BCR-ABL1 MUTATION TESTING IN CHRONIC MYELOID LEUKAEMIA AND PHILADELPHIA CHROMOSOME-POSITIVE ACUTE LYMPHOBLASTIC LEUKAEMIA

Funded and developed by Incyte Biosciences in collaboration with a Steering Committee of European experts This brochure contains product-related information

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Steering Committee of European experts

Thomas ErnstUniversity Hospital Jena,

Germany

Nick CrossUniversity of Southampton

& Wessex Regional Genetics Laboratory, Salisbury, UK

Hugues de LavalladeKing’s College Hospital,

London, UK

Lucia CavelierUppsala University,

Sweden

Jean-Michel CayuelaSaint-Louis Hospital Paris,

France

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Simona SoveriniUniversity of Bologna,

Italy

Torsten HaferlachMunich Haematology Medical Practice

& Munich Leukaemia Laboratory, Germany

Thomas LionLabDia Labordiagnostik

& Children’s Cancer Research Institute, Austria

Katerina Machova PolakovaInstitute of Hematology and Blood Transfusion

& Charles University Prague, Czech Republic

Joaquin MartinezComplutense University de Madrid; Hospital 12 de Octubre & Spanish

Centre of Oncology, Spain

Pascal VannuffelInstitute of Pathology and Genetics,

Belgium

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Importance of molecular monitoring and mutation testing in chronic myeloid leukaemia (CML) and Philadelphia chromosome-positive acute lymphoblastic leukaemia (Ph+ ALL)

Regular monitoring of BCR-ABL1 transcript levels in response to treatment is crucial in order to detect the emergence of resistance in patients with CML and Ph+ ALL (this term includes all BCR-ABL1–positive ALL cases).1–5 Point mutations in the kinase domain of the BCR-ABL1 fusion protein can impair or prevent the binding of tyrosine kinase inhibitors (TKIs), reducing their efficacy and ultimately leading to TKI resistance. Resistance to TKIs in CML and Ph+ ALL patients can drive disease progression.2,3 Therefore, timely detection of point mutations in the BCR-ABL1 kinase domain that are known to confer TKI resistance can facilitate appropriate treatment decisions.1

This brochure provides you with:

A summary of clinical

recommendations

Practical considerations

for sampling

A checklist to ensure all

relevant information is provided to the lab

An overview of the available TKIs and their

resistance profiles for themutations known toconfer TKI resistance

MOLECULAR MONITORING

MUTATIONTESTING

pp.9–10

pp.5–6

p.8p.7

CML and Ph+ ALL

References1. Baccarani M, et al. Blood. 2013;122:872– 84. 2. Soverini S, et al. Br J Haematol. 2016;173:337– 49. 3. Branford S. Hematology Am Soc Hematol Educ Program. 2016;2016:156 – 63. 4. Leonard JT and Stock W. Biol Blood Marrow Transplant. 2016;22:1913–4. 5. Chiaretti S and Foa R. Hematology Am Soc Hematol Educ Program. 2015;2015:406 –13.

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Summary of clinical recommendations: CML

When to perform mutation testing for patients with CML

Monitoring of BCR-ABL1 transcript levels can identify those CML patients with an optimal response, or those in warning or failure of TKI treatment (Table 1).1

According to European LeukemiaNet (ELN), BCR-ABL1 mutational analysis in CML is recommended according to the below.1 Note that mutation testing cannot be performed on samples with BCR-ABL1 <0.1%.

