Pathogenesis and Diagnosis of CML

Objectives

• To provide general background on Ph+ CML, including epidemiology,

pathogenesis, symptoms, diagnosis, and disease course

• To review consensus definitions of response and current

treatment recommendations

• To elucidate the role of molecular monitoring in the

management of CML

• To describe clinical data supporting the approved

therapies for Ph+ CML

2 Ph+ CML, Philadelphia chromosome–positive chronic myeloid leukemia.

Chronic Myeloid Leukemia

• CML is a leukemic transformation

Blood of the WBCs
stem cell
Lymphoid Myeloid
stem cell stem cell • Ph+ CML is caused by the protein
encoded by the abnormal fusion
Myeloblast gene BCR-ABL
Lymphoblast

• The fusion gene is formed as a

consequence of the translocation
Red
Platelets between 2 regions of
blood cell chromosomes 9 and 22
Basophil Neutrophil
Lymphocyte Plasma Eosinophil
Natural cell
killer cell
WBCs • The resulting BCR-ABL fusion
gene and fusion chromosome, the
Philadelphia chromosome, are the
hallmark of Ph+ CML diagnosis
WBC, white blood cell.
3 National Comprehensive Cancer Network. NCCN Guidelines for Patients. Chronic Myelogenous Leukemia. V1.2014.
Epidemiology of CML

Age-Adjusted Incidence Rate

New Cancer Cases Worldwide (as defined by SEER)
20121 2008-20122

97%
3% 87%
13%
Leukemias All cancer cases CML Other leukemias

• 1 to 2 new cases of CML are diagnosed per 100,000 people annually3

• The prevalence of CML is increasing annually due to reduced mortality

with newer treatments4,5
SEER, Surveillance, Epidemiology, and End Results Program.
1. International Agency for Research on Cancer. GLOBOCAN 2012: estimated cancer incidence, mortality and prevalence worldwide in 2012.
http://globocan.iarc.fr/Pages/fact_sheets_population.aspx. Accessed July 20, 2015; 2. Surveillance Epidemiology, and End Results Program. SEER Cancer
Statistics Review, 1975-2012. http://seer.cancer.gov/csr/1975_2012/. Accessed July 20, 2015; 3. Baccarani M, et al. Ann Oncol. 2009;20(suppl 4):105-107; 4.
4 Rohrbacher M, Hasford J. Best Pract Res Clin Haematol. 2009;22(3):295-302; 5. Huang X, et al. Cancer. 2012;118(12):3123-3127.
Philadelphia Chromosome Is the Hallmark of CML

Chromosome 9

Chromosome 22 • BCR-ABL transcripts

t(9;22)
(qualitative PCR) are also
BCR ABL confirmatory evidence of
Ph+ CML1
Fusion containing
BCR-ABL gene
(Philadelphia chromosome) • Presence of the Philadelphia
chromosome is a diagnostic
marker of CML in most
patients2,3
BCR-ABL protein

Deregulated tyrosine kinase activity

5 1. Baccarani M, et al. Blood. 2013;122:872-884; 2. Faderl S, et al. N Engl J Med. 1999;341(3):164-172; 3. Baccarani M, et al. Ann Oncol. 2009;20(suppl 4):105-107.
Role of BCR-ABL in Pathogenesis

• BCR-ABL activates several

BCR-ABL protein
signaling pathways in leukemic
cells that play critical roles in
the pathogenesis of Ph+ CML1
FAK RAS/RAF JAK/STAT AKT

• Overexpression or constitutive
MEK/ERK BCL-2 family activation of these pathways
results in drastically increased
cell proliferation, survival, and
Cell motility Cell proliferation Cell survival
motility, as well as decreased
cellular adhesion1,2
Malignant Phenotype1,2

6 1. Faderl S, et al. N Engl J Med. 1999;341(3):164-172; 2. Frazer R, et al. Ulster Med J. 2007;76(1):8-17.
Disease Course of Ph+ CML

• CML occurs in 3 phases, based on laboratory findings and clinical symptoms:

chronic phase (CP), accelerated phase (AP), and blast crisis (BC)1

Chronic Accelerated Blast

phase phase crisis

• 1%-14% BM blasts • Blasts of 15%-29% or blasts • Blasts ≥ 30%

(PB or BM)2 < 30% plus promyelocytes (PB or BM )3
> 30% (PB or BM)3
• < 20% basophils (PB) • Extramedullary blast
• Basophils in PB ≥ 20%3 proliferation, apart
• No symptoms or few from spleen3
mild symptoms2 • Persistent thrombocytopenia
(< 100 × 109/L) unrelated to
therapy3
• CCA/Ph+, major route, on
treatment3

BM, bone marrow; CCA/Ph+, clonal chromosome abnormalities in Ph+ cells; PB, peripheral blood.
7 1. Baccarani M, et al. Ann Oncol. 2009;20(suppl 4):105-107; 2. Baccarani M, et al. Blood. 2006;108(6):1809-1820; 3. Baccarani M, et al. Blood. 2013;122(6):872-884.
Symptoms and Clinical Presentation

• Ph+ CML is detected incidentally

during routine blood tests in about
half of patients who are
asymptomatic at diagnosis1,2

• At presentation, some patients

with Ph+ CML may be
experiencing fatigue, night sweats,
fever, weight loss, abdominal
fullness, splenomegaly,
and/or bone pain1,2

• Leukocytosis, anemia, and

thrombocytosis are also
hematological signs of Ph+ CML2

1. American Cancer Society. Leukemia—Chronic Myeloid (Myelogenous). http://www.cancer.org/acs/groups/cid/documents/webcontent/003112-pdf.pdf. Accessed

