secondary to cytopenia (n=1) transient treatment delays (n=10) fludarabine dose-reduction (n=3)

50. MabThera plus fludarabine in indolent NHL: toxicity 34/40 patients completed therapy Six patients were taken off therapy: prolonged cytopenia (n=3), large cell transformation (n=2), pulmonary hypersensitivity (n=1) Herpes simplex/zoster in 6 of 40 patients (15%): prophylactic acyclovir Patients with IPI ?2 had a 22-fold increase in grade 3/4 neutropenia Preservation of mean Ig levels and NK cell counts

51. MabThera plus fludarabine in indolent NHL: efficacy In the intent-to-treat group: ORR = 88%, CR/CRu = 75%, PR = 13% Median duration of response = 35+ months bcl-2 molecular conversions: 13/15 (87%) in peripheral blood; 14/16 (88%) in bone marrow

52. MabThera plus fludarabine: conclusions MabThera plus fludarabine: excellent activity with acceptable toxicity Acyclovir prophylaxis: strongly recommended Trial of reduced fludarabine: warranted Long-term follow-up: to determine durability Considerations schedule of MabThera? addition of other drugs? which regimen to choose? additional research necessary

53. Immunochemotherapy in untreated and relapsed indolent NHL Wolfgang Hiddemann University of MunichMunich, Germany

54. Follicular Lymphomas Overall Survival

55. Follicular LymphomasNew Therapeutic Approaches Interferon alpha Anti-lymphoma antibodies Myeloablative radio-chemotherapyfollowed by stem-cell transplantation Allogeneic stem-cell transplantation

56.

69. Prolonged MabThera therapyto extend remission Michele Ghielmini Swiss Group for Clinical Cancer Research (SAKK) Oncology Institute of Southern SwitzerlandBellinzona, Switzerland

70. Questions in indolent lymphoma MabThera single agent or in combination? Best schedule for monotherapy? Are we ready for prolonged maintenance?

71. Paradigms in follicular lymphoma: monotherapy versus polychemotherapy

72. Paradigms in follicular lymphoma: chemotherapy versus autologous transplantation

73. Single-agent MabThera is active in indolent lymphoma

74. MabThera single agent or in combination? Single-agent treatment (including MabThera) remains a good option in indolent lymphoma because More aggressive therapy has more side effects and does not prolong survival

75. Rationale for testing prolonged MabThera therapy MabThera 375mg/m2 weekly x 4: CR (5�10%) compared to ORR (50�60%) relatively short response duration correlation drug exposure � response rate other treatments usually given for 4�8 months

76. SAKK 35/98 study design

77. SAKK 35/98:response in follicular lymphoma 202 patients (64 chemo-na�ve)

78. SAKK 35/98:event-free survival in follicular lymphoma

79. Hainsworth trial of induction and maintenance: response Schedule: MabThera 375mg/m2 weekly x 4 at 6-month intervals for 2 years 62 patients (all chemo-na�ve)

80. Hainsworth trial of induction and maintenance: progression-free survival

81. First-line treatments for follicular lymphoma

82. Best schedule for MabThera monotherapy? Prolonged administration is the optimal schedule for single-agent MabThera Should we treat even longer?

83. Effect of extended MabThera treatment on immunoglobin levels

84. New SAKK 35/03 study design

85. Ongoing trials of MabThera maintenance Indolent EORTC CVP � MabThera � MabThera maintenance EBMT PBSCT � MabThera � MabThera maintenance Aggressive ECOG CHOP � MabThera � MabThera maintenance

86. Are we ready for prolongedmaintenance? Outside clinical trials, we are not yet ready for prolonged maintenance We look forward to the data from randomised trials

87. Conclusions Single-agent MabThera is a good treatmentfor indolent NHL MabThera works better if given for longerthan 6 months Long term maintenance remains investigational

88. MabThera in Waldenstr�m�s macroglobulinaemia Steve Treon Harvard Medical School and Dana Farber Cancer InstituteBoston, Massachusetts, USA

90. Clinicopathological definition of WM Presence of a monoclonal IgM protein, irrespective of serum level Underlying pathological diagnosis of lymphoplasmacytic lymphoma usingREAL/WHO criteria

91. Expression of serotherapy target antigens on tumour cells in WM

92. Lymphoplasmacytic cell depletionby MabThera

93. WM Clinical Trials Group (WMCTG) Dana Farber Cancer Institute Brigham and Women�s Hospital Massachusetts General Hospital Beth Israel Hospital St Vincent�s Hospital Long Island Jewish Memorial University of Maryland Cleveland Clinic Foundation Northwestern University Rush Presbyterian UCLA Medical Center Fred Hutchinson Stanford University McMaster University, Canada St Bartholomew�s, UK Karolinska Institut, Sweden Hopital Schaffner, France McCallum Cancer Center,Australia National Cancer Institute,Brazil

94. MabThera in WM(Median number of weekly infusions = 4)

95. WMCTG trial: protocol 99-253: extended dose MabThera in WM 4 weekly infusions of MabThera 12 weeks later if patient is not progressing 4 weekly infusions of MabThera

96. Response duration following standard and extended MabThera therapy in WM

97. Pre-therapy IgM levels predict clinical response to extended MabThera in WM 18/20 patients (90%) with serum IgM levels<6,000mg/dL responded versus 1/6 patients (16.6%) with serum IgM levels>6,000mg/dL responded (p=0.002) No correlation with baseline bone marrow tumour cell involvement

98. MabThera and Fludarabine in WM n=42 (21 evaluable) Six cycles of Fludarabine Eight infusions of MabThera ORR 19 (90%) CR 3 (14%) PR 13 (61%) MR 3 (14%) Response duration Not reached (3�44+ months)

99. versus chemotherapy or combined chemotherapy and antibody?