Only in patients with acceleratedor blast phase CML

At diagnosis

Only in patients with accelerated

or blast phase CML

In case of warning, treatment failure, or

progression to accelerated phase or blast phase

In case of warning, treatment failure, or progression toaccelerated phase or blast phase

At any time during treatment

First-line treatment Second-line treatment

Month Optimal Warning Failure Optimal Warning Failure

BaselineHigh risk orCCA/Ph+,

major route

No CHR or Loss of CHR on

imatinib or Lack of CyR

to first-line TKI or High risk

3Ph+ ≤35%

and/or BCR-ABL1 ≤10%

Ph+ 36–95% or BCR-ABL1

>10%

No CHR or

Ph+ >95%

BCR-ABL1 ≤10% and/or

Ph+ <65%

BCR-ABL1 >10%and/or

Ph+ 65–95%

No CHR orPh+ >95% or

New mutations

6Ph+ 0%and/or

BCR-ABL1 <1%

Ph+ 1–35% and/or

BCR-ABL1 1–10%

Ph+ >35% and/or

BCR-ABL1 >10%

BCR-ABL1 ≤10% and/or

Ph+ <35%Ph+ 35–65%

BCR-ABL1 >10%and/or

Ph+ >65%and/or

New mutations

12 BCR-ABL1 ≤0.1% BCR-ABL1 >0.1–10%

Ph+ >0% orBCR-ABL1 >1%

BCR-ABL1 <1%and/or Ph+ 0

BCR-ABL1 1–10% and/or

Ph+ 1–35%

BCR-ABL1 >10%and/or Ph+ >35%

and/orNew mutations

Then, and at any time

BCR-ABL1 ≤0.1%CCA/Ph–

(–7 or 7q–)

Loss of CHR orLoss of CCyR orConfirmed loss

of MMR* orMutations or

CCA/Ph+

BCR-ABL1 ≤0.1%

CCA/Ph– (–7 or 7q–)

orBCR-ABL1 >0.1%

Loss of CHR orLoss of CCyR or

PCyR orNew mutations orConfirmed loss ofMMR* or CCA/Ph+

Table 1. ELN definitions of response to first-line and second-line treatment (following imatinib resistance) in CML1

* In two consecutive tests, of which one with a BCR-ABL1 transcript level ≥1%. CCA, constitutional chromosomal abnormalities; CCyR, complete cytogenetic response; CHR, complete haematological response; CyR, cytogenetic response; MMR, major molecular response; PCyR, partial cytogenetic response; Ph, Philadelphia chromosome; TKI, tyrosine kinase inhibitor.

Republished with permission of The American Society of Hematology, from European LeukemiaNet recommendations for the management of chronic myeloid leukemia: 2013, Baccarani M, et al., volume 122, 2013; permission conveyed through Copyright Clearance Center, Inc.

References1. Baccarani M, et al. Blood. 2013;122:872– 84.

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Summary of clinical recommendations: Ph+ ALL

When to perform mutation testing for patients with Ph+ ALL

Minimal residual disease (MRD) is used to monitor the presence of residual leukaemic cells in Ph+ ALL (definitions of MRD are shown in Table 2). There is increasing evidence for a role for MRD in determining which patients should undergo allogeneic stem cell transplantation (allo-SCT) and which patients should be considered for post-transplant therapy. MRD is a strong predictor of haematological relapse after allo-SCT, even in the TKI era.4 Persistent MRD or an increase in MRD can be caused by TKI resistance mutations within the BCR-ABL1 fusion gene. Timely detection of BCR-ABL1 mutations and subsequent treatment optimisation may avoid relapse.5

Table 2. ESMO response parameters in Ph+ ALL according to MRD6

According to the European Society for Medical Oncology (ESMO), BCR-ABL1 mutation testing in Ph+ ALL is recommended in cases of persistent MRD or progressive disease.6

Terminology Definitions

CR (complete haematological remission)

• Leukaemic cells not detectable by light microscopy in BM/PB/CSF (BM <5% blasts)

MolCR (complete molecular remission/MRD negativity)

• Patient in CR • MRD not detectable by sensitive molecular probe(s) (sensitivity ≥10–4)

MolR (molecular/MRD response, less than molCR)

• Patient in CR, not in molCR• Low-level non-quantifiable MRD (<10–4/0.01% or <1 leukaemic cell

in 10,000)• Assessable by MFC (lower detection limit, between 10–3 and 10–4,

higher sensitivity with 8 –12 colour techniques)

MolFail (molecular failure/MRD positivity)