8 August 11, 2014; 2. Frazer R, et al. Ulster Med J. 2007;76(1):8-17.
Diagnosis of Ph+ CML

Cytogenetics1
• Examines BM cell metaphases to count how many contain Ph+ chromosome
• Also called karyotyping

Fluorescence in situ hybridization (FISH)

• Detects specific DNA sequences of cells in interphase or metaphase2
• For detection of BCR-ABL translocation, BM or blood cells are analyzed
using 2 differently labeled probes that bind to specific parts of BCR-ABL3

Real-time polymerase chain reaction (RT-PCR)4

• Tests for presence of BCR-ABL at the molecular level (qualitative RT-PCR)
• Quantitative RT-PCR (RQ-PCR) provides a numerical measure of BCR-ABL
transcript levels to evaluate disease burden

1. American Cancer Society. Leukemia—Chronic Myeloid (Myelogenous). http://www.cancer.org/acs/groups/cid/documents/webcontent/003112-pdf.pdf.

Accessed August 11, 2014; 2. Schoch C, et al. Leukemia. 2002;16(1):53-59; 3. Oliveira AM, French CA. Acta Cytol. 2005;46(6):587-594; 4. Akard L, Wang YL.
9 Clin Lymphoma Myeloma Leuk. 2011;11(5):385-395.
Measurement of Treatment Response

Hematologic response (HR)1

• Measure of blood counts and differentials
• Complete HR (CHR)
- WBCs < 10 × 109/L, basophils < 5% - Platelet count < 450 × 109/L
- No blasts in the differential - Nonpalpable spleen

Cytogenetic response (CyR)

• Chromosome banding analysis of BM cell metaphases2
• Partial CyR (PCyR): 1%-35% Ph+ metaphases, with ≥ 20 metaphases examined1,2
• Complete CyR (CCyR): no Ph+ metaphases, with ≥ 20 metaphases examined1,2

Molecular response (MR)

• Measurement of BCR-ABL transcript levels relative to those of a control gene2,3
• Major MR (MMR): ratio of BCR-ABL expression to that of a control gene ≤ 0.1%
according to the International Scale (IS)1,2

1. Baccarani M, et al. J Clin Oncol. 2009;27(35):6041-6051; 2. Baccarani M, et al. Blood. 2013;122(6):872-884; 3. Cross NCP. Best Pract Res Clin Haematol.
10 2009;22(3):355-365.
Correlation Between Response and Disease Burden

Number of Leukemic Cells1

1012 Hematologic
Cyto-

BCR-ABL Transcripts, log101-3

1011 CHR (< 1-log) genetic

1010 CCyR (2-log)

109 MMR (3-log) Molecular

108 MR4 (4-log)

107 ≈ 5-log reduction Deep molecular

response2
106 Undetectablea
BCR-ABLIS
Diagnosis Time

a Definition
depends on assay sensitivity, which varies by study.
11 1. Baccarani M, et al. Blood. 2006;108:1809-1820; 2. Baccarani M, et al. Blood. 2013;122:872-884; 3. Radich JP. Blood. 2009;114(16):3376-3381.
 Molecular Monitoring

12
Regular Molecular Monitoring
Is Recommended for Optimal Disease Management
Diagnosis 3 months 6 months 12 months

PCyR and/or CCyR and/or MMR

BCR-ABLIS ≤ 10% BCR-ABLIS < 1% BCR-ABLIS ≤ 0.1%

ELN1 TEST EVERY 3 MO EVERY 3-6 MO

NCCN2 TEST EVERY 3 MOa EVERY 3-6 MO

Monitoring 3-4 times a year is associated with

• Lower risk of progression3 • Fewer inpatient hospital visits5
• Longer PFS3 • Reduced financial burden5
• Increased treatment adherence4
PFS, progression-free survival.
a Every 3 months after treatment initiation and for 3 years after achievement of CCyR.

1. Baccarani M, et al. Blood. 2013;122(6):872-884; 2. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Chronic
Myelogenous Leukemia. V1.2015; 3. Goldberg S, et al. Curr Med Res Opin. 2013;29(9):1075-1082; 4. Guerin A, et al. Curr Med Res Opin. 2014;30(7):1345-1352;
13 5. Guerin A, et al. J Med Econ. 2014;17:89-98.
International Scale for BCR-ABL
Improves Accuracy of Molecular Monitoring
Number of Leukemic Cells1,2
BCR-ABLIS
Ratio
IRIS 100% 1012 • The IS for BCR-ABL aligns data to
baseline3
a common scale for the accurate
10% 1011
interpretation of response3,4
1% 1010
• Reporting MMR requires alignment
IRIS MMR3 109 to the IS,1 which can be established
0.1%
108 through application of a laboratory-
MR4 0.01% specific conversion factor3
MR4.5 0.0032% 107

0.001%
106

IRIS, International Randomized Study of Interferon and STI571.

1. Baccarani M, et al. Blood. 2013;122(6):872-884; 2. Baccarani M, et al. Blood. 2006;108(6):1809-1820; 3. Hughes T, et al. Blood. 2006;108(1):28-37; 4. Branford
S, et al. Leukemia. 2006;20(11):1925-1930; 5. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Chronic Myelogenous
14 Leukemia. V1.2015.
Summary

• Diagnosis of Ph+ CML is confirmed by the presence of the Philadelphia chromosome

and/or BCR-ABL gene

• Standardized molecular monitoring is important for managing Ph+ CML because the
depth and kinetics of response correlate with patient outcomes

• EMR is associated with optimal outcomes, including subsequent MMR and deeper
responses and improved rates of EFS, PFS, and OS

• MMR is associated with a reduced risk of losing CCyR, improved PFS and EFS, and
subsequent deeper molecular responses; sustained MR4/MR4.5 is associated with the
possibility of treatment discontinuation without disease recurrence

15