101. Fc?RIIIa (CD16) polymorphisms are associated with major clinical responses to MabThera in WM Typical allotype distribution 17% V/V; 45% V/F; 38% F/F Major response rate: 36.1% (13/36) for V-carriers vs 9.1% (2/22) for F/F (p=0.030)

103. Applying bedside and benchtop lessons to the future use of MabThera in WM: Use of immunomodulating agents to augment ADCC activity

104. Response to Thalidomide treatment is accompanied by an increase in plasma IL-2, IFN-? and percentage of NK cells in MM patients (n=5)

105. MabThera-induced ADCC of ARH-77 cells is enhanced by Thalidomide and Revimid

106. Thalidomide and MabThera in WM

107. Marked antitumour activity of MabThera plus Thalidomide in relapsed/refractory MCL MabThera 375mg/m2 every week x 4 weeks Thalidomide 200mg every day, increased to 400mg orally every day and continued until progression Patients relapsed or refractory to CHOP (or CHOP-like) chemotherapy 10/11 (90%) patients responded; three CR, seven PR Durable responses (9�24+ months)

108. Conclusions Extended MabThera therapy is active in WM with an ORR of 73% and a median response duration of 29+ months Combination therapy with MabThera and Fludarabine is associated with higher ORR (90%), though benefit on extending response duration remains to be established Position 158 polymorphisms on CD16 are associated with clinical responses to MabThera in WM, and support the role of NK cell involvement and ADCC function for MabThera clinical activity in WM

109. Acknowledgements Research Fund for Waldenstr�m�s at the Dana Farber Cancer Institute International Waldenstr�m�s Macroglobulinemia Foundation Waldenstr�m�s Cancer Fund Bailey Family Foundation Peter and Helen Bing Research Fund NIH Career Development Award Genentech Inc., IDEC Pharmaceuticals, Inc., Berlex Oncology Inc. and Celgene Inc.

110. Future directions in the treatment of indolent NHL Finbarr Cotter St Bartholomew�s and the London School of MedicineLondon, UK

111. Current approaches in indolent lymphoma Chemotherapy plus MabThera MabThera plus CHOP MabThera plus fludarabine Maintenance MabThera Thalidomide plus MabThera IFN plus MabThera

113. Factors in resistance to monoclonal antibodies MabThera works through P38 and NFkB (to lower bcl-2 protein)

114. The road to lymphoma

115. Pathways of apoptosis

116. Bcl-2 blocks lymphoma cell death

117. Bcl-2 antisense (Genasense; GNS) enables cell death

118. GNS in lymphoma:single agent response

119. GNS augments MabThera-induced apoptosis

120. GNS induces apoptosis and sensitises MabThera killing after 24 hours

121. bcl-2 genes in MabThera and GNS

122. MabThera decreases bcl-2 protein

123. What about proteosome inhibition? (PS341 Millenium)

124. The near future: �controlling themitochondrial gatekeeper is key�

125. Biologics: �controlling the mitochondrial gatekeeper is key�

126. Thanks

127. Case study and panel discussion Kevin Imrie Toronto-Sunnybrook Regional Cancer Center Toronto, Canada

128. Case presentation: Lauren 49-year-old woman referred with newly diagnosed follicular lymphoma History of present illness presented in April 2002 with right upper quadrant abdominal and back pain night sweats, but no weight loss abdominal ultrasound to rule out cholecystitis revealed adenopathy Past history positive only for traumatic ruptured kidney (remote) and oophorectomy ECOG performance status = 0

131. Laboratory results CBC haemoglobin 118g/L white blood cell count 27.9x109/L platelets 220x109/L LDH 289IU/L (normal <250) Flow cytometry CD10/CD19/CD20/CD23/FMC7/CD79b+

132. Summary 49-year-old woman with symptomatic, untreatedfollicular grade 2 lymphoma International Prognostic Index = low-intermediate FLIPI: poor risk (three risk factors)

133. Lauren: treatment 1 Started on CVP in September 2002 with an aim to consolidate with anti-idiotype vaccine or a radioimmunoconjugate on a clinical trial Had a transient response during CVP, but progressed by cycle eight (April 2003)

135. Lauren: treatment 2 Entered on clinical trial of CHOP � MabThera in May 2003 Randomised to CHOP + MabThera arm inSeptember 2003

137. Lauren: current status Completed MabThera plus CHOP in August 2003 Randomised to receive MabThera maintenance (375mg/m2 i.v. every 3 months for 2 years)