• Patient in CR, not in molCR/molR• Quantifiable MRD (≥10–4/0.01% or ≥1 leukaemic cell in 10,000)• Assessable by MFC (lower detection limit, between 10–3 and 10–4)

MolRel (molecular/MRD relapse)

• Patient still in CR, prior molCR/molR• Loss of molCR/molR status (≥10–4/0.01% or >1 leukaemic cell

in 10,000)• Assessable by MFC (lower detection limit, between 10–3 and 10–4)

Relapse• Loss of CR status • Haematological relapse (BM ALL blasts >5%)• Extramedullary relapse (CNS, other site)

ALL, acute lymphoblastic leukaemia; BM, bone marrow; CNS, central nervous system; CR, complete response; CSF, cerebrospinal fluid; MFC, multichannel flow cytometry; molCR, molecular CR; molFail, molecular failure; molR, molecular response; molRel, molecular relapse; MRD, minimal residual disease; PB, peripheral blood. Hoelzer D et al, Acute lymphoblastic leukaemia in adult patients: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up, Ann Oncol, 2016, 27, Suppl 5, v69-v82, by permission of Oxford University Press.

References4. Leonard JT and Stock W. Biol Blood Marrow Transplant. 2016;22:1913–4. 5. Chiaretti S and Foa R. Hematology Am Soc Hematol Educ Program. 2015;2015:406–13. 6. Hoelzer D, et al. Ann Oncol. 2016;27:v69–v82.

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Practical considerations for sampling 1,7–9

Timing of sending blood samples

Further information needed by the testing laboratory

Type of blood sample required

Peripheral blood samples (at least 10 mL) should be drawn into EDTA vacuum tubes to ensure successful RNA extraction

Samples should be kept at ambient temperature; do not freeze blood samples

Blood samples should be sent to the testing laboratory as soon as possible and within 48 hours of collection

Your testing laboratory may provide you with a form or checklist with all relevant information required

Providing as much information as possible will aid the testing laboratory in the interpretation of results, if appropriate

References1. Baccarani M, et al. Blood. 2013;122:872– 84. 7. Soverini S, et al. The Oncologist. 2016;21:1–8. 8. Foroni L, et al. Br J Haematol. 2011;153:179–90. 9. Hughes T, et al. Blood. 2006;108:28–37.

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Reason for mutation testing request Accelerated or blast phase CML at baseline Warning response to current TKI according to ELN 2013 guidelines for CML Failure response to current TKI according to ELN 2013 guidelines for CML Progression from chronic phase to accelerated or blast phase CML Ph+ ALL at baseline Persistent MRD for Ph+ ALL Progressive disease or relapsed/refractory Ph+ ALL TKI switch for reason other than resistance (e.g. intolerance)

Other, please specify:

Current treatment and associated response

Treatment:

Line of treatment:

Associated response:

Date and result of last BCR-ABL1 transcript level/MRD monitoring assessment

Date:

Date of previous mutational analysis (if any)

Results of previous mutational analysis (if any)

No mutation

Mutation, please specify:

Previous treatment(s) and associated responses (if any, optional)

Treatment:

Line of treatment:

Associated response:

Treatment:

Line of treatment:

Associated response:

Treatment:

Line of treatment:

Associated response:

For a downloadable version of this checklist please contact Incyte Medical Information (eumedinfo@incyte.com).

In case of any outstanding questions, please contact your local testing laboratory:

Name:

Email:

Transcript type e1a2 e13a2 e14a2 e19a2 Rare, please specify:

Breakpoint P190 P210 P230

Type and phase of disease Chronic phase CML Accelerated phase CML Blast phase CML Ph+ ALL

Checklist

Date of initial diagnosis:

Result:

Job title:

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Overview of available TKIsOnce BCR-ABL1 mutations have been detected, choosing the most appropriate TKI for your CML or Ph+ ALL patient should take into consideration several factors, including the therapeutic indications of the available TKIs (Table 3), previous medical history, comorbidities and resistance profiles of each TKI for mutations that are known to confer clinical resistance (Table 4).

Table 3. Overview of therapeutic indications for five TKIs currently approved by the European Medicines Agency for CML or Ph+ ALL10–14

TKI Indication

Imatinib

• Adult and paediatric patients with newly diagnosed Philadelphia chromosome (BCR-ABL) positive (Ph+) chronic myeloid leukaemia (CML) for whom bone marrow transplantation is not considered as the first line of treatment

• Adult and paediatric patients with Ph+ CML in chronic phase after failure of interferon-alpha therapy, or in accelerated phase or blast crisis

• Adult and paediatric patients with newly diagnosed Ph+ acute lymphoblastic leukaemia (ALL), integrated with chemotherapy

• Adult patients with relapsed or refractory Ph+ ALL, as monotherapy • Adult patients with myelodysplastic/myeloproliferative diseases (MDS/MPD) associated with

platelet-derived growth factor receptor (PDGFR) gene re-arrangements • Adult patients with advanced hypereosinophilic syndrome (HES) and/or chronic eosinophilic

leukaemia (CEL) with FIP1L1-PDGFRα rearrangement

Dasatinib

Adult patients with:• newly diagnosed Philadelphia chromosome positive (Ph+) chronic myelogenous leukaemia (CML)

in the chronic phase• chronic, accelerated or blast phase CML with resistance or intolerance to prior therapy including

imatinib mesylate• Ph+ acute lymphoblastic leukaemia (ALL) and lymphoid blast CML with resistance or intolerance

to prior therapy

Nilotinib

• Adult and paediatric patients with newly diagnosed Philadelphia chromosome positive (Ph+) chronic myelogenous leukaemia (CML) in the chronic phase

• Adult patients with chronic phase and accelerated phase Ph+ CML with resistance or intolerance to prior therapy including imatinib. Efficacy data in patients with CML in blast crisis are not available

• Paediatric patients with chronic phase Ph+ CML with resistance or intolerance to prior therapy including imatinib

Bosutinib

• Adult patients with chronic phase, accelerated phase, and blast phase Philadelphia chromosome positive (Ph+) chronic myelogenous leukaemia (CML) previously treated with one or more tyrosine kinase inhibitor(s) and for whom imatinib, nilotinib and dasatinib are not considered appropriate treatment options

Ponatinib

Adult patients with:• chronic phase, accelerated phase, or blast phase chronic myeloid leukaemia (CML) who are

resistant to dasatinib or nilotinib; who are intolerant to dasatinib or nilotinib and for whom subsequent treatment with imatinib is not clinically appropriate; or who have the T315I mutation

• Philadelphia chromosome positive (Ph+) acute lymphoblastic leukaemia (ALL) who are resistant to dasatinib; who are intolerant to dasatinib and for whom subsequent treatment with imatinib is not clinically appropriate; or who have the T315I mutation

References10. Glivec® (imatinib) – Summary of Product Characteristics. Novartis Europharm Limited 2017. 11. Sprycel® (dasatinib) – Summary of Product Characteristics. Bristol-Myers Squibb Pharmaceuticals Limited 2017. 12. Tasigna® (nilotinib) – Summary of Product Characteristics. Novartis Pharmaceuticals UK Ltd 2017. 13. Bosulif® (bosutinib) – Summary of Product Characteristics. Pfizer Limited 2018. 14. Iclusig® (ponatinib) – Summary of Product Characteristics. Incyte Biosciences UK Ltd 2018.

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Mutation TKI sensitivity*

T315ILess sensitive to dasatinib, bosutinib, imatinib and nilotinib than ponatinib

T315ALess sensitive to dasatinib than ponatinib, nilotinib, imatinib or bosutinib

F317L/V/I/CLess sensitive to dasatinib and imatinib than ponatinib, nilotinib or bosutinib

Y253H, F359V/C/ILess sensitive to nilotinib and imatinib than ponatinib, dasatinib or bosutinib

E255KLess sensitive to nilotinib, imatinib and bosutinib than ponatinib or dasatinib

V299LLess sensitive to dasatinib, bosutinib and imatinib than ponatinib or nilotinib

M244V, L248V, G250E, Q252H, D276G, F311L, E355G, L387M/F, H396R/P, E459K

Less sensitive to imatinib; varying sensitivity to nilotinib, dasatinib and bosutinib

Any other mutation Sensitivity profile not established

Table 4. TKI sensitivity for patients with BCR-ABL1 kinase domain mutations 2,15

Notes:

TKI, tyrosine kinase inhibitor.

*Many publications have reported in vitro results showing 50% inhibitory concentration (IC50) data that indicate how sensitive/resistant mutations are to the different TKIs; however, in vitro data alone should not be used in clinical decision making. The actual resistance of individual mutant subclones to specific TKIs in vivo can be determined by quantitative monitoring of the respective clone size during therapy.

References 2. Soverini S, et al. Br J Haematol. 2016;173:337–49. 15. Soverini S, et al. Leuk Res. 2014;38:10–20.

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References

1. Baccarani M, Deininger MW, Rosti G, et al. European LeukemiaNet recommendations for the management of chronic myeloid leukemia: 2013. Blood. 2013;122:872– 84.

2. Soverini S, De Benedittis C, Mancini M, Martinelli G. Present and future of molecular monitoring in chronic myeloid leukaemia. Br J Haematol. 2016;173:337– 49.

3. Branford S. Molecular monitoring in chronic myeloid leukemia – how low can you go? Hematology Am Soc Hematol Educ Program. 2016;2016:156 –63.

4. Leonard JT, Stock W. The persistence of minimal residual disease in Philadelphia chromosome positive acute lymphoblastic leukemia: we know it's bad, now what? Biol Blood Marrow Transplant. 2016;22:1913– 4.

5. Chiaretti S, Foa R. Management of adult Ph-positive acute lymphoblastic leukemia. Hematology Am Soc Hematol Educ Program. 2015;2015:406 –13.

6. Hoelzer D, Bassan R, Dombret H, et al. Acute lymphoblastic leukaemia in adult patients: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2016;27:v69 – v82.

7. Soverini S, De Benedittis C, Mancini M, et al. Best practices in chronic myeloid leukemia monitoring and management. The Oncologist. 2016;21:1–8.

8. Foroni L, Wilson G, Gerrard G, et al. Guidelines for the measurement of BCR-ABL1 transcripts in chronic myeloid leukaemia. Br J Haematol. 2011;153:179–90.

9. Hughes T, Deininger M, Hochhaus A, et al. Monitoring CML patients responding to treatment with tyrosine kinase inhibitors: review and recommendations for harmonizing current methodology for detecting BCR-ABL transcripts and kinase domain mutations and for expressing results. Blood. 2006;108:28–37.

10. Glivec® (imatinib) – Summary of Product Characteristics. Novartis Europharm Limited 2017.

11. Sprycel® (dasatinib) – Summary of Product Characteristics. Bristol-Myers Squibb Pharmaceuticals Limited 2017.

12. Tasigna® (nilotinib) – Summary of Product Characteristics. Novartis Pharmaceuticals UK Ltd 2017.

13. Bosulif® (bosutinib) – Summary of Product Characteristics. Pfizer Limited 2018.

14. Iclusig® (ponatinib) – Summary of Product Characteristics. Incyte Biosciences UK Ltd 2018.

15. Soverini S, Branford S, Nicolini FE, et al. Implications of BCR-ABL1 kinase domain-mediated resistance in chronic myeloid leukemia. Leuk Res. 2014;38:10–20.

Notes:

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Funded and developed by Incyte Biosciences in collaboration with a Steering Committee of European experts

For more information, please contact Incyte Medical Information (eumedinfo@incyte.com).

EU/ICLG/NP/18/0030; SE/ICLG/NP/18/0001Date of preparation: May 2018

NL/ICLG/NP/19/0009